Sadly, we have recently witnessed various publicly reported cases of suicide in some National Dailies, which has sparked widespread discussions. Some of the expressed views appear to consider suicide as a strange and new development. But is this truly new or are we witnessing an epidemic of suicide deaths? Traditional folklore has it that the legend of Sango, the god of thunder in Yoruba history committed suicide, following a tragic sequence of losses. A similar pattern is described by Chinua Achebe, with reference to Okonkwo in his classic work of fiction, ‘Things Fall Apart’. Thus, the concept of death being a preferable option to shame, humiliation and feelings of hopelessness in the face of adversity is not completely new. It is also very likely that these events have always occurred but were not widely reported.
The World Health Organization (WHO) estimates that 1 million suicide deaths occur every year. This number is staggering, especially when we appreciate that there are several regions of the world – such as Nigeria and other developing countries, which do not have accurate death records and a reporting system. Thus, this WHO figure is undoubtedly a gross underestimate. To put this in perspective, this figure translates into one suicide death, every 40 seconds. And in the time, it has taken for you to read this article up until this point, at least 2 human beings somewhere on this planet, would have intentionally taken his or her own life. The number of attempted suicides annually, is about 20 times the number of completed suicides – estimated at 20 million cases worldwide.
Why would anyone consider ending his or her own life?
Several risk factors predispose to suicide, but what is consistent is that such individuals experience such intense and overwhelming emotional pain that they simply feel that they can no longer cope. The commonest risk factor is depression. This is a mental health disorder, which occurs when certain levels of chemicals in the brain are very low. The chemicals involved, are responsible for improving our mood and making us feel good about ourselves. Thus, when the levels are low, affected individuals feel sad, miserable, hopeless and worthless. They may also feel overwhelmed by the problems (real or imagined) that confront them and therefore, begin to imagine that they have become a burden to their families and loved ones. It is with the background of these types of thoughts, that death becomes an appealing outcome, in the face of such overwhelming problems.
Other risk factors include negative life events such as job or financial losses, death of loved ones, shame and public loss of dignity, loneliness, impulsiveness, and access to means. Males are also at greater risk, as suicide is thrice as common among males as compared to women. Mental illness, chronic physical illness, alcohol or drug abuse, and overwhelming emotional distress may also increase the risk for suicide.
Impact of suicide
It has a devastating impact on surviving family members, friends and colleagues. They often undergo a lot of emotional turmoil, with feelings of guilt, betrayal, regret and feelings of inadequacy – with thoughts such as “if only I had been a more observant/caring/prayerful/dutiful parent, spouse, friend or colleague; perhaps this would not have happened.” Thus, in addition to the grief of mourning their loved ones, they also have to cope with these feelings of regret and inadequacies. Their misery is often worsened by the stigma and shame of being ridiculed as the family member of someone who committed suicide. Moreso, as some people will insinuate that the spouse/friend/family/colleagues must have done something to push them to their wits end, or at best, were not supportive enough. These sorts of insinuations are not helpful at all and should be actively discouraged.
How can we help?
The family and friends of individuals who have completed suicide are going through a lot of emotional stress and require us to show empathy and understanding, as well as provide emotional support to help them come to terms with the tragedy that has befallen them. We should help to ease their pain; and not compound it. If their symptoms of distress do not abate after a few weeks, they may need to see a mental health professional for expert help.
Suicide is a common but tragic occurrence, which negatively affects everyone connected with the affected individual. Several risk factors acting together may increase the chances of suicide occurring. However, it is preventable and in the next session, we shall be focusing on prevention strategies for suicide.
Kunle, was a brilliant, gentle soft-spoken gentleman and 300L Medical Student when he met Tope, a pretty, intelligent 100L Biochemistry student who always had a smile for everyone. He was infatuated with her and she in turn was flattered by his attention. They soon became an item on campus and everyone knew they were almost always together. What a dashing couple, everyone complimented. It looked like a match made in heaven. Then the subtle manipulation and coercion started.
Kunle would want to know where Tope was almost every 5 minutes. The social media and the mobile phone became a tool of incessant monitoring and soon the relationship started feeling like a prison to Tope. He would want to know why she liked a particular guy’s picture on facebook, where she was at any given time and what she was doing. Who else was there? And on and on it went. She started becoming irritated and told him so. He immediately apologized and pleaded that it was because he now loved her so much that she pre-occupied his thoughts every minute. She relaxed and was somewhat flattered at the attention he was lavishing on her.
Months down the line, he started telling her to stop seeing such and such friends, because he did not approve of them. He started criticising what and how she dressed. Her friends started grumbling and told her he was becoming too possessive, but she shrugged it off. He visited her in the hostel unannounced and met her talking to a male classmate in front of the hostel. He flew into a mad and jealous rage and wanted to fight her male classmate – but he recused himself and left. He then went on to slap Tope for cheating on him. She was shocked to her marrow and she called off the relationship at that point. But he came back every single day to wait at her hostel entrance and plead with her all the way to her department.
He did not mind that her friends insulted him and made fun of him. After a week of persistent pressure, Tope relented and accepted him back. They later got married and had children. But 7 years after their marriage, Tope’s friends read in the newspapers that Kunle had beaten Tope to death over a domestic disagreement. The friends further learnt that Kunle’s controlling behaviour became much worse after marriage, and was associated with frequent beatings. But as she was already pregnant, her family had counselled her to be patient. And then it became a recurring theme, especially after he had successfully alienated her from her previous support network.
Why do people tolerate intimate partner violence?
Several reasons, but as illustrated above, they usually don’t start the relationship with a slap or violent actions. It often starts with carefully cultivated love and attention; which then progresses to possessive behaviour. And then he becomes controlling and wants to assert his authority on every issue. When she steps out of line or goes against him, he resorts to violence and aggression to ‘punish’ her and assert his power or dominance over her. So, it is usually a slow process over time, and the lady would have become emotionally invested…or married. Truth be told, it is very difficult to break off long standing ties and relationships.
What are the facts?
A woman is assaulted or beaten every nine seconds, and 20 women are abused by an intimate partner every minute. In England alone, a woman is killed every 3 days as a result of domestic violence. Intimate partner violence, while often perpetrated by men against women, can and do also occur from women against men. But women are more often than not, on the receiving end of abusive relationships.
Intimate partner violence is sustained by a culture of blame and shame
It is common to hear refrains such as: what did you do to provoke him? Did you abuse him? Oh, you pushed him first? So, what were you expecting? He is a man, he has to react and so on. These are all ways by which we blame the victim and reinforce/reward the perpetrator. We need to emphasize that NO PROVOCATION can ever justify domestic violence. We don’t go around the streets fighting and beating everyone who offends us, do we? No level of violence is ever acceptable or ‘normal’ in any relationship. A person who resorts to violence once, is likely to repeat it – unless he/she receives therapy.
Mrs Bolanle Tunde: My Dear, will you be going with me for antenatal clinic today?
Mr Tunde: I am so sorry Darling, I can’t make it as I have an emergency to deal with in the office. Can I plead with your Mummy to go with you instead?
Mrs Bolanle Tunde: Ok, no worries. I will go with Mummy then.
Two hours later, at the clinic.
Doctor: Mrs Bolanle Tunde, your pregnancy is almost term now and the last ultrasound scan you did last week, revealed that the baby is still lying horizontally in your womb, instead of coming down with the head. So, the way forward is that once you complete 9 months (36 weeks), we will not wait for you to go into labour, as the chances of the baby coming out via a normal delivery are very slim. We will arrange to perform a caesarean section (C/S) so we can safely bring out the baby without any complications.
Bolanle’s Mummy: Erh, Doctor, did you just say operation for her to give birth?
Doctor: Yes Ma, the reason is because…….
Bolanle’s Mummy: Cuts in rudely: “Doctor, there is no need. In my family, we always give birth normally without operation. I gave birth to her normally and by the special grace of God, she will also give birth normally. My daughter, let’s go.” Gets up and drags Mrs Bolanle Tunde out of the consulting room.
Once outside, she calms down and faces her daughter. “Bolanle, the devil is a liar. I will call my priest now and he will pray for you. There is nothing beyond the power of God. Prayer can overcome any problem. Just relax and trust me. You must give birth naturally”.
Three weeks later, Bolanle falls into labour and promptly heads to a prayer house to allow her deliver naturally. After 24 hours of labour pains, and when she is completely exhausted and on the verge of collapse, they eventually decide to take her to the hospital. The doctors assist Bolanle – as the baby’s shoulder and one arm were already out, and they eventually manage to deliver her of a baby boy. The baby is alive but very weak and has to be taken to the special care baby unit (SCBU). Everybody is relieved at the eventual good outcome. The boy is named Oriyomi. The new Grandmother is proud that her daughter eventually delivered ‘naturally’.
Fast forward to 10 years later. Mrs Bolanle Tunde presents at the clinic with Oriyomi on account of poor academic performance and not being ‘smart’. He is still in Primary 2, as he struggles to recognize the alphabets correctly. He also has difficulty with basic sums and subtractions. The mother complains that he cannot be sent on an errand as he does not understand the value of money. The doctor takes a detailed history and it then becomes clear that Oriyomi did not start walking until the age of 3 years; and he was almost 8 years before he attained meaningful language understanding. Compared to his other siblings, as well as other children of his age, he is also very slow. The parents are worried that something may be wrong with him.
The doctor sends them for an assessment of his Intelligence Quotient (IQ). The results indicate that Oriyomi has a low IQ which has accounted for his very poor academic performance. Thus, in the context of the history and the results, the doctor then counsels Mrs Bolanle Tunde, that her son, Oriyomi, may have suffered some brain damage as a result of the prolonged labour during his delivery. He further explains that this may have explained the slow development (walking at 3 years and speech at 8 years) as well as his not being as smart as other children of his age.
Mrs Bolanle Tunde: Hmm, Doctor. So, what is the solution? Will you prescribe some drugs for him to improve?
Doctor: I am so sorry Ma, but unfortunately, there are no medications for this problem. The brain has no replacement, and once damaged in this manner, drugs can’t help. But what we can do is to try and identify Oriyomi’s strengths and see how we can build upon them. We will need other people to work with him, as well as special teachers too.
Conclusion: Pregnancy, child birth and early life (first 2 years in particular) are crucial time periods for a child’s brain development. It is therefore very important to have regular antenatal care; ensure that delivery is in hospital; or supervised by competent medical personnel. Performing a c/s when necessary should not be stigmatized, to avoid these types of complications. Lastly, seeking quality health care and prayers are not mutually exclusive….they can go together.
Alhaja Fati is 72 years old and a retired accountant who has been progressively exhibiting difficult behaviours. She has recently started accusing her husband (of 45 years standing) of trying to kill her, so he can marry another wife. Sometimes she does not recognize him and wakes up at night screaming that there is a stranger in her bed who wants to harm her. On one occasion, she grabbed the bedside lamp holder and struck him on the head with it. Thus, they currently sleep in different rooms. Sometimes she wants to go for a stroll in the middle of the night and will become irritable and agitated if she is not allowed to do so. She sometimes would go out of the house and subsequently not remember the way back home.
She has also become very forgetful and sometimes has difficulty recognizing her own children or remembering their names. While the memory problems have been relatively easier to bear, the behavioural problems have completely exhausted her husband, who is himself frail, and hypertensive. She sometimes refuses to eat food. The children currently live in faraway Kano, and other cities in Europe and America, while she lives in Lagos. The longstanding housekeeper that they have had for nearly two decades was sent packing, when her husband caught her slapping Alhaja, and threatening to beat her if she did not finish eating her food. The subsequent House-helps have not lasted beyond 3 months before they become fed up of the constant harassments and accusations.
The children have contemplated taking Mama to live with them for some time, so that Daddy can get some respite. But they will have to go to work, and Mama may walk away and get lost in their absence. Long stay homes for the elderly are very few and the standards of care provided is a source of concern. They had tried asking relatives from the village to come and help, such that they will put the person on a salary but they have not secured someone reliable. In the past few weeks, she started defecating while fully clothed, and would not say anything until they start perceiving the foul odour. Thus, Alhaja was taken to a hospital where she was referred to a psychiatrist. They were informed that she had dementia and placed on some medications, but she has refused to use the drugs, so they are back at square one. These problems have been ongoing for about 3 years now and they are all at their wits end at this point.
Dementia occurs when there is a marked and very severe deterioration in brain functions among the elderly. The symptoms are not always exactly the same in different individuals but the most consistent complain is a gradual but progressive worsening of the ability to remember things.
The categories of problems usually experienced may therefore be classified into 3 groups: memory problems or excessive forgetfulness; Behavioural problems such as refusing to eat, defecating inappropriately, or becoming aggressive; and problems with day to day functioning, such as dressing and grooming.
Emotional burden of caregiving for senior citizens with dementia:
The responsibility of caring for senior citizens with dementia is a demanding responsibility that often requires round the clock surveillance. It gradually wears down the patience and goodwill of relatives and caregivers; who may then become resentful, irritable and may eventually tip over into elder abuse. It takes an emotional toll on the caregivers, as they may have to make sacrifices in other aspects of their life – such as work, family and social interactions. There is also the financial responsibility involved to perform tests, take to hospital, employ a housekeeper or nurse, or pay to keep in a nursing home etc.
Those directly responsible for caregiving, need to plan it in such a way that no single person is overwhelmed. Often times when these problems begin to occur, the children are already grown and scattered across different cities or may even be outside the country. And with the breakdown of the extended family system network and increased urbanization, it becomes a very difficult problem to resolve. While nursing homes for the elderly are springing up all over the place, they require strict supervision and monitoring to prevent elder abuse in these homes. Indeed, elder abuse can also occur within their homes.
Behavioural problems may be controlled with medications but even more importantly, it is crucial that they benefit from a comprehensive medical review to check for other health issues which may also be contributing to their poor performance, such as hypertension – causing strokes, or diabetes – causing confusion.
Conclusion: The burden of caring for the elderly in the context of dementia is by no means an easy; it requires everyone to contribute and share the responsibility.
Mrs Ishola is a proud nursing mother of a 4 months old baby girl, who works in a Telecoms Company as an IT specialist. She had the best evaluation scores at the periodic IT expertise examination of her Firm and the top 3 have been selected for an all-expenses paid trip to Silicon Valley for 3 months. She discussed with her husband about turning down the offer because of their baby, but he encouraged her to accept the offer. Her mother also volunteers to take care of the baby in her absence. After her departure, the baby cries inconsolably every day, refuses meals and begins to lose weight. The baby also becomes very sickly with frequent episodes of diarrhea and malaria. After two weeks, Grandma is completely exhausted and does not know what else to do for the baby.
What is obvious here, is that the baby is unhappy and missing her Mummy. We now know that even infants can be miserable when either their needs are not met, or they are deprived of emotional support and comfort. Similarly, young children – including those as young as 4 or 5 years old, can be quite sensitive and aware of what is going on around them. So, for example, if the parents are fighting all the time and there is tension in the home, the child may become very uneasy and unsure of how to react. Such children may find it difficult to verbalize what they are going through – as they are not even be mature enough to think about it properly. However, their emotional safety and feelings may be negatively affected.
What are the possible causes of mental health problems in children?
I want us to realize before we go even further, that everything we do as human beings: our thinking, emotions, behavior, our intelligence – all these are functions that are performed by our ‘headquarters’, our brain.
Mental or emotional problems affecting children and young persons can occur as a result of factors affecting their brain. These factors may be:
Biological problems such as injury to the brain during pregnancy or when the labour is delayed for a very long time, or the child suffers from infections which affect the brain etc.
ii).Psychosocial problems, such as when the child is experiencing physical, emotional, or sexual abuse; when the parents’ divorce or one of them dies etc. Living in deprived circumstances, exposure to violence, and experience of bullying amongst others, may all affect the normal development of the young brain.
How do children show that they have mental or emotional problems?
This depends on the nature of mental health problems that the child is experiencing. The child may not grow or achieve milestones like the other children of the same age, for example, may not walk, or talk at the expected time. He may also not be as intelligent as expected, when compared to other children of the same age. The child may have difficulties with language and communication skills, and may also suffer from epilepsy. Socially awkward or inappropriate behaviours may also be present.
All of these symptoms are more than likely when there has been an injury to the growing brain. Other common presentations, especially when the child is reacting to a pycho-social risk factor, may include change in mood, becoming withdrawn or irritable, becoming quarrelsome in school, bedwetting – for a child who had earlier stopped bedwetting etc. Younger children may become clingy, cry excessively, or refuse to go to school. The manner of presentation also depends on the age of the child.
How common are mental health problems in children? These problems are very common in children, with Nigerian studies showing that 1 in every 5 Nigerian children, may be suffering from a mental health problem. The commonest conditions are anxiety, depression and attention deficit hyperactivity disorder (ADHD). Other important types of mental health problems in children include Autism, Learning Disability and epilepsy. Furthermore, nearly half (50%) of all adult mental disorders would have started by the age of 14 years. Even more importantly, Nigeria’s population is a youthful one, and we need to watch out for their mental and emotional wellbeing.
What should we do if we suspect that our child may be having some problems? We should ensure that the child is seen and evaluated by a qualified mental health professional, without any delay. This is very important because early detection and intervention for these problems, can significantly improve the ultimate outcome.
In conclusion, children and adolescents can, and do suffer from mental and emotional health problems. Early detection and intervention are crucial in order to improve and build upon the child’s strengths.