A professor of Psychiatry at the Ahmadu Bello University Zaria and a member of the Africa CDC Advisory Committee on Non-Communicable Disease, Mental Health and Injuries in Africa, Taiwo Lateef Sheikh, in this interview with Sade Oguntola, says suicide, a deliberate act to die, is more common in youths in Africa, though these are preventable deaths. Excerpts:
What is the average suicide rate in Nigeria? What are the reasons suicide occurs?
Data on suicide and suicide attempts worldwide is rather poor, this is even more so in Nigeria. In many places, it is underreported and/or misrepresented. People don’t want to agree that someone has died by suicide. Many barriers do not allow people to come out and say that they feel suicidal. Today, suicide is the 10th leading cause of death globally. This is particularly bad in low- and medium-income countries, including Africa.
On average, the rate of suicide in Africa is about 11 to 12 per 100,000 people, based on the World Health Organisation’s 2019 estimates. The global average for suicide is put at nine per 100,000 people. In African countries like Lesotho, Eswatini, Zimbabwe, South Africa, Mozambique, Central African Republic, Botswana, Eritrea, Cameroon and Côte d’Ivoire, suicide rates are extremely high with rates above 15 per 100,000 popupation. It is as high as 40 per 100,000 in Lesotho and Eswatini. In Nigeria, it’s an average of five per 100,000 people. We don’t have a suicide register; suicide is a crime in Nigeria.
So, why is suicide high in Africa and Nigeria?
Suicide occurs in both the rich and the poor countries of the world. But it’s a little bit more over-represented in poor countries due to many factors. One is that poverty limits the available preventive measures for suicide. Also, other factors such as substance use disorders, mental health conditions, unemployment, civil strikes, forced migrations and disasters are overrepresented in Africa.
Who is at risk for suicide?
Empirically, over 90 percebt of people who engage in suicide, or are trying to die by suicide have one mental health condition or the other, or have substance use problem or a combination of both. About 70 percent of people who have mental health conditions and engage in suicidal act have depression. Persons that have attempted suicide have a higher risk of trying to die by suicide another time. Suicide is higher in men than women and male suicide rate is highest within the African region. It is about 18 by 100,000 population compared to the global average of 12.4 by 100,000 population. Also, the risk of suicide is further increased if the man lives alone, have a mental health condition or abuse drugs.
Suicide is the fourth leading cause of death among young people of ages 15 to 29. A lot of mental health conditions start in that age group and over 85 percent of substance abuse disorders are among the age group. This explains the overrepresentation of risk factors for suicide among youths in lower medium income countries; especially Africa
Individuals with a relative who died due to suicide or attempted suicide stand a higher risk because they are exposed to the same social determinants that make suicide more likely. Lifestyle and resilience also determine the propensity to develop certain conditions, including mental health conditions.
What are suicide warning signs to be on the lookout for in individuals?
Studies have shown that people who died by suicide would have required help in the past, month before the act. Such a person could have been overwhelmed by many stressful situations, including the loss of a job, the death of a close relative, or other calamities like house collapse, and become suicidal due to a lack of psychological support. When a very social person becomes reclusive, not wanting to meet with others, wanting to be left alone in the room, or starts feeling guilty and begging for forgiveness for reasons that cannot be explained while exhibiting a low mood, it can be a red flag for suicide.
Even if there is an offence, the magnitude is not enough to explain the degree of the begging for forgiveness and feeling of guilt while exhibiting a low mood. Feeling sad, crying over nothing and losing pleasure in what really should have been pleasurable to that person. Such people could also start to feel worthless, have low self-esteem, and say such things as “I am the worst person on earth, the ugliest person on earth, and so on.” They may also make remarks of saying good bye or giving out their properties. The moment you see these signs, you know something is likely to happen. So, if someone has a mental health condition and has tried to die by suicide before, lives alone, or has experienced serious catastrophic life events like the loss of livelihood or loved ones and it’s manifesting as guilt feelings, mood change, feelings of worthlessness, and hopelessness, are warning signs that most likely, something is wrong. A previous history of suicide attempts is a warning that the person can still attempt to engage in the act of suicide again.
Is there any way we can work around stigma, misconceptions and the criminalisation of suicide to improve access to care and help for people?
These are huge barriers to disclosure and the uptake of preventive services for suicide prevention. Myths and misconceptions act as drivers of suicide. These misconceptions are based on cultural, traditional and religious biases. Some cultures believe that suicide is evil and the work of some spirits or gods and, as such, anybody who engages in suicide activity will bring in very bad spirits to the community. As such, people who die through suicide cannot be buried in the community, but in the forest. Some religions do not give the final rituals to people who died by suicide and relatives of people who died by suicide are excommunicated.
Misconceptions that are culturally driven also trivialise suicide. People say that just because his wife left him, he killed himself. Also, society blames the person who has died of suicide rather than the conditions related to it.
All these things, in addition to the criminalisation of suicide and attempted suicide, now create another level of barrier to disclosure, accessing services and definitely negate getting enough data on suicide in Nigeria. People hide their intent because they can be jailed when they are caught. But we need data to develop suicide prevention programmes; make budgetary allocations available, know how many institutions we will need for interventions, and to know how best to integrate these services.
There is no evidence that criminalising suicide can reduce the threat. Rather, it is the opposite. Countries where suicide is criminalised have higher incidences of suicide than countries where suicide has been decriminalised. Making suicide a criminal offence will not allow people to come out. And even where someone dies by suicide, because of the stigma, the family would not allow neighbours to know about it. That case will not be captured in the data.
Is Nigeria implementing any national suicide prevention strategy to tackle this problem?
We do not have a national strategy for suicide prevention in Nigeria. However, within the past month, I personally have participated in the drafting of a national suicide prevention framework for the country. It still needs to go through other bureaucratic processes before it becomes an instrument to be used for suicide prevention in the country.
On the 28th of December 2022, Nigeria’s former president, Muhammadu Buhari, signed into law the National Mental Health Act. A section of the law confers some protection for people who are engaging in the act of suicide attempt. The National Mental Health Act recognises that people have the right to life, right to treatment and care, as enshrined in Nigeria’s constitution. It also says that anyone diagnosed by a medical officer as having a mental health condition and who engages in acts that could be self-injurious or harmful to others, should be taken in for treatment. This is the first time we’re having such a compassionate law, however, suicide attempt is still a criminalised act in Nigeria.
So, I will not say that Nigeria is not doing anything about suicide prevention, but we are still far from where we should be. Importantly, in terms of a national framework and legislation, collectively, we have not been able to address suicide and suicidal attempts in Nigeria through policy document.
Can crisis lines be useful in suicide prevention in Nigeria?
The crisis lines are toll-free call lines that people can call to reach out for help from anywhere without necessarily being present at the health facility. At its end, people are trained to be able to de-escalate the problem, talk to them because they can understand the issue and then refer them to the nearest available services. Through GPS, they will know the location of the caller.
This toll-free line has shown to be very effective in providing first-line intervention to people in crisis and this kind of service (crisis lines) are ideally suited for low- and medium-income countries where health budgets are very limited.
Now, this is where Lifeline International, a global non-profit organisation that has over 200 crisis line centres worldwide, an organisation that I am representing in Africa, comes into play. It currently has a presence in six African countries. Lifeline International has the technology to help countries set up toll-free lines that people can call. When 1,000 people call at the same time, it will go to different responders automatically. Lifeline international has the expertise to train the first line responders on the crisis lines to know how to de-escalate situations, offer comforting counselling and psychological first aid, and link callers to where further support and interventions can be provided.
A crisis line is very important, it tends to reduce exclusion, where you go to a clinic and you’re talking about feeling like dying and the health care provider is saying ‘go away’, because you are not the only one who has a problem. Through it, we can also provide good data bank of suicide attempts in the country, for effective planning for suicide prevention in Nigeria. Crisis call lines are few in Nigeria; almost all are not toll-free and, as such, are expensive.
So, there’s nothing wrong with Nigeria partnering with Lifeline International on this. The National Mental Health Act has not decriminalised suicide. We need to expunge that section from the Criminal Code Act. Suicide is not just a deliberate act to die; it is a condition that is preventable anywhere in the world. People who engage in acts of suicide don’t want to die. They want to escape from their pain and suffering, but their brain cannot think of another way out. That is why they need help and we need to “create hope through action.”
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