Dr.Raphael Ogbolu is a Consultant Psychiatrist with the Lagos University Teaching Hospital (LUTH), Idi – Araba in Lagos. He is also the Coordinator, Suicide Research and Prevention Initiative (SURPIN). In this interview with our Correspondent CHINWE MADUAGWU, he said young people between the ages of 20 and 49 are more at risk of committing suicide. Explaining the implications, he said “if our main workforce is seriously contemplating ending their own lives, then the overall long term productivity of the country becomes a problem.”
Dr. Ogbolu also expressed worry over the high rate of substances abuse among Primary and Secondary School children, saying this is the reason Nigeria has become a Destination and Source for drugs, unlike in the past when it was a transit route.
TNE: What is the Suicide Research and Prevention Initiative (SURPIN) about?
It is an initiative that has been in the pipeline in the hospital for over three years the aim of which was to contribute towards the fight to reduce suicide. Eventually, we felt we needed to take action this year when suicide seemed to be gaining a lot of spotlight. But it’s something that has been in the pipeline over the past three years based on the suicide-related cases we have been seeing in the hospital.
SURPIN is mainly focusing on research because we don’t have data, and to act as a suicide prevention plan because we don’t have a concerted national plan.
TNE: Would you say that suicide is such an issue that really needs a ‘special’ body to focus on it?
Yes, it is an issue because every life should be valued. No life should just be lost for something as avoidable as suicide. For that reason, it’s definitely something that needs more attention.
But without having a definite plan, without the responsibility falling on anyone’s shoulders, we probably won’t be able to address the issue. That’s why the hospital decided to take the step for us to move forward.
TNE: Beyond research, do you do any other thing?
Oh yes! First, the aim is to provide support – crisis intervention for those who are at risk of attempting suicide. The angles are research and prevention. The research component is to collect data so that we even know how big a problem it is in Nigeria because we don’t have reliable statistics on suicide. For you to map out a plan and know how effective your plan is, you have to know where you are coming from; that’s why the research component is very important and also for policy formulation.
The prevention component is targeted at three main groups – those who are at risk of attempting suicide, of which a large chunk are people with clinical depression and those who have substance abuse. Some people have said that about 90% of people who committed suicide had a depressive disorder. It means that if we can address depression effectively, we will go a long way in addressing suicide. A number of them also have substance abuse disorder (addiction). If we focus on these two, we will go a long way in preventing suicide.
The second group are those who have attempted suicide who may be brought to the hospital. After somebody has made a suicide attempt but doesn’t die, that person has to adjust back to life, we, therefore, try to provide support for them.
The third group are often the neglected group; that is the family of the person who has attempted suicide or those who are bereaved. This may also include co – workers and very close friends of the person. These people are often neglected and they themselves are going through a lot of problems having to adjust with the stigma of a family member who has just committed suicide. Some of them may go into depression themselves.
For the first two groups, we have suicide hotlines (0908 021 7555, 0903 440 0009, 0811 190 9909,0701 381 1143). If someone is on the verge, going through depression or seriously contemplating suicide, such person(s) can call the lines and we offer free counselling services. We try to guide them to go and see a therapist.
We are also involved in health education and advocacy because you need to educate the public. But it starts with research to be able to collect data so we know what to put forward to policy makers.
TNE: If somebody attempts suicide once and fails, is there a possibility of such a person attempting it a second time?
The greatest likelihood of somebody dying by suicide is a previous attempt.. Therefore, once you have somebody who has previously attempted suicide, they are at the highest risk of eventually succeeding. You have to pay particular attention to them.
TNE: You said your hotlines are for those contemplating suicide. Do you think that somebody planning to commit suicide will want to reach out to another person to stop him?
Yes, this is because a number of people who committed suicide had mentioned it to somebody. The problem is that they may wave it off. They would have said things like ‘this life, honestly, I’m thinking it should just end’ and we just wave it aside. The person saying that is because they are ambivalent – should I, should I not?’ Most people who have survived an attempt whom we have interacted with have told us they were torn between two minds and that’s what we are hoping to capitalise on. That person who is going through depression sometimes just wants to talk to somebody. When there is nobody to talk to, they just end it all. We have had people who called in at that point..
TNE: So, suicide is not an impulsive act?
We have people who have died by suicide, which was apparently impulsive especially those as a result of substance abuse. It can be impulsive but even then their succeeding will depend on the method they use. Even with those who are impulsive, there are still some ambivalence. If provided with an opportunity to think it through they won’t do it. Some people are impulsive and they take action, but if they survive, you find out that if somebody had intervened at the time, they wouldn’t have done it.
Suicide means that you intended to kill yourself. But there are some people who harm themselves but not with the intention of killing themselves. We call that self harm. Unfortunately, there is a thin line between self harm and suicide. We have had cases where people committed self harm without the intention of dying but they ended up dying and because it is a deliberate action on their part a lot of times it is grouped as suicide.
TNE: Who is SURPIN partnering with to ensure your message gets to the intended audience?
We have identified Non-Governmental Organizations (NGOs) who are into mental health and we are working with them. We have also identified the religious leaders as one of the most important gatekeepers and stakeholders. They will reach so many people. We have organised workshops on medical – religious collaboration where we have been able to train a number of religious leaders both Christians and Moslems on how to identity at least depression; so that when they identity depression, they provide their religious counseling but guide them to receive orthodox treatment.
TNE: There is so much talk about depression. What exactly is depression?
Depression is a medical disorder, which affects the mood. It is one of the mental health disorders, but this one is primarily a mood disorder. There are certain chemicals called neurotransmitters in the brain when the levels of these neurotransmitters drop, the symptoms of depression manifest. That’s why we say it is a medical condition because we know there is a cause. It is not a spiritual thing. Once that happens, the mood drops, the person becomes sad and with the mood dropping the person loses interest in the things he used to enjoy; the person feels a loss of energy, has problems with sleep, among other symptoms. Some of the things that can cause the neurotransmitters to drop include the life stressors that the person has faced. It may be loss of a loved one, unemployment, financial problems, chronic medical condition etc. Also some people may be genetically predisposed, which means they may have inherited the vulnerability along their generation, when life stressors now act on that person, it brings out the clinical depression.
However, having a genetic predisposition does not mean definitely you’ll have depression. Stressors have to act on the vulnerability. But it also means such a person should be more careful in dealing with life stressors.
TNE: Is it possible to be ‘more careful’ in dealing with life stressors?
Yes it is. Those who talk about stress management will tell you and they are right, that most of the things we perceive as stressors are things that if properly analyzed can be grouped into the avoidable and non-avoidable. It’s just that we haven’t looked deeply. Some of the things that stress us, if properly analyzed can be modified or have their effects on us reduced or be totally avoided. Therefore, we advice people to identify their stressors, avoid the ones they can and those they can’t avoid, find ways to copy with them or get around them.
TNE: Can we say then that depression is preventable if one is not genetically predisposed?
Even if you are genetically predisposed, it is preventable. If you manage your life stressors and are able also to manage your life style, you can prevent it. For instance, a number of people who get addicted to substances may eventually get depressed. So, it’s the addiction that makes them depressed; if a person then avoids it, he won’t be depressed. Again, some people who get addicted to substances – alcohol, cocaine etc, eventually get to the point where they are struggling to stop and if they can’t, they feel useless and become depressed.
If people take steps to avoid certain conditions including chronic medical conditions that predispose one to depression, then they will avoid depression.
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TNE: You said substance abuse may lead to depression; is it not possible that depression could lead to substances abuse?
It can go both ways. The same things with the relationship with chronic medical conditions. Somebody who has depression can be at risk of developing diabetes, hypertension and others. Many people who are depressed fall back on alcohol just to get rid of life’ s stress but before they know it, they have added another problem.
TNE: Substance abuse seems to have gained ground especially among secondary school children. You hear of them mixing codeine with their mineral drinks, taking palm wine and other alcohol to school. How did we get to this point?
The example of mixing codeine with drinks is very mild. We have seen what is of grave concern to us and it’s unfortunate that nobody is paying attention to it. It has snuck up on us and it is going to really devastate this country.
We are seeing junior secondary students who are abusing cocaine. Even primary school pupils are abusing substances. It is bad and it’s going to get worse.
In decades past, Nigeria used to be a transit route for drugs, not a destination. Now, it has become a destination and it is also becoming a source.
Again, because of the war against opium in the U.S a lot of wealthy people are withdrawing their children from there and bringing them here. These people have not received treatment, they have not changed their ways and we are putting them into our system. Also, we have people who are living off these drugs largely, making a fortune out of it.
For instance, there are people who go to the universities especially the private ones, they identify the socialites and offer them huge amount of money, with cars attached, to be their agents in the school. For the person who is not from a disciplined home, who has not built up good morals or somebody coming from a family struggling to send them to school, that’s a very huge incentive. Many are doing that; building mansions all over Lagos and beyond from using students to polute other students.
Some who market cough syrups load them in their cars, go to schools and sell them at double the price to students. They make their money and rise in their companies not minding the damage to the young ones.
To the question, how did we get here; it’s because we have lost our morals. It also has to do with a lack of consequences. Any society where there is a lack of consequences, people get away with anything. Unfortunately too, the institutions that used to help in the past – Churches and Mosques, seem to have failed too. These days we market money. All that matters is how much you have not how you made it. Unfortunately again, the religious institutions took over the role of building morals when the family couldn’t handle it due to the pressure of modern living where the mother has to work unlike in the past when she stayed at home and watched over the children. Now, everybody is working, even the children themselves. Many children are funding themselves through school. Some even feed their parents while in the university. How can a parent rein in such child? Whereas if we had quality free education funded by government, the child will not have to fund himself/ herself through school and the parents will have value and control over the children. It is just a whole basket of things gone wrong.
TNE: In all of these – substance abuse and suicide – does SURPIN partner with the police in finding solutions?
With suicide we do. During the World Health Day, the State Commander of the Rapid Response Squad was one of the speakers at an event we organized. We have been able to come to agreement not to neglect the medical aspect of attempted suicide just because it is a crime to attempt suicide. With substance abuse it’s a bit different. Some of our patients say the police abuse the substances with them. To have a proper disciplined police, the officers have to be taken care of such that when someone offers bribe they can reject it because they know their salaries can meet the needs of their families. You can’t expect somebody who is hungry to say no to bribe. The police have to be taken care of if they are to be effective in fighting substance abuse.
TNE: Doesn’t the fact that attempted suicide is a criminal offence militate against what your group is trying to do?
That’s why information dissemination is important. Not every one knows that it is a crime to attempt suicide so some of those attempting don’t know they are committing a crime, therefore, they may call. That’s also why we need to decriminalize it so that those who know will be encouraged to call.
However, oftentimes the person who calls after an attempt is not the person who attempted but people around them. We still get calls.
TNE: From the cases you have dealt with, what category of people would you say are more prone to attempting suicide?
Going with the preliminary data we have from the Lagos University Teaching Hospital, it has largely been the young, between 20 and 49 years of age and slightly more males than females. The reasons they give are the same things everybody else goes through. The fact that we have more young people wanting to end their lives should be a concern for the government. If our main work force is seriously contemplating ending their own lives, then the overall long term productive productivity of the country becomes a problem and that’s why the issue of suicide should not be a concern for psychiatrists only but to public health physicians. For this reason, we are working with the Institute of Public Health in Ile – Ife in order to reach as many people as possible.
TNE: You said life stressors contribute a lot to depression and suicide. What then is stressing the young ones to make them want to end their lives?
Remember we said earlier that a number of them are now breadwinners in their families and it is not a small number. However, it’s not always about finances. Take for instance, the case of the UNILAG student; she was embarrassed by her roommates. Recently, we’ ve had a number who attempted suicide because their grades were poor. Whilst the adults are thinking about making money and taking care of their families, at their level, what matters is being accepted by their peers, doing well in school etc. If anything goes wrong in those spheres, it’s like their world has come to an end.
TNE: You once said that a suicide death occurs every 40 seconds around the world. How did you arrive at this statistics?
Really, the information we are trying to pass across is to create an awareness on the enormity of suicide on the global level. Since we say that about 800,000 to one million people die annually from suicide worldwide, simply divided, that figure by the number of days to hours, to minutes that’s how we got the 40 seconds. We are not saying that literally somebody dies every 40 seconds.
TNE: How can we identify somebody who is depressed or is going into depression and someone who is suicidal?
The first sign you will observe in someone who is depressed is mood change. In almost all cases of depression, there would be mood drop, sadness, extreme unhappiness and oftentimes these will show in the person’s attitude and demeanor and you can usually see it on their face.
If you see somebody who is usually cheerful, bright and smiley suddenly looking as though the whole world is on his or her shoulders, that’s the first sign.
When a person loses interest in the things that used to interest them, that’s another pointer. Some of them will keep complaining of being tired, no energy, changes in appetite; usually less but sometimes it could be more. People with depression could over-eat but typically they present with loss of appetite. The same thing happens with sleep; sleeplessness sets in though there are some who sleep excessively, they can’t get out of bed and it’s most likely tied to the feeling of ‘I don’t want to do anything,’ the person doesn’t want to face the day.
Other signs include lack of concentration, feeling of undue quilt – something that happened years back, the person will out of the blues recall it and start expressing feelings of guilt. Some may appear as though they have memory issues but it’s not a memory problem but rather because they cannot concentrate. The lack of concentration now makes it look as if the person is forgetful. So ‘forgetfulness’ can also be a sign.
For suicide, you’ll first see the signs of depression but the person begins to express hopelessness. For instance, somebody who has been looking for a job, you’ve been encouraging him and suddenly he stops making the effort, stops applying and then he begins to say things like ‘what’s this life all about?’ The person is losing hope. Hopelessness is the strongest predictor of suicide. Once it is present as a part of depression, the next thing usually is thought of suicide. The person would begin making remarks alluding that life is worthless. Such comments are warning signs that the person is becoming suicidal.
Some will go about settling quarrels and debts because they are preparing.. Some become more morbid, some will go to the extent of procuring what they will use to kill themselves and some will visit suicide websites – sites that tell people how to kill themselves step by step. That’s why it’s important for parents to check their children’s browsing history.
Again, somebody you know going through serious challenges suddenly becomes exuberant and happy and it’s not like his or her situation has changed – the problems are still there, but suddenly the person is happy, it’s a sign to watch out.
TNE: Could it not be that the person has found Jesus?
Finding Jesus is relative in the sense that it could be the person found Jesus and has decided to go and meet him. Suddenly, in their minds, they are like ‘I’ve found the solution and my worries/problems will soon be over.’ The sudden happiness is because they are preparing, they’ve sorted out all they need to sort and they are happy. Those are the things to watch out for.
TNE: We see or hear people complain about feeling unwell, yet when they visit the hospital nothing is found to be wrong with them still they complain of I’ll health. Is that a pointer to depression or something else?
There are a number of physical complaints that people can have that are really not physical conditions but psychiatric conditions, not just depression. Somebody who suddenly becomes paralyzed and they have done all tests and nothing is wrong, sometimes the person may have what is called conversion disorder and it’s a psychiatric condition. It’s not so common but we see it and it happens because there are unresolved psychology problems that manifest in that way because the person is unable to consciously deal with it.
It is believed that Africans cannot conceptualize depression as a word and so most African languages don’t have a word equivalent to depression. When Africans are depressed, because they can’t verbalize it, it manifests as physical symptoms; they complain about something crawling all over their body, internal heat etc. When we evaluate such complaints, we find it’s depression.
TNE: Is depression treatable?
It is quite treatable. Not just treatable, but effectively treatable. For more than 50 years we’ve had effective treatment for depression. Depression is a chronic condition, which means it can last for a long time. So even with effective treatment, you may still have to manage it and the management may or may not include medication in the long term. Treatment may also involve psychotherapy. Depression may also recur if it is not managed well especially when someone has a risk factor for it.
TNE: Can one snap out of depression without treatment?
It is known that depression can have a natural life circle of six and nine months where without treatment it may fizzle out. Without treatment those neurotransmitters will rise but the issue is that even though we know that, we can’t predict what will happen so why let it run its natural course when you can treat it and not let the person go through the punishment.