East Asian Arch Psychiatry 2023;33:114-9 | https://doi.org/10.12809/eaap2342

ORIGINAL ARTICLE

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Mohd Nur Shakir Bin Kamaruddin, Department of Psychiatry and Mental Health, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor Branch, Selangor, Malaysia
Nurul Azreen Binti Hashim, Department of Psychiatry and Mental Health, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor Branch, Selangor, Malaysia
Salina Binti Mohamed, Department of Psychiatry and Mental Health, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor Branch, Selangor, Malaysia
Zahir Izuan Bin Azhari, Department of Psychiatry and Mental Health, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor Branch, Selangor, Malaysia

Address for correspondence: Dr Nurul Azreen Binti Hashim, Department of Psychiatry and Mental Health, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor Branch, 47000 Jalan Hospital, Sungai Buloh, Selangor, Malaysia. Email: azreen@uitm.edu.my

Submitted: 14 August 2023; Accepted: 16 November 2023

Introduction

Suicidal behaviour can affect individuals of all ages, sexes, and backgrounds. According to the World Health Organization, approximately 703 000 people worldwide die by suicide every year, and the suicide mortality rate in 2019 was 9.0 per 100 000 people.¹ Suicide was the fourth-highest cause of death among young people aged 15 to 29 years.² However, many cases are unreported owing to misclassification (eg, recorded as accidents) or underreported owing to their sensitive nature.

Many individuals attempt suicide or have suicidal ideation. Suicidal ideation and behaviours are a unidimensional construct, with passive ideation, active intent, and behaviour existing along a continuum. Young adults are at the highest risk of suicidal behaviour.^3,4 The risk factors for suicidal behaviour are female sex, younger age, fewer years of formal education, prior mental disorder, earlier age of onset of suicidal behaviour, physical health, illicit substance dependence, alcohol dependence, personality disorder, loneliness, hopelessness, and adverse life events.^3,5 Protective factors for suicidal behaviour include strong religious affiliation and orthodoxy, family cohesion and support, and good coping skills.^3,5

Attitudes towards suicide also exist along a continuum, ranging from a more accepting and permissive attitude that understands suicide under some circumstances without approving of it to condemnation of suicide under any circumstances.⁶ Suicide is considered a sin, and attitudes towards it are negative. However, attitudes towards suicide among young people are more agreeable nowadays.⁷ Favourable or permissive attitudes towards suicide are positively associated with suicidal behaviour, whereas unfavourable or rejecting attitudes towards suicide are negatively associated with suicidal behaviour.^8-10

The prevalence of psychological distress (depression, anxiety, and stress) is high among undergraduate students,^11,12 and psychological distress is positively associated with suicidal behaviour.^13-15 In Malaysia, psychological distress and permissive attitudes towards suicide have been found to affect suicidal behaviour.¹⁶ In West Malaysia, religious affiliation, psychological distress, family support, and a permissive attitude towards suicide affect suicidal behaviour.^8,17-19 This study aimed to determine the associations between suicidal behaviour, psychological distress, and attitudes towards suicide, as well as the prevalence of suicidal behaviour among university students in East Malaysia.

Methods

This cross-sectional study was conducted among students attending a public university in East Malaysia between November and December 2022. Based on a reported 7% prevalence of suicide in a similar population²⁰ and a potential non-response rate of 20%, a sample size of 521 was required to achieve 95% confidence level and 5% margin of error. The inclusion criteria were being undergraduate students at the university, age ≥18 years, and able to communicate in Bahasa Melayu. Using convenience sampling, every fourth student was randomly selected to ask to complete the Malay versions of the Suicidal Behaviour Questionnaire-Revised (SBQ-R), the Attitudes Towards Suicide Scale, and the Depression Anxiety Stress Scale - 21 items.

The SBQ-R consists of four items that measure dimensions of suicidality to screen for suicide risk. The items include lifetime suicidal ideation and/or suicide attempts, the frequency of suicidal ideation over the past 12 months, threats of suicide, and the likelihood of future suicidal behaviour. Suicidal behaviour is dichotomised as high or low suicidal behaviour; the cut-off score for high suicidal behaviour is ≥7. The SBQ-R has high internal consistency (Cronbach’s alpha = 0.76-0.88) and good concurrent validity (r = 0.61-0.93).⁸ The Malay version has a Cronbach’s alpha of 0.65 to 0.80.^8,20

The Depression Anxiety Stress Scale - 21 items measures psychological distress in terms of depression, anxiety, and stress. It has high reliability and validity, with a Cronbach’s alpha of 0.74 to 0.93.^21,22 The Malay version has a Cronbach’s alpha of 0.84 to 0.86.²³

The Attitudes Towards Suicide Scale comprises 37 items in 10 subscales; each item is measured in a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate more positive attitudes towards suicide.⁶ The Cronbach’s alpha of the subscales ranges from 0.35 to 0.84.⁶ The Malay version has a Cronbach’s alpha of 0.72 overall and 0.57 to 0.76 for the subscales; the four factors with the highest loading were ‘ability to understand and accept suicide’, ‘believability of suicidal threats’, ‘judgement and ability to help’, and ‘acceptability of assisted suicide’.²⁴

Data were analysed using SPSS (Windows version 23.0; IBM Corp, Armonk [NY], USA). Factors associated with suicidal behaviour were determined using the Pearson Chi-squared test. Independent factors associated with suicidal behaviour were determined using both simple and multiple logistic regression.

Results

Of 521 students included, 197 women and 290 men (mean age, 19.13 years) completed the questionnaires, giving a response rate of 93.4% (Table 1). The prevalence of high- risk suicidal behaviour (SBQ-R score ≥7) was 23.8%. The prevalence was highest among those of the Kadazan-Dusun- Murut ethnicity (29.1%), followed by Malay (25.8%), other ethnicities (22.3%), and Bajau (11.4%); it was also higher in Christians than in Muslims (27.8% vs 22.2%), in females than males (33.0% vs 17.6%), and in those of the middle 40% income group than in those of the bottom 40% income group or top 20% income group (24.3% vs 23.9% vs 20.0%).

Psychological distress was extremely severe in 17 (3.5%) participants, moderate to severe in 115 (23.6%) participants, and normal to mild in 355 (72.9%) participants. Anxiety was extremely severe in 116 (23.8%) participants, moderate to severe in 143 (29.3%) participants, and normal to mild in 228 (46.7%) participants. Depression was extremely severe in 32 (6.6%) participants, moderate to severe in 133 (27.3%) participants, and normal to mild in 322 (66.1%) participants.

High-risk suicidal behaviour was positively associated with favourable attitudes towards suicide (‘ability to understand and accept suicide’ and ‘acceptability of assisted suicide’) and psychological distress (stress, anxiety, and depression) and negatively associated with unfavourable attitudes towards suicide (‘judgement and ability to help’) [all p < 0.01, Table 2].

In simple logistic regression analysis, high-risk suicidal behaviour was independently associated with female sex (odds ratio [OR] = 2.31, 95% confidence interval [CI] = 1.51-3.52, p < 0.001), ‘ability to understand and accept suicide’ (OR = 1.27, 95% CI = 1.20-1.33, p < 0.001), ‘judgement and ability to help’ (OR = 0.80, 95% CI = 0.73-0.87, p < 0.001), ‘acceptability of assisted suicide’ (OR = 1.24, 95% CI = 1.12-1.37, p < 0.001), stress (OR = 1.21, 95% CI = 1.16-1.25, p < 0.001), anxiety (OR = 1.16, 95% CI = 1.13-1.20, p < 0.001), and depression (OR = 1.18, 95% CI = 1.14-1.22, p < 0.001) [Table 3].

In multiple logistic regression analysis, high-risk suicidal behaviour was independently associated with stress (adjusted OR = 2.84, 95% CI = 1.49-5.43, p = 0.002), depression (adjusted OR = 1.92, 95% CI = 1.09-3.38, p = 0.03), anxiety (adjusted OR = 1.57, 95% CI = 1.16-3.03, p = 0.01), and permissive attitude towards suicide (‘ability to understand and accept suicide’) [adjusted OR = 1.13, 95% CI = 1.05-1.22, p = 0.04] (Table 3).

Discussion

In the present study, 23.8% of students in a public university in East Malaysia reported high-risk suicidal behaviour, which is higher than the 7% reported in a study among college students in West Malaysia, which has a higher level of urbanicity.²⁰ Rural areas have a higher prevalence of suicidal behaviour, compared with urban areas.^25,26 Furthermore, 60.2% of participants were from low- income households, which is also associated with suicidal behaviour.²⁷ The present study was conducted during the COVID-19 pandemic; since that time the prevalence of suicidal ideation has increased.²⁸ Although 23.8% of participants reported high-risk suicidal behaviour, only 2.9% reported being diagnosed with a psychiatric illness. This may reflect a gap in psychiatry services or poor mental health literacy among undergraduate students in East Malaysia.²⁹

Female participants had a higher prevalence of suicidal behaviour, consistent with findings in other studies.^3,4,20,30 Psychological distress is more prevalent among females^12,14,31 and is positively associated with suicidal behaviour.^13-15 Possible reasons for this include hormonal changes and differing psychosocial stressors in females.³²

Suicidal behaviour was found to be positively associated with favourable or permissive attitudes towards suicide and psychological distress and negatively associated with unfavourable or rejecting attitudes towards suicide, consistent with findings in other studies.^{8-10,16,33,34} Stress, anxiety, depression, and a permissive attitude towards suicide (‘ability to understand and accept suicide’) were predictors of suicidality, consistent with findings in other studies.^13,15,31

Religion has been reported as a predictor of suicidality,³⁵ but the present study did not find any such association. One possible explanation is that religious devotion or degree of religiosity is the actual variance for suicidal behaviour, rather than the type of religion. Religiosity refers to an individual’s appraisal of the meaning of life through religious beliefs, values, and practices. Strong religious affiliation is associated with a more rejecting attitude towards suicide and a lower prevalence of suicidal behaviour.^8,19,36,37 People from similar religions differ significantly in their attitudes towards suicide and suicidal behaviour based on their levels of religiosity.³⁸ Among Muslim countries, those with higher degrees of religiosity are less accepting of suicide and have lower suicidality.³⁹ Strong religious devotion is a protective factor against suicidal behaviour.^3,5

This study has several limitations. The cross- sectional design cannot infer causal relationships. Self-report questionnaires are prone to bias, and participants tend to underreport symptoms. For example, only 1% of participants reported drinking alcohol, but the Malaysia National Health and Morbidity Survey 2019 shows a much higher percentage, especially in East Malaysia.⁴⁰ Another example is that 23.8% of participants reported high-risk suicidal behaviour, compared with only 7% in another study; this difference might be due to biases arising from self- report questionnaires. Additionally, mental health disorders were not assessed using DSM-5 or ICD-10 by a trained professional. In our university, 60.2% of students were from low-income households, and there were fewer students of Chinese and Indian ethnicities. Therefore, generalisation of our results to university students in West Malaysia may not be applicable. Future studies should include factors such as academic stress and pressure, social isolation, and family and relationship issues.

Conclusion

The prevalence of suicidal behaviour is high among students in a public university in East Malaysia. Predictors for suicidal behaviour were psychological distress and favourable attitudes towards suicide (‘the ability to understand and accept suicide’). Services and education for mental health awareness and screening for early detection and intervention of psychological distress should be provided to university students. Attitudes towards suicide are multidimensional, and not all influence suicidal behaviour. Implementation of suicide awareness policies and suicide prevention training is crucial.

Contributors

All authors designed the study, acquired the data, analysed the data, drafted the manuscript, and critically revised the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of Interest

All authors have disclosed no conflicts of interest.

Funding / Support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data Availability

All data generated or analysed during the present study are available from the corresponding author on reasonable request.

Ethics approval

This study was approved by the Institutional Review Board of the Universiti Teknologi MARA (reference: 600-TNCPI (5/1/6), REC/06/2022 (FB/33)).

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