SHORT COMMUNICATION Escalation of Suicide Amidst The COVID-19 Pandemic in Malaysia: Progressive Strategies for Prevention

Charles Ganaprakasam1, Syeda Humayra2, Kalaivani Ganasegaran3, Philominah Arkappan4 1Department of Educational Psychology and Counselling, University of Malaya, 50603 Kuala Lumpur, Malaysia 2Faculty of Medicine, University of Cyberjaya, Persiaran Bestari, Cyber 11, 63000 Cyberjaya, Selangor, Malaysia 3Department of Mass Communication, School of Management & Business, Manipal International University, Malaysia 4Accounting Department, School of Management & Business, Manipal International University, Malaysia


Introduction
The COVID-19 global health crisis has inflicted a tremendous amount of mental tribulation, especially in developing nations 1 . Since the COVID-19 outbreak has been declared as a public health crisis, many countries across the South Asian region reported a sharp increase in suicide cases. For instance, suicide cases in Thailand, Singapore, and Nepal have surged tremendously during the outbreak of COVID-19. Thailand health officials revealed that 2,551 suicide cases were reported in the first half of 2020, which is a 22% increment from the same period in 2019 2 . In parallel, Singapore reported 452 suicides in 2020, the nation's highest number of cases since 2012, amid the isolation and psychological distress brought about by the COVID-19 pandemic 3 . Furthermore, in Nepal, the number of suicide cases increased by almost 25% compared with previous years amidst the COVID-19 outbreak, whereby 559 suicide incidents occurred every month 4 .
In Malaysia, there has been a dramatic upsurge in suicide cases since the beginning of the COVID-19 outbreak in January 2020. According to recent statistics by the Royal Malaysian Police Department, a total of 631 suicide cases were recorded in 2020 and 468 cases were reported between January to May 2021 5 . Compared to the year 2019, suicide cases in Malaysia almost doubled on average in all age categories in the 5 months of 2021 that is 94 cases per month compared to 51 cases per month in 2019 5 .
The increased psychological distress and poor mental health status amidst COVID-19 supports the escalating suicide mortality subjectively. Hence, this unexpected pandemic situation demands a comprehensive framework for tackling the massive upsurge of suicide among people from developing countries. In line with that, the aim of this viewpoint is to revisit the efforts implemented by the current Malaysian government and propose several prevention strategies to combat suicide during this global health crisis. i.
Introduction of tele-counselling programmes (Psychosocial Helpline) via associations with humanitarian NGOs, such as Mercy Malaysia. ii.
Mental health related psychosocial support services in hospitals for COVID-19 patients, quarantined individuals, family members of infected persons, and health care or medical personnel. iii.
Utilisation of forums, podcasts, shout-outs, and necessary campaigns to educate people on the essence of maintaining good mental health during the pandemic. iv.
Initiation of the White Flag Campaign to reach out to people with financial and mental health difficulties. v.
University-based programmes and online webinars to provide students with psychological support. For instance, the Counselling Department of the University Utara Malaysia (UUM) conducted various psychosocial programmes and counselling sessions to support the students' mental health status.

Who is the vulnerable population or those at risk of suicide?
Based on the rising number of suicidal cases, it can be interpreted that COVID-19 could result in a severe mental health crisis among the general public, and more importantly, the vulnerable or at-risk populations. Particularly, children, adolescents and youths, individuals with pre-existing mental health issues, and migrant workers are found to be among the vulnerable population during this health crisis [7][8][9][10] . Identifying the target population is critical towards implementing appropriate prevention or intervention strategies, and ensuring their mental health state.

What progressive measures should be considered?
Suicide prevention is possible through collective efforts of the society, community and individuallevel support management. Hence, it cannot be directed within the health sector aloneaction must be taken by several other institutions including schools, homes, communities and workplaces. In this article, we propose several intervention strategies that can be adopted to minimise the risk of increasing suicide and promote better mental health. i.
Since several studies hypothesise that mental health crises may further escalate during the post COVID-19 era 11 , it puts children and adolescents at a greater risk of experiencing psychological distress 12 . Hence, suicidal and non-suicidal self-injury (NSSI) screening is vital for early identification of symptoms in primary and secondary school settings after the school reopened. Since NSSI has proven to be a critical risk factor for future suicide attempt 13 , so identifying the onset of NSSI among students can be a significant step towards mitigating the suicide cases in near future. ii.
Evidence revealed that students reportedly experienced more psychological distress during this pandemic period 14 , therefore the role of school Guidance and Counselling teachers is vital to provide detailed information on the risk factors, warning signs, coping skills, debunk the myths of suicide, and promote better help-seeking behaviours in both students and parents. iii.
The Ministry of Education should collaborate with school/university staff, local authorities, social activists, educational and mental health organisations to develop special training programmes for teachers' guidance and understanding on trauma-related approaches, and establish empirically proven treatment to overcome the histories of trauma 15 . iv.
As depression is often linked to suicidal ideation, agencies involved in the licensing and training of counsellors should provide comprehensive training and guidelines for the practice of computer-based cognitive behavioural therapy which is an effective treatment for reducing depression and also achievable for people from urban and rural areas 16 . v.
Maximising and encouraging the use of self-healing activities such as yoga 17 , and mindfulness meditation 18 among the target population as an alternative method to maintain the mental health. It can also be implemented in people with pre-existing mental health www.msocialsciences.com issues since Tele-psychiatry services are still under-developed in many developing countries 19 . vi.
The media plays an important role in developing a sense of optimism among the general public during this pandemic 20 . Broadcasting positive recovery stories and promoting mental health literacy through various platforms such as media reports, advertisements, and social networking sites can be initiated as additional efforts to reduce the stigma attached with suicides and mental health issues. vii.
The government and NGOs should proactively engage with migrant workers by selecting representatives of this population to voice their problems during this COVID-19 health crisis and also emphasise the involvement of volunteers with and without mental health expertise from their native speakers to provide better support and awareness from their own community. viii.
Lastly and most importantly, government-based organizations should regularly monitor and update the suicide registry system to track unidentified suicide cases and implement progressive measures. According to the World Health Organisation (WHO), very limited number of countries around the world have good quality records system on suicide 21 . For instance, in Malaysia, the last National Suicide Registry was last updated in 2007. This lack of data accuracy is immensely strenuous when used to identify long-term solutions to mitigate the hidden pandemic of suicide.
Although the number of counselling/psychology private practices have been flourishing to mitigate mental health problems during this COVID-19 outbreak, serious questions arise regarding the effectiveness of the interventions in a multicultural context. Cultural competence, including dimensions of knowledge (e.g., understanding the meaning of culture and its importance to healthcare delivery), attitude (e.g., having respect for variations in cultural norms), and skills (e.g., eliciting patients' explanatory models of illness), are necessary for improving health care preventions 22 .
In the past, the Indian community has shown disproportionately higher suicide rates compared to other ethno cultural groups in Malaysia 23 , which indicates the need of evidence-based research in community setting. Thus suicide risk assessment across the various ethnic groups in Malaysia is recommended for tailoring population-based interventions and providing better mental health support. However, shortage of resources and financial aid from the government to support research and practice concerning suicide intervention and prevention acts as the prime obstacle in developing comprehensive, culturally-sensitive mental health services across the nation. Perhaps, the recent annual federal budget for the year 2021 by the Malaysian government with significant reduction in monetary allocation for mental health services is also a contributing factor 24 . This demonstrates that the inadequacy of financial resources can be perceived as a major hindrance in the development of a comprehensive mental health care plan.
Mental health related research and practice is totally different in high-income countries. No significant rise of suicide cases have been reported in developed countries, such as Canada, New Zealand, Norway, Sweden, Peru, and United States, during this global public health crisis 25 . Although the exact reason is unknown, it might be attributable to the concentrated efforts from the national government that provided comprehensive mental health services, including empirically proven intervention and prevention strategies.
Analysing culturally-responsive prevention and intervention strategies through active research practices is essential to determine what works with whom, by whom, and in what context. There should be a concentrated effort by the government to help move forward by strengthening progressive measures through encouraging credible research and practices. Since Malaysia is rich in cultural diversity, a multicultural, sensitive approach is needed to tackle this serious public health concern. Furthermore, the Ministry of Health should conjointly work with various ongoing missions or organisations for effective, empirical solutions to overcome the escalating suicides during this pandemic.