Working Together Towards a Zero-suicide Singapore

Mr Deputy Speaker, please allow me to read the struggles of Lucy, not her real name, and her suicidal thoughts to this House. I quote verbatim: "I have been a witness to a suicide, I have lost a friend to suicide and I struggle with suicidal ideation on a near daily basis. It cost me my university education, landed me in tens of thousands of dollars in debt, and left me with little means to earn enough to pay back my study loan and survive on my own. I will likely never be able to earn more than $1,000 per month and will likely take my life than die of other causes in the near future."

Other than Lucy, there were 46 more people who came forward to share with me about their experiences with suicide, among the 400 respondents to the public consultation on mental health conducted by my team and I. Like Lucy's and the many near and far ones who have reached out to me, each and every one of their stories was heartbreaking to know and read, as they agonised over their struggles to live.

Suicide is a global public health concern. Close to 800,000 people lose their life to suicide every year, nearly one-third of which occur among young people.

Here in Singapore, teenage suicides peaked in 2018 – the highest since suicide tracking started in 1991. Sadly, so did the number of elderly aged 60 and above who took their own lives. From 2017 to 2019, there were 1,204 attempted suicides yearly. Last year, the Immigration and Customs Authority reported that there were 8.36 suicides per 100,000 Singapore residents in 2018, up from 7.74 in 2017. Suicide has entrenched itself as the leading cause of death for those aged 10 to 29.

Sir, these worrying numbers could be higher, given issues of under-reporting. According to the Attorney-General's Chambers, a classification of "suicide" only occurs when there is clear evidence of suicidal intent and self-harm. From my interactions with suicide-bereaved parents, the cause of death is sometimes categorised as "fall from a high place" or "unnatural death" and also labelled as such on the requests of family. In addition, we must also not forget that for every suicide and attempted suicide we know, there are many more people struggling with self harm and suicide ideation that we have little data on. In fact, estimates from WHO show that for every suicide, there may have been more than 20 suicide attempts that go undetected.

So, whilst some may argue that our numbers are not high by international standards, we are still not doing enough because the number of deaths by suicides in Singapore has remained relatively unchanged from 9.5 suicides per 100,000 residents in the 1980s to 8.3 suicides per 100,000 residents today.

How have we managed to develop from a third-world to first-world country and yet not be able to successfully tackle this issue of suicide? How is it that we still have the current number of suicide deaths we have today? One large reason might be the disappointing fact that Singapore was not listed as one of the few "high income" countries with a national suicide prevention strategy even though we are a member state of WHO – because we do not have one! National suicide prevention strategies are essential for working towards the ultimate goal of suicide reduction. According to WHO, such a strategy is important as it indicates a government's clear commitment to prioritising and tackling suicide, while making resources available for necessary interventions.

Mr Deputy Speaker, Senior Minister of State Amy Khor's assurance at Budget 2020 that a whole-of-Government review of our mental health strategy will be undertaken to identify gaps and strengthen existing inter-agency efforts brought much hope to many who are struggling. Building on this, I hope to use the rest of this speech to ask the Government to go further in developing a national response that aims for zero suicides under this review as part of a multi-ministry and multi-sectoral effort.

But first, let me take this opportunity to address the discourses about suicide. It is a common fear that talking about suicide could encourage suicide behaviour, hence many friends and families who are concerned about their loved ones in distress often struggle with asking about suicide ideation or intent.

Similarly, Minister Ong Ye Kung shared his concerns in this House that talking about suicide numbers in schools "may heighten suicide risk in vulnerable youths". While I appreciate the intention of these concerns, I would like to point out that youths today already consume a large volume of media online related to mental health and suicide. Youths have shared with me that schools often try to keep quiet about students who died due to suicide, but this backfires as students are often already in the know about their peers' mental health and suicidal intention. The expert consensus is that, to have a chance at preventing suicide, we must talk about suicide responsibly.

Earlier this month, Senior Minister of State Edwin Tong indicated that allowing for treatment for self-inflicted injuries in MediSave or MediShield Life could encourage suicidal behaviours, although exceptions could be made for those with existing mental health conditions. In this House, a few colleagues expressed their concerns last year that decriminalisation of suicide could send the wrong signal in incentivising suicide. These views perpetuate the stigma by shrouding suicide in exclusion. Experts indicate that incentives for help-seeking are helpful in combating stigma, allowing those who are struggling to feel more comfortable in seeking support.

Mr Deputy Speaker, apart from poor mental health that Senior Minister of State Edwin Tong gave concession to, we must also recognise that there are social and environmental factors embedded within our society and structures that also contribute to an individual's intention to self harm or suicide or to take their own life. Intense feelings of hopelessness can also arise from sudden and adverse life events including unemployment, trauma and the loss of loved ones. Not every suicide is a result of mental illness, nor is someone with mental illness always suicidal.

Lastly, we must take the lead in recognising that suicide is far from a selfish choice and cannot be blamed on the individual. My cousin, who has attempted suicide several times, often shares that he feels that he's a burden to his family, including me, even as he acknowledged that he knows how much we love him.

Studies have shown that people who attempt to take or took their own lives commonly feel that their lives hamper others, viewing their decisions as relieving their loved ones. The following excerpt of a suicide letter from an elderly victim broke my heart, I quote: "Father is reluctant to leave all of you. I have failed so badly that I have no choice." This is the reality of suicides, and those who succumb can hardly be labelled as selfish.

Mr Deputy Speaker, as recommended by the WHO, it is fundamental for the Government to lead and coordinate efforts in suicide prevention, starting from the establishment of a national strategy, to show this Government's priority in tackling suicides. This should first start from identifying currently available resources and committing further resources and funding to improve suicide prevention and efforts to support individuals struggling with suicide. One example would be to expand funding for organisations like SOS, the Samaritans of Singapore, not just to operate our de-facto national suicide helpline, but to ensure timely follow-ups with callers who need further support. We should also consider increasing resources and funding for mental healthcare services to address wait time and patient load issues.

I am deeply alarmed that our public hospitals do not track whether an admission is due to attempted suicide. Yet, studies show that 83% of people who die by suicide visit some kind of doctor a year before their death. Hence, healthcare facilities, especially emergency facilities and departments, are a logical place to prevent suicides. By getting our hospitals to track suicide attempts, our national strategy is better placed to coordinate the continuity of care for these suicide attempters. In the mould of the Zero Suicide Initiative, we must ensure that on the individual level, that we acknowledge each person's pain, empower them to make safe decisions and on the systems level, build hope for recovery with a continuity of care approach across agencies.

We should also note that since the decriminalisation of suicides, data of suicide attempts is no longer required by the Criminal Code. Without data surveillance of attempted suicides, our ability in developing informed strategies is limited.

Through a national strategy of data surveillance coordinated across Government agencies and community partners, the transparency and awareness of the support available can be improved, allowing various stakeholders better position their role and plan their work in tackling suicides. A robust framework of monitoring and evaluation is also required, thereby instilling a sense of accountability among those in charge of interventions.

We have a crisis on our hands with the spike in teenage suicides. I would like to lend a voice to the suicide-bereaved mothers of the PleaseStay. Movement. They believe there needs to be clear and strong suicide prevention and post-suicide intervention protocols in schools. Despite their inconsolable grief, they came forward to share what they believe could be done to prevent more teen suicides so that other parents do not have to go through the same pain. Families and friends, especially other students in the school, will inevitably suffer from grief and trauma to varying degrees and urgently need this post-suicide intervention support.

Many education systems such as the state government of Victoria in Australia establish step-by-step guidelines on what to do in the event of a suicide attempt and/or in an occurrence of suicide, making them publicly available as part of a whole-of-society effort. Notwithstanding the peer support networks that Minister Indranee cited in response to my question in Committee of Supply (COS) on MOE's suicide prevention strategy, I am sure we all agree that laying out clearly MOE's suicide protocols to parents and students can only help confront increasing suicides amongst teens.

Mr Deputy Speaker, as much as the Government must take the lead in suicide prevention, the complex and multi-faceted nature of suicide means that all of us are a part of this national response towards zero suicides.

Studies show that 50% to 60% of all persons who died by suicide gave some warning of their intentions to a friend or family member. One mother from the PleaseStay. Movement shared she was not aware that her 11-year-old son was suicidal until it was too late. Young people have often asked me what the warning signs are and how they can help their friends.

We need more public education programmes in schools, workplaces and communities on suicide prevention 101, including learning these warning signs: from unusual and sustained changes in actions, to actions like withdrawal, loss of interest, words like verbal statements such as "Everybody will better off without me", "What is the point of living?", and feelings – guilt, hopelessness; also, biological and physical aspects like poor sleep and loss of appetite.

Key gatekeepers like police, teachers, grassroots leaders and more must also be trained in suicide first-responder training so that they can intervene appropriately for suicide attempts. Community support groups like the SOS as the first community responder, or the PleaseStay. Movement and new groups like Caring for Life are key stakeholders in this whole-of-society effort to reduce and prevent suicides.

However, without a national strategy for these efforts to align to, we risk having a fragmented and sub-optimal approach to supporting survivors and bereaved parents.

Mr Deputy Speaker, I would like to conclude by imploring the Government to take action now to arrest the rising suicide numbers by initiating a National Suicide Prevention Strategy with a vision towards a Zero-Suicide Singapore, together with community partners and citizens. We must stand firm in the belief that suicides are preventable and commit to the efforts in making that possible.

Why zero suicides? Because unlike any other targets – like 2020 for gender equality, 30 by 30 for food security – that we have made in this House when it comes to loss of lives; human lives, nothing short of zero has ever been good enough for us. A Zero-Suicide Singapore as a goal joins the Vision Zero aspiration of our workplace safety and health policies and the Zero Accident movement in our public transportation policies too.

And we would not be alone. The United States aspires towards a nation free of the tragedy of suicide in its national prevention strategy. Japan envisions a society where no one is driven to take their own life. South Korea wants to create safe and healthy communities free from suicide. And last but not least, Sweden’s Vision Zero Policy which was ratified by its parliament in 2008 aims to build a nation where no one should be in a situation of such vulnerability that suicide is seen as the only way out.

Mr Deputy Speaker, as they say, if we fail to plan, we plan to fail. And we most certainly must not fail our people like Lucy. We must work together towards a zero-suicide society that cares because every life matters. To Lucy and those of you who are struggling with suicidal thoughts out there, please know this: "You are not a burden nor are you alone. Yes, the world will be a better place in it. Please stay."

Mr Deputy Speaker, MOH is committed to mental well-being and suicide prevention and to this end, Singapore adopts a multi-pronged approach.

Internationally, based on WHO's 2016 age-standardised death rates, Singapore’s age-standardised death rates from suicide – 7.9 per 100,000 resident population – is lower compared to not just countries like South Korea at 20.2 and Japan 14.3, but also countries like Finland and US – 13.8, and 13.7 respectively. It is also lower than the annual global age-standardised suicide rate of 10.5 per 100,000 population. In Singapore, the number of suicides involving 10- to 19-year-olds fluctuated from 13 cases in 2014, 27 in 2015, 22 in 2016, falling to 12 in 2017 and rising again to 22 in 2018. The number of elderly suicides has declined from 126 cases in 2014 to 115 cases in 2018 despite an ageing population.

Nonetheless, we recognise that every suicide is one death too many and we have and will continue to strengthen our strategies to prevent suicides, as guided by the National Mental Health Blueprint and Community Mental Health Masterplan.

Through partnering Ministries and agencies, we have adopted a multi-prong approach to suicide prevention based on the following key strategies of building mental resilience; encouraging help seeking and early identification; supporting at-risk groups; and providing crisis support.

We have also invested in resources for mental health as well as put in place monitoring and tracking mechanisms to evaluate the effectiveness of our programmes.

As noted by Ms Ong, there are social and environmental factors that contribute to the individual's intent to self-harm. Therefore, our strategy targets upstream protective factors in addition to strengthening downstream supportive services. Suicide prevention and intervention strategies have been developed in schools, workplaces and in the community. Let me briefly highlight our many efforts under the four key strategies.

As part of suicide prevention strategy, MOE has focused on upstream efforts to build students’ social and emotional skills and resilience through the school curriculum, CCAs and various programmes. The Health Promotion Board (HPB) also offers mental well-being programmes to equip students with the skills to cope with stress, overwhelming emotions, interpersonal conflicts, change and transitions.

At the workplace, HPB conducts mental well-being roadshows and workshops to provide stress management tips and techniques to employees. MOM’s Workplace Safety and Health Institute, in partnership with other agencies have developed an assessment tool, iWorkHealth, as well as a website to help workers identify workplace stressors and resources to improve one’s mental well-being.

Under the National Seniors’ Health Programme, HPB organises healthy ageing workshops that include psycho-social education modules aimed at empowering our seniors aged 50 years and above with the knowledge and skills to manage their mental well-being.

Early identification and encouraging help seeking are vital for suicide prevention. Hence, we have invested in raising mental health literacy through training and education programmes. Beyond SOPs, school teachers are trained to identify students experiencing distress, provide timely support and refer students in distress to school counsellors or mental health professionals for further interventions. Peer support structures are also being established in schools and Institutes of Higher Learning (IHLs) by HPB as well as MOE.

The Community Health Assessment Team (CHAT) offers easy access to mental health resources and help via different avenues for young persons between 16 and 30 years old. Young persons may either visit the CHAT hub, log onto CHAT’s online portal for its WebCHAT service or call CHAT’s hotline.

Samaritans of Singapore (SOS) conducts programmes on how to identify suicide warning signs and where to seek help.

The Agency of Integrated Care (AIC) has been working with community-based organisations to set up Community Outreach Teams to reach out to seniors with or who may be at risk of dementia or depression.

Anti-stigma efforts play an important role in encouraging persons in distress to seek help early. Hence, in 2018, the National Council of Social Service (NCSS) rolled out a multi-year public education campaign, called "Beyond the Label" to achieve this objective. NCSS also recently launched the Beyond the Label Helpbot, Belle to make access to mental health information and resources to the community easier for the general public.

We recognise that persons who are greatly distressed and attempt to take their own life requires help and the criminal justice system may not be the best option. As of 1 January 2020, attempted suicide is no longer a crime in Singapore. However, the Government will continue to track reports of such cases. Additionally, public hospitals are working on tracking attempted suicide cases that they attend to.

There are a range of services in place to support at-risk groups of all ages in our community. For instance, we have trained Silver Generation Ambassadors to identify seniors who live alone, and to proactively offer them befriending services, identify and escalate cases with mental health needs.

We also have services in place to support persons in distress who require assistance such as Institute of Mental Health (IMH)’s 24-hour mental health helpline and the SOS' hotline which is funded by NCSS.

I agree with Ms Anthea Ong that every life matters, and we will continue to strengthen our efforts. During this year’s COS, MOE shared that they will feature mental health education in the revised Character and Citizenship Education (CCE) and MOH will also be setting up an Integrated Youth Service (IYS) in Woodlands this year.

MOM has also announced their intention to work with tripartite partners to develop a Tripartite Advisory on Mental Well-being. In addition, the Tripartite Alliance for Fair and Progressive Employment Practices (TAFEP) has recently clarified that companies should not ask for declaration of applicants’ mental health conditions unless there is a job-related requirement.

We have established platforms for a coordinated interagency approach to suicide prevention. For example, the Inter-Agency Research Workgroup for Youth Suicides, brings together agencies to study the issues surrounding youth suicides and to facilitate deeper collaboration between the various agencies. The workgroup will be sharing their recommendations, for agencies to follow up later this year.

Since February this year, more than 800 people from different walks of life responded to Minister Desmond Lee’s open call and will have an opportunity to be part of the Youth Mental Well-being network to be established. This Network brings people together to identify opportunities and gaps to work on, to improve youth mental well-being.

There is no easy solution to suicide prevention as the causes are complex and multifaceted. Even as we undertake a whole-of-Government review to enhance our efforts, a whole-of-society approach is necessary to build mental resilience in order to prevent suicide in Singapore.

Mr Deputy Speaker, even as we celebrate life, we all know too well that it can sometimes be stressful and challenging. COVID-19 for instance poses yet another huge test for all of us, not least in mental resilience. Beyond the Government’s resources and support as well as the many community programmes and efforts, I urge my fellow Singaporeans to stand together, look out for each other, develop strong empathy and reach out your hand to others to uplift them.

Only together, can we ensure each other's mental well-being, especially in such unprecedented times.

On this note, let me conclude by thanking the Member for her selfless efforts to promote mental well-being and prevent suicides. Let me assure her and all Members of this House that the Government, too, will not let up our efforts on this front. [Applause.]

*Question put, and agreed to.*

*Resolved, "That Parliament do now adjourn."*

Adjourned accordingly at 7.13 pm.