This article first appeared in Forum, The Edge Malaysia Weekly on July 3, 2023 - July 9, 2023

Suicide attempts by young Malaysians in schools or universities are under-reported and under-managed, and Malaysia must do better to prevent suicide among our youth. According to the World Health Organization and Relate Malaysia (a mental health non-profit), an estimated 250 Malaysians attempt suicide each day, at least three of them complete the act, and suicide is the fourth most common cause of death among Malaysians aged 15 to 29.

Suicide among young people is preventable and educational institutions are ideal sites for suicide prevention programmes. However, designing effective programmes requires an appreciation of the complex causes and tipping points of suicidality. Encouragingly, there is now greater recognition among young people, their parents, educational institutions and other relevant stakeholders of the importance of mental health. This recognition, along with strong stakeholder commitment, will be vital in developing timely and evidence-based crisis responses to save young lives.

Suicide is a leading cause of death among youth. Official suicide statistics may be understating the extent of the problem due to systematic under-reporting, decentralised databases and stigma, but even then, the data that we do have already depicts a troubling picture of youth mental health.

Based on police records between 2019 and 2021, youth suicide (between 15 and 29 years old) makes up more than half of all suicide cases and is on the rise in Malaysia. This concerning rise is compounded by the severe psychological effects of suicide bereavement and the suicide contagion effect among youth, whereby a single suicide case could lead to a suicide cluster, perhaps by means of peer examples. Such clusters highlight the urgency of addressing youth suicidality.

However, suicidality is complex and cannot fit into traditional medical models of causality in which one root cause produces a range of symptoms. For example, a brain tumour produces multiple symptoms like headaches, seizures and speech problems. In contrast, suicidality cannot be attributed to a single root cause or diagnosis because its symptoms and risk factors could be manifold and often directly influence or reinforce one another.

In fact, one single mental disorder diagnosis is rarely observed in suicide victims. More frequently, combined burdens from psychiatric conditions and other social pressures are observed. According to the Australian Institute for Suicide Research and Prevention’s J M Bertolote and colleagues, this complexity largely precludes upstream preventive strategies such as early identification or targeting specific psychiatric disorders.

Therefore, according to international best practices and the WHO, suicide prevention strategies should be universal (via awareness and screening efforts), selective (via gatekeeper training) and indicated (via interventions for high-risk students). This op-ed explores the three themes of “universal”, “selective” and “indicated” suicide prevention strategies focused on Malaysian secondary schools and universities.

Educational institutions are appropriate sites to conduct such programmes as they provide many of the touch points and resources needed to administer the programme to youth from diverse backgrounds. Although there are commendable efforts across different institutions to tackle the issue of youth suicide and mental health, there remains scope to strengthen programme design in the three guiding principles of universal, selective and indicated suicide prevention strategies.

Universal suicide prevention awareness efforts are programmes that increase suicide awareness and mental health literacy of the entire youth population, as opposed to target subgroups. Many of the evidence-based universal suicide prevention programmes take place in schools, such as the Signs of Suicide in the US and the Strengthening Evidence Base on School-based Interventions for Promoting Adolescent Health (SEHER) project in India.

These programmes incorporate suicide prevention information into standard curricula and equip teachers and lecturers with the skills for interactive delivery. In Malaysia, the mental health promotion and suicide awareness efforts in public and private universities are mostly one-off or seasonal events, with neither the efficacy assessments nor the curriculum integration and staff training efforts highlighted in the aforementioned countries.

Beyond awareness efforts, universal screening is recommended in healthcare settings by regulatory agencies such as the Joint Commission on Accreditation of Healthcare Organizations, and in school settings by research studies (such as that by Salem State University School of Social Work’s R G Mirick and colleagues) to optimise identification of at-risk individuals. Although many Malaysian universities offer on-campus counselling services that include mental health assessments and support, systematic suicide screening efforts are often absent. Placing the onus on students to access mental health support may be problematic, as it requires them to have adequate insight and high mental health literacy levels. Thus, a universal programme can help to improve access to mental healthcare services and improve suicide prevention.

Gatekeeper training provides knowledge and intervention skills for selected teachers, lecturers, student peers or school administrators who may have direct contact with students who are at risk of suicide.

Although gatekeeper training is the most common form of campus-based suicide prevention strategy internationally, the long-term effectiveness of gatekeeper training in Malaysia remains questionable. In studies by National University of Malaysia’s Amran Fadzrul Roslan, Ching Sin Siau and their colleagues, improvements in knowledge of suicide and self-efficacy in helping suicidal individuals were only seen among participants immediately after the training, but not maintained upon follow-ups three or six months later.

Thus, for more effective gatekeeper training, Malaysian universities can consider conducting it with intrinsically-motivated stakeholders such as student leaders. For example, the QPR Gatekeeper training in the US, which is endorsed by the Suicide Prevention Resource Centre in the country, has been shown to be more effective when conducted with representatives from student organisations or youth volunteer centres, rather than teachers or lecturers.

In this component, students at risk of suicide are first identified, before being connected to evidence-based and culturally-responsive care delivered by kind, trusted and familiar professionals, peers, teachers or lecturers. Follow-up protocols should also be in place to ensure that the referral appointment occurs and the care transition is supported.

Interventions for high-risk individuals is an important part of the Zero Suicide Model by the US-based National Action Alliance for Suicide Prevention, which emphasises having responsive systems of support while simultaneously enabling at-risk individuals to be an active participant of their own care.

In Malaysia, even when high-risk students are referred by school counsellors to external mental healthcare professionals (like therapists, counsellors, psychologists or psychiatrists), the current mental healthcare system may not be able to cope. Mental health services in the private sector may be too expensive, while those in the public sector are challenging to access due to health workforce shortage and longer waiting times. Strengthening the mental healthcare system is beyond the scope of this op-ed and requires a multi-stakeholder and multi-year commitment.

For at-risk students, these gaps can be highly detrimental, given that suicidality alternates between stable states and tipping points. Thus, in line with recommended standard care guidelines by the US-based National Action Alliance for Suicide Prevention, collaborative safety planning between the student, mental health professionals, family and friends should be a part of the individualised treatment plan. This plan would include having easy access to crisis hotlines, having significant others to assist in reducing access to lethal means, and building networks of support with family and friends.

Youth spend most of their time in educational institutions, where effective and affordable prevention programmes can be implemented for far-reaching impact and at reasonable cost. Encouragingly, Malaysia is improving our mental healthcare policies, most recently the removal of Section 309 of the Penal Code in parliament in June, decriminalising attempted suicide.

Thus, the timing is now favourable to improve suicide prevention programmes in Malaysian educational institutions. This could entail implementing universal suicide screening at critical entry points such as during orientation week where suicide risk of many students can be identified at an early stage. This should be accompanied by swift and consistent personalised feedback in indicated interventions, accompanied by a supportive monitoring system that appropriately tracks moods and risk, to channel at-risk students to appropriate interventions.

Digitalisation, automation and artificial intelligence may also be used to reduce the resources required for intervention delivery, while simultaneously increasing efficiency and scalability. If done correctly, screenings can be more efficient and extensive, monitoring can be more consistent and crisis interventions can be more timely. These are all building blocks for an effective suicide prevention system, alongside addressing the social determinants of health.

Suicide is everyone’s problem, and the highest expression of a civilization is to support those who need our help the most. We can and must do better, especially for the youth of Malaysia.

Farihin Ufiya is a manager at Angsana Research and Consulting, the founding director of Nyawa (Mental Health Aid Association) and will start her PhD in neuroscience in 2023. Jernell Tan is the co-founder and advocacy lead of Nyawa, as well as the documentation and monitoring coordinator of Suara Rakyat Malaysia (Suaram). Dr Khor Swee Kheng is CEO of Angsana Health and specialises in health systems.

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