Let’s talk about suicide

SINGAPORE - Suicide is a subject which is often avoided – but that could be the last thing that someone who is expressing suicidal thoughts needs.

“When someone says, ‘I’m going to kill myself’, the usual response would be: ‘You shouldn’t say that’ and it shuts them down,” said Rui (not his real name), who is in his 30s and has struggled with suicidal thoughts.

Rui, who attends meetings with the Light in the Dark support group launched by Samaritans of Singapore, said he wishes people understood that suicidal thoughts are a painful, overwhelming reality for many, and not attempts at seeking attention.

“People who say ‘I’m going to end it’ are asking for help in the only way they can,” he said.

Experts say the key is to treat ideation as a signal that support is needed.

People often think that asking loved ones in distress if they are suicidal might plant the idea in their heads, when the truth is that it might actually protect them, say experts. 

There are many misconceptions around suicide, including that suicidal thoughts affect only individuals who have mental illnesses.

However, they can also occur in people who have not been formally diagnosed with a mental health condition, or, at least, are not known to have had a mental illness before their deaths, said Associate Professor Mythily Subramaniam, assistant chairwoman of the Institute of Mental Health’s (IMH) medical board for research.

“In these cases, the trigger may be a major life event like humiliation, loss, failure or conflict, combined with poor coping resources, social isolation or a sense of being utterly overwhelmed,” she said.

The risks may be even greater for adolescents.

A February study by KK Women’s and Children’s Hospital (KKH) found that young patients who had tried to hurt themselves typically did not have serious mental health disorders, but instead had psychosocial problems and emotional regulation difficulties.

The study looked into the psychosocial stressors and risk profiles of adolescents who visited KKH’s emergency department for suicidal or self-harm attempts from January to December 2021. The authors reviewed 221 medical records of patients aged 10 to 19.

The most frequently observed mental health challenges were stress-related and emotional coping difficulties, which were present in 50.7 per cent of patients, and mood and anxiety symptoms, present in 53.4 per cent of patients.

Left unassisted, their mental health distress can rapidly escalate and manifest in behaviour that is a risk to themselves, the authors of the study said.

Awareness and prevention a whole-of-society effort

Bringing the topic of suicide into the open has become paramount, as it remains the leading cause of death among young people aged 10 to 29 for the sixth consecutive year. 

It is one of the most urgent public health challenges for Singapore, said Prof Mythily.

The issue requires a whole-of-nation approach, with a lead agency to coordinate proven prevention efforts, training for the community to recognise warning signs, and continued research funding to find better ways of preventing it, she said.

Both Prof Mythily and Professor Chong Siow Ann, a senior consultant at IMH’s Research Division and Department of Psychosis, said that those who come into contact most often with youth, such as teachers, national service (NS) officers, human resources staff and community volunteers, should be better trained to recognise the warning signs if someone is at risk.

Schools, NS units and workplaces should also provide stronger support to those affected by a suicide to reduce risk and promote healing.

Prof Mythily and Prof Chong recently concluded a study where suicide survivors were interviewed.

They said mental health hotlines such as the Samaritans’ hotline 1767 and the national mindline 1771 should have youth-friendly chat and text options, as these are young people’s preferred communication channels. Currently, the two hotlines offer a text option only through WhatsApp.

National efforts must also address stigma, so that young people feel they can seek help without fear, the healthcare professionals added.

Ms Chan May Peng, lead counsellor and senior manager at the Samaritans, said suicide ideation is more common than many realise.

It can stem from stressors and traumatic experiences at different stages of life such as childhood trauma or abuse, relationship breakdowns, employment or financial struggles, or living with a chronic illness.

Those who are vulnerable could also be suffering from social isolation and loneliness, mental health conditions, a lack of support systems, and cultural or societal stigma that discourages them from seeking help.

There could be broader influences, such as neurological or genetic vulnerabilities, or social media, in the form of cyber bullying, online harassment or platforms that may unintentionally normalise or romanticise suicide, Ms Chan said.

“The more people are aware of and willing to talk about suicide, the wider the community safety net becomes, so that no one falls through the cracks,” she said.

In Singapore, there were 434 suicide deaths in 2023, and 476 in 2022.

In 2024, the provisional number of suicide deaths was 314, but the final number will likely be higher after investigations into cases are concluded.

For instance, the provisional number of suicide deaths in 2023 was 322, a figure that was then widely reported as the lowest in two decades. However, the final figure turned out to be 35 per cent higher, at 434.

Project Hayat, the group behind Singapore’s first suicide prevention White Paper in 2024, has launched a study to better gauge the true number of suicides as a better guide for policies.

Critically, these numbers tell just part of the story.

According to the World Health Organisation, more than 720,000 people die by suicide every year, and for each suicide, there are an estimated 20 suicide attempts.

Project Hayat has called for a coordinated approach to suicide prevention, with a central body to spearhead efforts.

Spotting the warning signs

IMH, which conducted face-to-face interviews with suicide survivors for a recently concluded study, said in a Sept 17 press release that key risk factors include previous suicide attempts, having a mental health condition, ongoing physical health challenges such as greater functional limitations and insomnia, and relationship breakdowns.

Prof Mythily, the study’s principal investigator, said a significantly higher number of acute warning signs tends to appear in the week before death. These include substance abuse, a sense of purposelessness, heightened anxiety and social withdrawal.

Other signs could include changes in sleep patterns – either sleeping too much or too little – and saying things like “You’d be better off without me”, said Ms Charlene Heng, deputy director of SOS Academy, the training wing of the Samaritans.

Prof Chong, the co-investigator of the IMH study, said: “Look out for someone talking about death, feeling like a burden, or saying they have no future. Notice if they are searching online for ways to harm themselves, withdrawing from friends, school or work, or showing severe insomnia, agitation or reckless behaviour.

“Red flags include extreme agitation, or, paradoxically, a sudden calmness after a period of great distress, which can mean they have made a decision to kill themselves.”

Mr Alex Yeo, executive director of suicide prevention charity Caring for Life, said that one warning sign is the act of posting farewell messages on social media.

These can be very short. For instance, someone might send a message to his friends on social media, expressing gratitude for their support, and ending it with “but I think it’s time for me to rest”.

“How many people actually realise that this is an indirect cry for help and you need to do the right thing to prevent a potential attempt,” Mr Yeo said.

“At the end of the day, when it comes to suicide ideation, it’s really a presenting symptom of a deeper root problem.”

A mother who lost her child

A mother in her 40s, who lost her 12-year-old daughter to suicide in 2024, said the happy-go-lucky and feisty child had shown mostly very general signs of stress, apart from one sign that she found out about only after the girl had died.

After her daughter’s death, the mother sought out her notebooks and a suicide note, and realised her child had developed a highly critical inner voice that was not expressed outwardly.

Her daughter had loved to draw and write stories, but the girl later discredited them, even writing “failed” in a huge font across one of them.

Despite being of average height, the child lamented that she was short, and her lethargy, likely due to depression, fuelled her belief that she was lazy. She did not own any devices, but would secretly sneak the common phone or tablet into her room to read manga or watch anime at night.

She looked tired in the day and would doze off, which was something that did not happen before, said the mother, who started attending counselling sessions by the Samaritans, as well as its support groups, after the organisation reached out to her through its suicide survivors programme.

The mother noted from her daughter’s writings that the child would binge to “take care” of her mental health, but she had thought her child’s good appetite was a sign that she was growing.

A school journal showed that she would draw a lot when she was sad or angry, and she produced her most vivid drawings in the months before her death.

Going through that book after her child’s death, the mother found writings about how she did not seek help for a big challenge because she thought that she could manage on her own, and had doubts that talking to others would help.

And so, the child hid her struggles from her family well.

“The challenge is how we, as parents, can discern between signs of depression and behavioural traits typical of children of her age,” said the mother.

“(For the child), there is a difference between (the) feeling (of) being loved and (the) feeling (of) being unneeded – which surfaced recently in a conversation with a suicide survivor and also my daughter’s suicide note; not sure how to address the latter, but, nonetheless, (awareness of) these aspects can be strengthened,” said the mother.

Conversations must be held; everyone can help 

Caring for Life’s Mr Yeo emphasised that new stresses such as being scammed can lead to suicidal thoughts. He said people under severe stress may no longer be capable of seeking help, and it would be up to those around them – family, friends, colleagues and superiors – to step up.

The people closest to them can help them to re-anchor themselves and find a reason to live, and to seek help to address the deeper issue that had led to the suicide ideation, said Mr Yeo.

Action should be taken the moment suicidal thoughts are disclosed. Even if there is no plan, early intervention in the form of listening with empathy, linking the person to support, and reducing his or her isolation can dramatically lower the risk of an attempt, said Prof Chong.

The Samaritans’ Ms Heng said that, as a society, all of us can learn to spot risks earlier, and create spaces where people feel safe to talk about their struggles without judgment.

“For members of the public, it can be as simple as checking in with your community and network,” she said.

“Struggles are not always obvious, but providing an empathetic listening ear can help your friends and family feel safe about sharing these hidden troubles.”

SOS Academy offers community-based programmes, such as Be A Samaritan, where the public can learn how to support someone in a suicide crisis, Ms Heng said.

Ultimately, the key to reduce stigma around suicide is to have open discussions about it, so it becomes as normal and acceptable as talking about any other health concern, said Prof Mythily and Prof Chong.

If someone tells me he or she is feeling suicidal, what should I do?

(Source: IMH, Samaritans of Singapore)