IDRAAC (Institute for Development Research Advocacy and Applied Care) in association with the Department of Psychiatry and Clinical Psychology at the St Georges Hospital University Medical Center and the Faculty of Medicine at the University of Balamand organized a symposium title: “Suicide in Lebanon: Where Are We?”. Results from the studies that were discussed during the symposium showed that Lebanese suicide attempts, estimated at 2%, are almost the mean value of suicide attempts in 17 countries worldwide (2.7%). According to the World Health Organization (WHO)’s estimates, Lebanon is far below the global mean of completed suicides (0.2% in Lebanon as compared to 1.4% globally). The director generals of the Ministries of Public Health, Interior and Municipalities and Justice revealed that joint efforts have been exerted by their ministries in order to update the laws, to improve the reporting of deaths mechanism, to unify death certificates and to determine the role of the forensic doctors. They also stressed the importance of suicide prevention through providing mental health services and establishing a helpline for suicide.
The symposium, was held at the Balamand University-Achrafieh, with the participation of experts who discussed the subject of suicide from different perspectives: mental health, governmental, legal, religious, academic and civil society.
Following an introductory speech by Prof. Elie Karam, President of IDRAAC, the first session was moderated by the Head of the National Mental Health Program at the Ministry of Public Health Dr. Rabih Chammay and the head of the Lebanese Psychiatric Society Dr. Wadih Naja, where data on Lebanon’s suicidal behavior and completed suicide was presented. Prof. Karam noticed that, “based on the WHO’s estimates, Lebanon has far below the global mean of completed suicides (0.2% in Lebanon as compared to 1.4% globally).” In contrast, he said, nationally representative data from Lebanon and as part of the World Mental Health Surveys (WMH) that IDRAAC conducted revealed that “Lebanese suicide attempts were almost around the mean value of suicide attempts in surveyed countries (17 countries) (2% in Lebanon versus 2.7% in the total sample surveyed)”.
“When comparing ratios of WHO estimates of completed suicides to WMH estimates of suicide attempts across different countries (France, Belgium, Germany, Italy, South Africa, Spain and the United States), Lebanon had the lowest ratio,” he added.
Prof. Karam said that there are two possibilities: the first is that the numbers presented by WHO regarding completed suicides are less than the real numbers, which means that serious measures must be taken in order to better report and document the completed suicide cases in Lebanon. The second option, according to Karam is that “Lebanon has in fact lower completed suicide rates than other countries, which means that the Lebanese community has unusual protection against completed suicide in Lebanon which could be of benefit to research around the world”.
Suicide Risk Factors in Lebanon and the World
Dr. Georges Karam, senior member at IDRAAC and president of Alzheimer’s Association Lebanon, described suicide as “a major public health concern” in Lebanon. He presented extensive data on specific risk factors in Lebanon, the Middle East and the World.
“We studied the interaction of temperament on suicidal behavior, the effect of parent psychopathology, the effect of childhood adversities, the effect of war exposure, the effect of traumatic events and finally the effect of psychotic experiences, on suicidal behavior.”
Dr. Karam revealed that “a clear association was present among all those risk factors”, and added: “from a public health perspective, the strong and consistent associations between mental disorders and suicidal behavior suggest that suicide prevention efforts should include a focus on screening and treating mental disorders in both developed and developing countries”. He also noted that “recent global studies found that children who are victims of bullying are 9 times more likely to be subject to suicidal thoughts than other children, while adults bullied at their workplace are twice more likely to think about suicide than others.
Suicide Helpline: Year One
Mrs. Mia Atoui, co-founder and member of the executive board of Embrace, also delivered a speech whereby she stated that “suicide is quickly becoming a major public health concern in Lebanon, as according to statistics from the Internal Security Forces, one person is dying of suicide every 2.5 days and one person attempts suicide every 6 hours.”
She also said that “in 2014, suicide rates witnessed a 30% increase in comparison with 2013, and a similar prevalence rate has been reported in 2017, based on an unpublished study from reports also by the ISF (Bizri et al, 2018).”
Atoui added that “Embrace, in partnership with the MOPH’s National Mental Health Program, is working on consolidating an official cooperation to launch a national helpline for suicide prevention and emotional support.”
She said “the Embrace LifeLine, which provides over-the-phone suicide risk assessment, emotional support and referrals to necessary community resources, was established in 2017, within a framework of a non-interventionist approach, under the guidance of the Centre for Research and Intervention for Suicide and Euthanasia in Canada (CRISE). September 2017, saw the soft launch of the helpline, operating from 12 pm till 2 am, and receiving to date over 80 calls”.
For his part, director of MOPH’s National Mental Health Program Dr. Rabih Chammay said that the helpline constitutes a pillar on the level of intervention in the case of suicide, adding that this helpline includes training in mental health care and developing social health service centers, as well as self-help applications for self-help and maps allowing citizens to access direct services.
Suicide Attempts According to the National Mental Health Registry
Dr. Ghada Abou Mrad from the MOPH’s National Mental Health Program and Ms. Edwina Zoghbi from the World Health Organization, spoke about the “Findings on Suicidality from the Mental Health Registry in Lebanon”.
They said “a mental health registry was established and piloted in 2016 to identify trends in mental health disorders and treatment. This registry includes a component on suicidality (suicidal ideations and attempts)”.
They pointed out that data was collected from 9 psychiatrists through an electronic program specifically designed for the project.
“According to the findings, a total of 779 patients were registered from 32 facilities between September 2016 and February 2017. Amongst them, 116 (15%) attempted suicide, 61% of whom were females. Around 10% were less than 18 years of age, while 58% were aged between 18 and 34 years. As for diagnosis, 44% had depression, 20% had schizophrenia, and 15% had anxiety. The majority of them (93%) were provided with psychotropic medications, 44% were referred to psychotherapy, and 16% were admitted to hospitals”. They also emphasized on the importance of further data collection in this area.
Deaths Statistics Based on Hospitals Data
Head of Statistics Department at the MOPH Mrs. Hilda Harb said that “until 2017, reliable and complete information on causes of death were lacking in Lebanon.”
She explained in her speech that many attempts were being taken to improve the form of the death certificate and automate its database, but many barriers were preventing the task, stressing that certain causes of death due to their sensitive nature, and due to social factors, might not be recorded accurately on the official death certificate, which makes a hospital death notification, with all medical associated causes, more useful.
In this context, Mrs. Harb stated that “the MOPH initiated in 2011 a hospital based surveillance system of all maternal deaths, neonatal deaths, all births and birth defects, and was later developed to include all deaths.”
“This system is based on the hospitals data that include the medical causes of death, which allowed the collection of medical information on all deaths that occur at any hospital or arrive to any hospital, without of course mentioning the identity of the deceased,” she pointed out.
“We now have information by nationality, place of death, place of origin, place of residence, gender, age and cause of death, including suicide,” Mrs. Harb added that the ministry is regularly working in order to improve the quality of hospital mortality reporting, by training medical doctors on the proper documentation of causes of death according to adopted standards.
Death Reporting and Certificates and the Role of the Forensic Physician
The second session moderated by Dr. Abla Sibai, the Chair of the Epidemiology and Population Health Department at the Faculty of Health Sciences (FHS) at the American University of Beirut (AUB), evolved around “Suicide and Death Certification in Lebanon”. Dr. Sibai said that she conducted a study in 2002 on the causes of death, where she found, during her interviews with the deceased’s relatives and her reviews over the official registers, that the death certificates lack accuracy.”
She noted that a death certificate is divided into three parts, one of which is reserved to the medical doctor who must determine the cause of death.
In this context, she gave examples of the causes of death mentioned in certificates, including “natural death” and “old age,” pointing out that efforts are being deployed on the national level in an effort to improve the death certificate.
Judge John Azzi, President of the court of appeal in Beirut, discussed the current situation of the cause of death and suicide reporting in Lebanon from a legal standpoint and presented possible improvement methods.
Judge Azzi stressed that “suicide is unacceptable in all the languages on earth,” adding that the Lebanese law punishes whoever drives any person in any way to commit suicide or helps him kill himself.
“Suicide is killing and killing oneself is a crime, and any accomplice is punished as being a criminal,” he stated, pointing out that a medical doctor can never confirm a death as a suicide, but through investigation, this can be confirmed. “Some crimes are being covered as suicide,” he said.
The judge added that “according to the latest statistics by the Internal Security Forces conducted in 2018 (from 01/01/2018 until 15/02/2018), 25 suicide cases were reported in Lebanon, 14 of which are Lebanese, and 11 of other nationalities, including domestic workers.” These cases include shooting, hanging, falling off a high floor and poisoning, but they cannot be confirmed according to Azzi.
He continued by saying that in the year 2014, 143 suicide cases were registered, where the rate of men was higher than that of women, with an age ranging between 25 and 40 years, stating however that this number cannot be considered final, given the number of unreported suicide attempts and completed suicides, where the cause of death gets changed for social or religious reasons.
In this regard, he stressed the importance of a helpline in order to fight against suicide.
Dr. Bilal Sablouh, a forensic physician (specialist in Forensic Medicine) at the Ministry of Justice, discussed the diagnosis of suicide in Lebanon and the role of forensic medicine in collecting and analyzing evidence, and giving his opinion in order to help the judicial authorities in making the appropriate decision in the cases of suicide.
He explained that “the forensic doctor does not mention the word “suicide” in his report but determines the signs and says whether or not they correspond to self-injury.”
Sablouh noted that there is no forensic psychiatry in Lebanon and a forensic physician is often tasked with contacting psychiatrists to obtain a victim’s report and send it to the judge.
He concluded with a series of recommendations, including the need to limit the appointment of forensic physicians to those who have a degree in forensic medicine, to introduce forensic psychiatry in Lebanon and to activate the role of specialists in forensic medicine and criminal science, calling for training of the forensic doctors and the concerned parties to deal with suicide cases.
He also emphasized the need to establish forensic medicine centers that are properly equipped at the human and technical levels.
Dr. Lina Oueidat, adviser to the Prime Minister Saad El Hariri, and adviser to the Ministry of Interior and Municipalities and National ICT Coordinator, tackled the topic of “Suicide Registry in Lebanon and the Death Certificate: Comparative Analysis of other Countries.”
She said “extensive work was conducted on exhaustive death certificates data over 3 years, a detailed analysis was conducted on 65, 000 detailed death certificates (40 fields/certificate) from the years 1997-1998-1999 and on a sample of analysis on death certificates in 2015, 2016.”
Dr. Oueidat said that they were facing problems in the integrity and in the clarity of the data, the type of the death certificate, the culture of the certifiers regarding death in general, and suicide in particular. Therefore, she declared that recommendations will be presented to the Lebanese authorities in cooperation with the World Health Organization in order to achieve coordination regarding this issue.
Roles of the Ministries
Following these presentations, a roundtable was held entitled: Suicide Data: A National Concern.
During the session, which was moderated by Judge Ralph Riachi and Dr. Elie Karam, talks were delivered by Director General of the Ministry of Public Health Professor Walid Ammar, Director General of the Personal Civil Status at the Ministry of Interior and Municipalities Gen. Elias Khoury and Director General of the Lebanese Ministry of Justice Judge Mayssam Noueiri, where they spoke about their ministries’ role concerning suicide.
Riachi said that “there is a need to update the laws regarding the registration of the civil status registry, including the birth and death certificates, adding that a suicide ruling must not be mentioned in a death certificate but in other non-public documents, in order to protect the individual’s privacy.
Ministry of Public Health: Our Aim is Prevention not Census
Professor Walid Ammar said that the issue of suicide requires the cooperation of several official and health parties from both the public and private sectors, explaining that the Ministry of Public Health is concerned with suicide in terms of prevention rather than census, despite the latter’s importance in helping in the efforts to prevent and provide treatment.
He mentioned significant achievements over the past three years, in terms of a national mental health strategy and integration of mental health services within primary healthcare, stating that “it is very important for an individual with mental health issues to have access to mental health services in order to prevent potential suicide.”
He added that a helpline has been established and work is ongoing with schools in particular concerning prevention mechanisms.
Ammar also said that the MOPH is cooperating with the Ministry of Interior and Municipalities regarding the reporting process and the death data, stressing that “there are serious attempts from the Ministry of Interior and Municipalities to make progress in this field.”
In the same context, he noted that the MOPH has a system at the hospitals to register causes of death, since 90% of them happen at the facilities, pointing out that the system remains incomplete awaiting the contribution of the Ministry of Interior and Municipalities.
“In the meantime, we developed the model and we started training the medical doctors,” he said, adding that keeping the identities confidential encourages people to give information.
Ministry of Interior and Municipalities: Seeking a Unified Death Certificate
General Elias Khoury said that there are 25 fields that need to be filled in the current death certificate, with three parties working on filling them before it reaches the civil status department, explaining that the mayor (mokhtar), who is the main player, fills 15 fields, the physician has 6 fields to fill and the rest is for the official of the civil status.
On the issue of suicide, he said that conducting a census on suicide cases in Lebanon would have been easier, if it was limited to the civil status, meaning that if we were counting only Lebanese, but there are cases of suicide of non-Lebanese residents, including Syrians and Palestinian refugees.
“We do not have many death certificates of Syrian nationals, since those who die, whether inside camps or elsewhere, are being buried at the nearest place without obtaining data on these cases and the causes of death,” he clarified.
“As for the Palestinians, the Directorate of the Civil Status in not in charge of their affairs, but the registration of their death falls under the responsibility of the Public Directorate of the Political Affairs and Refugees,” he stated.
Ministry of Justice: Explaining the Role of a Forensic Doctor
Judge Mayssam Noueiri stressed that the old laws are without a doubt in need to be amended and updated, noting however, that this does not prevent the use of the current laws to accomplish the necessary through explanations and referring to international treaties and human rights, and this is the role of judges and the Ministry of Justice
She emphasized the need to further explain the role and responsibilities of the forensic doctor, “where does his duty start and where does it end.”
Noueiri said that a death certificate must not include any characterization of the death, whether it was a result of suicide, murder or other.
She stressed that the Ministry of Justice will coordinate with other concerned parties in order to determine the role of the forensic doctor in this regard, taking into consideration the limited resources at the disposal of the ministry.
Suicide from the Islam and Christian perspectives
Sheikh Dr. Mohammad Al Noukkari tackled the issue of suicide from the perspective of Islam, noting that “the Quran texts warn the people against any act that could cause death and that the fate of whoever commits suicide is eternal suffering on Judgment Day.”
He also explained that “Islam, through its principles and teachings, links the human being to a network of daily relationships, whether in his individual or collective prayers, and familial and social relationships that prevent him from seeking isolation and abusing alcohol and drugs.
These relationships, the sheikh continues, have made the suicide rate among Muslims less than other rates in the world, according to statistics.
In turn, Father George Dimas, Chancellor of the Orthodox Archdiocese of Beirut and Rector of the Orthodox Schools in Beirut, discussed the suicide from a Christian perspective, speaking of the Orthodox Church’s position towards suicide and recalling the Lord’s commandment “Thou shall not kill”.
He also tackled the development of the Church’s historical perspective in this regard, as well as the scientific perspective.
“Some of the fathers of the Orthodox Church supported suicide in some cases, while others opposed it at all cases,” he said.
Father Dimas summarized the position of the church through a series of pastoral recommendations, including showing mercy to the one who commits suicide and to care for his/her family, stressing that science has proved that the individual who commits suicide lost his/her capacity to make appropriate judgments, since the majority of suicide cases result from a defect in mental functions that limit lucid behavior and thus deserves prayers like those who did not commit suicide.
At the end of the session, a long discussion was held between the speakers and the attendees about suicide, where Prof. Elie Karam of IDRAAC and the directors generals of the Ministries of Public Health, Interior and Municipalities, and Justice stressed that they will work with the different sectors to improve the mechanisms of reporting and evaluation based on data from Lebanon. They emphasized that this will benefit all those who suffer and will help avoid the tragedies of suicide based on the achievements of the top institutions around the world that study suicide, its causes and means of prevention.