Having any 4 of these 10 warning signs may signal higher suicide risk, IMH study finds

Warning: This story contains references to suicide

SINGAPORE: Anger, purposelessness, recklessness and anxiety – if a person exhibits four or more “acute warning signs” such as these, they could be at risk of suicide, a new study by the Institute of Mental Health released on Wednesday (Sep 17) found.

These signs appear a week before the person attempts suicide, said the Ministry of Health-funded study touted to be the first of its kind in Singapore.

In comparison, individuals who are not at suicide risk would display only one of the 10 warning signs.

The 10 warning signs are based on a framework developed by the American Association of Suicidology to assess suicide risk.

Put together, the first letters of each warning sign form the mnemonic “Is Path Warm”: Ideation, substance abuse, purposelessness, anxiety, (feeling) trapped, hopelessness, withdrawal, anger, recklessness and mood changes.

The study is the first in Singapore to use the “psychological autopsy” method, in which researchers carry out a detailed retrospective examination of the life and state of mind of someone who had died from suicide.

This involves gathering information from people who knew them, such as family and friends, as well as from coroner’s reports.

In total, the study involved 73 cases of deaths from suicides as well as 73 control cases which do not involve suicide – with ages ranging from 11 to 76 years for the suicide cases and 10 to 76 for the control group.

Face-to-face interviews were carried out between May 2021 and February 2024.

“The aim is to get a clear and accurate picture of the individual’s circumstances, personality and health to better understand what could have led to their death and provide locally relevant insights,” IMH said.

Based on provisional data provided by the Samaritans of Singapore, there were 314 deaths by suicide in Singapore in 2024, a decline from 434 in 2023 and 476 in 2022.

The study is significant as much existing research on suicide comes from Western contexts.

IMH said while core risk factors that led to death by suicide may be similar to those in Western countries, the way people experience distress and seek help can differ across cultures and social contexts.

Apart from the warning signs, the study also looked into the factors in a person’s life that are associated with suicide.

For example, the study found that those who died from suicide faced challenges such as unemployment, were smoking and drinking, and had relationship problems.

Associate Professor Mythily Subramaniam, the assistant chairman of the medical board (research) at IMH who led the study, said: “Suicide is never the result of just one factor, but it is a perfect storm when the struggles converge and become too much.

“It is important to understand that these overwhelming moments can happen in anyone’s life,” he added.

FACTORS ASSOCIATED WITH SUICIDE

By comparing between the suicide cases and those from the control group, the study’s researchers found statistically significant differences in lifestyle, personal relationships, socioeconomic and academic background, and mental and physical health factors.

For instance, more than half of those who died by suicide - 52.1 per cent - did not have an education qualification beyond a diploma from the Institute of Technical Education (ITE), compared to only 13.7 per cent of those not at risk.

They were also more likely to be unemployed in the year before they died, at 30.6 per cent of cases versus 5.5 per cent.

In addition, 38.5 per cent of those who died by suicide were known to have a change in the level of participation in religious activities over the year before death, compared to 18 per cent of the control group. This change includes both an increase or a decrease in level of participation.

In terms of lifestyle and relationships, the two groups also had significant differences, the study found.

Those who died by suicide were more likely to smoke, at 22.8 per cent compared to 11 per cent of the control group.

Almost 24 per cent of suicide cases were more likely to drink alcohol on a weekly basis compared to just 2.7 per cent of the control group.

IMH also highlighted that 70 per cent of suicide cases had hobbies, interests or participated in other activities, compared to 91.8 per cent of the control group.

Victims of suicide were also more likely to have experienced relationship difficulties, such as break-ups, threatened separations or instability in their significant relationships.

In addition, almost 12 per cent of those who died by suicide were reported to have uploaded posts on social media that seemed different than usual, compared to just 1.4 per cent in the control group. 

MENTAL HEALTH

The IMH study also affirmed past research that most, but not all, suicide cases are likely to have been diagnosed with mental health conditions.

Around 71 per cent of suicide cases were more likely to have been diagnosed with mental health conditions, compared to 13.9 per cent in the control group.

Major depressive disorder was the most common condition reported (40 per cent of cases), followed by schizophrenia and other psychotic disorders (17.1 per cent), and bipolar disorder (8.6 per cent).

Moderate to severe symptoms of depression were also more likely to be reported in those who died by suicide in the month preceding their demise - 54 per cent - compared to 8.2 per cent in the control group.

“These factors may reflect the severity of their mental health concerns,” IMH said.

Individuals who ended their lives were more likely to have reported poorer health compared to the previous year and experienced greater limitations in their daily functioning. They were also significantly more likely to have suffered from insomnia in the weeks leading up to their death.

Loved ones of those who died by suicide shared in the study that they often could not tell the difference between ordinary stress and serious mental health conditions like depression or psychosis.

As a result, treatment was often delayed, as families focused on easing the stress rather than recognising the need for the distressed individual to seek care or continue treatment.

Among those to have lost an older adult who had been treated for pain or other conditions, mental health problems of the older adult were often overlooked.

Professor Chong Siow Ann, IMH senior consultant of the research division and department of psychosis, said the warning signs such as withdrawal, hopelessness or mood changes can sometimes be subtle or mistaken for normal stress.

“It is not always straightforward but this means that there were opportunities to notice changes if people around them were aware of what to look for,” she said.

Where to get help:

National mental health helpline: 1771

Samaritans of Singapore Hotline: 1767

Singapore Association for Mental Health Helpline: 1800 283 7019

You can also find a list of international helplines here. If someone you know is at immediate risk, call 24-hour emergency medical services.