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Suicide and Undetermined Violent Deaths in Malaysia, 1966-1990: Evidence for the Misclassification of Suicide Statistics
T Maniam Asia Pac J Public Health 1995 8: 181 DOI: 10.1177/101053959500800307 The online version of this article can be found at: http://aph.sagepub.com/content/8/3/181

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Abstract Suicide statistics are generally recognised to be unreliable. This study of the reported rates of suicide in \Yest Malaysia between 1966 1990 sho#s that the mean crude suicide rate between 1966-1974 was 6.1 per 100,000, but had dropped drastically iwtxeen 1975-1990 to a mean of 1.6 -per 100,000. Three lines of evidence are presented to show that this reduction in the suicide rate is due to a systematic misclassification of medically certified suicides as deaths due to undetermined violent deaths (which refers to violent deaths not known to be accidentally o r deliberately inflicted). Firstly, the large drop in reported suicide rates corresponds closely to an increase in the rate of deaths due to undetermined violent deaths. There is a highly positive negative correlation between the two rates (coefficient of correlation, r = -0.9). Secondly, the misclassification a p p e a r s t o be mainly a problem with the medically certified deaths which follow the ICD classification. The mean ratio of uncertified to certified suicides before 1975 was 0.8, but from 1975 onwards the mean was 3.1. This is in contrast to the corresponding ratio for deaths due to all accidents which has remained fairly constant throughout these years. Thirdly, the race and sex differences for the rates of undetermined violent deaths are identical to those of suicide. Taking the misclassification into account the corrected suicide rate for West Malaysia is estimated to be between 8-13 per 100,000 since 1982. Asia Pac J Piiblic Health 1995:8(3):18 I-185

Suicide and Undetermined Violent Deaths in Malaysia, 1966-1990: Evidence for the Misclassification of Suicide Statistics
T hlaniam, RIBBS, RIPM, FAhlRI
Faculty of Medicine National University of Malaysia

Introduction
Suicidal behaviour is complex. It is profoundly influenced by socioeconomic and political realities as well as cultural and religious values. Psychopathological conditions such as depression, alcoholism, personality disorder and psychoses are known to be associated with suicides. It is widely recognised that reported suicide rates are highly unreliable for various reasons. Most so-called undetermined deaths are due to suicides.2 It has been estimated that the magnitude of underestimation of suicide is between 24% to 33% even in developed ~ountries.~ In 1974, Teoh4 commented that inspite of rapid social, economic and environmental changes, the rate of suicide has remained fairly constant at approximately seven per 100,000 population in West Malaysia. However, data published since seem to indicate that the West Malaysian suicide rate has declined dramatically to very low level^.^ The aims of this paper are, firstly to describe and analyse the changes in suicide rates and rates of death due to other (undetermined) violence from published data in West Malaysia as a whole as well as segments ofthe population, over the 25 years between 1966 and 1990; seeon@, to seek possible explanations for these changes and,

last&, to estimate the corrected suicide rate.

Materials and methods

Data on causes of death and population composition were obtained from the publications of the Department of Statistics, Malaysia, Vital Statistics, for the years 1966 to 19906. Over the past 25 years, 40%of all deaths in this country have been medically certified. Population figures according to age group (above and below 15 years of age) were not available for the years 1966 to 1968. In all calculations, the mid-year (30th June) population was used. Malaysia is a Southeast Asian country, geographically divided into West (Peninsular) Malaysia, where 82% of the total population of about 17.6 million live, and East Malaysia which comprises the states of Sabah and Sarawak on the island of Borneo. In West Malaysia, 55% of the population are Malays, 35% Chinese, and 10% Indians. Only rates for West Malaysia were calculated because data for East Malaysia are very patchy and inadequate. Classification of causes of death in Malaysia follows the system of the WHOS International Classification of Diseases (ICD). Up till 1971, ICD7 (7th edition) was used, ICDX from 1972 to 1981, and ICD9 thereafter.
181

Keywords: Suicide rates, undeterdeaths, mined vi o I e n t misclassification, Malaysia.

Address for correspondence: Dr T hlaniam, Department of Psychiatry Faculty of hledicine, National University of hlalaysia Jalan Raja hluda Abdul Aziz 50300 Kuala Lumpur, Malaysia

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Suicidal behaviour is illegal in Malaysian law. However, in practice prosecutions rarely, if ever, take place. Suicide is strictly forbidden for Muslims who are mostly Malays. In law, all unnatural causes of death must be reported to the police, who would request for a post-mortem examination to ascertain the actual cause of death. In practice, however, most deaths occurring outside the hospital are not medically certified. In some sectors of the population there is strong resistance to post-mortem examination. Uncertified deaths are reported by policemen and village headmen. Undetermined deaths refers to deaths recorded as being due to other external causes of death in ICD8 or death due to other violence not known to be deliberate or accidental in ICD9. Results Crude Suicide Rates The crude suicide rate for West Malaysia varies from 7.6 per 100,000 in 1969 to a low of 0.4 per 100,000 population in 1990 (Figure 1). The mean crude rate between 1966 to 1969 was 7.1, between 1970 to 1979 was 3.7, between 1980 to 1985 dropped further to 1.5 per 100,000, and has continued this slow decline thereafter. Sex-specific suicide rates Figure 2 shows that rnales have nearly twice the suicide rate as compared to females. Again the highest rates were found in the year 1969 (16.8 for males and 9.3 for females). The pattern of reduction for both sexes was remarkably similar. Race-specific suicide rates Indians as expected have the highest rate of the major ethnic groups in this country. In fact they have more than double the combined rate of the other two races (Figure 3). The Indians had particularly high rates in the years 1969 to 1974. Again, all three races had the highest risk in 1969 (42.4 per 100,000 for Indians, 15.6 for Chinese and 4.3 for Malays). Age-specific Suicide Rate The population structure in Malaysia has a proportionately larger number of
182

children and therefore the crude rate is not a good reflection of the suicide problem. The rate for population at risk (above 15 years of age) was 13.1 per 100,000 for 1969,and again shows large reductions in rates from 1975, and follows a.pattern similar to the crude suicide rate. This is not reported in detail here. In the interest of brevity, the age distribution of suicides is shown only for two years in Figure 4. The pattern is similar for other years. Crude Deafh Rate due to Undetermined Deaths In ICD8 (1965), the term deaths due to Other External Causes was introduced and in the 9th revision (1CD9), this was termed Other Violence and it included deaths due to injury not determined to have been accidentally or purposely inflicted. Such injury included poisoning, hanging, strangulation, suffocation, drowning, firearm injuries, falling from high places, et cetera. A comparison of this undetermined death rate due to such violence with the crude suicide rate shows remarkable reciprocal changes (Figure 5), i.e., when thesuicide rate drops the rate due to imdetermined violence rises. In fact, this inverse relationship is so close that the correlation coefficient, r, for the two rates is high, r = -0.9. When tested for significance by t-test, it gives a t value of -8.5 13 (where l t = r+ [(n-2) l (l-rz)], d.f.=n-2 = 17), and p<O.OO 1. Changes in Mode of Registration of Suicides The drop in the suicide rate from 1975 onwards is largely a drop in the certified suicides, after ICD8 was introduced in the country. Uncertified suicide reported by policemen and village headmen does not show much change. Between 1966 to 1974, the mean ratio of uncertified suicides to certified suicides was 0.8 but this changed drastically after 1974 when the mean ratio became 3.1. This indicates that between 1975 to 1985 uncertified suicides outnumbered certified suicides by three times. This change becomes more remarkable when compared with the ratio of uncertified to certified deaths due to all accidents, where the ratios between the two modes of registration are remarkably constant at

about 0.7 throughout these years, indicating that there has been no overall change in mode of registration of deaths (Figure 6). Discussion The crude suicide rate for West Malaysia has declined from a mean rate of 7.1 per 100,000 population between 1966 to 1969 to 3.7 per 100,000 between 1970 - 1979 and 1.5 between 1980 - 1990. This compares with a mean rate of 10.4per 100,000 for Singapore between the years 1966 - 1977. In Hong Kong, the crude suicide rate for 1981 was 18.1 whereas the corresponding rate for West Malaysia is 1.2 per 100,000 population*. Does Malaysia have a much lower suicide rate than neighbouring countries and is the decline a real one? A closer look at the data appears to indicate otherwise. There are many reasons why national suicide statistics differ? The sociopolitical situation of the late 1960s in West Malaysia leading to civil strife in May 1969 was highly traumatic and it is not surprising that both the suicide and the homicide rates in 1969 were the highest recorded in recent years. It is to.be noted that in times of war, the suicide rate drops but internal civil strife appears not to protect against suicide but rather has the opposite effect.7J0After 1969,with the sociopolitical situation returning to normalcy, the suicide rate appears to have dropped back to return to the usual level of about 5 to 6 per 100,000 from 1971 to 1974. But the massive drop in 1975 is very apparent and needs explanation. It is a truism among suicide epidemiologists that sudden large changes in national rates are artificial. That there has been an artificial drop in the Malaysian suicide rate is borne out by many factors. Firstly, there has been a large reduction in the number of medically certified suicides as opposed to that of uncertified ones. Could this have been because of the improvement of medical facilities such that fewer attempted suicides die in hospital? This is unIikely because of the rather sudden change in the suicide rate. What is more likely is that there has been a change in the practice of recording and classifying suicides in

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Asia-Pacific Journal of Public Health 1995 Vol. 8.No. 3

Fig 1. Crude Suicide Rates West Malaysia, 1966 1990
8I
=Or

Fig 2. Sex-Specific Suicide Rates - West Malaysia 1969 1990

- Male

+ Female

"

6 6

88

72

76

78

81

84

87

80

Not-: Only 1y - r r r are shorn, to ~void ovrrsrowdina

~~

4- indien

Chinese

Malay

E w
a

151

/ -

/-

1971 I 1981 -

Fig 5. Crude Suicide Rate & Death Due To Undetermined Violence - West Malaysia 1972 - 1990

Fg 6. Changes In Mode of Registrationof Suicides i and Acddents-WestMalaysia 1 6 1990 %

1
Nots: Undetermined V I O I ~ J refers t o all Other external M~ c a u m e s in ICD-6 or Other vtolencs In ICO-0

66

69

72

75

78

81

84

87

90

183
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Fig 7. Race-Specific Undetermined Violent Death Rates -West Malaysia 1972 1990

Fig 8. Corrected Suicide Rate (All Ages) West Malaysia 1972 - 1990

40

72

"

'

74

"

'

78

"

"

78

"

00

"

82

"

'

84

88

88

90

72

-Chinese + Indian

75

7 8

81

84
i; f-

67

90

Malay

Corrected rate obtained by adding reported suicides and undetermined deaths

1975. According to Kreitman (personal communication), whenever there is a sudden change in the suicide rate it is due to artificial reasons such as a change in the practice of classification. It is interesting that this sudden reduction has taken place soon after the introduction of a new system of classification of deaths -- the ICD8. It is expedient to categorise deaths under "other external causes" or "other violence" when not sufficient details have been provided or sought after. This line of argument is supported, secondly, by the fact that in Figure 7, a large drop in the crude suicide rate is almost exactly mirrored by a large jump in reported deaths due to undetermined violent deaths. An examination of the raw data shows that this change in crude suicide rate is almost entirely due to a reduction in medically certified suicides. This is also shown by the fact that the ratio of uncertified to certified suicides has changed dramatically after 1974. That this change is not due to a general change in the way deaths are registered in this country is borne out by the fact that the ratio ofuncertified to certified accidental deaths has remained constant as shown in Figure 6. Thirdly, an analysis of the race distribution of deaths due to undetermined violence further lends credence
184

Fig 9. Corrected Suicide Race By Race Moving Averages West Malayisa 1972 - 1990
50

40

0 0 0 0- 30 0
r
L

Q)

0 +J
[r

20

7 0

72

74

76

78

80

82

84

86

88

90

to the conclusion that many of these violent deaths may actually be suicides. Figure 8 shows that Indians have the highest rate of such deaths for every year from 1972, followed by the Chinese and the Malays, with the Indians having about double the combined rate of the other two races --just

as in the case of suicides in Figure 3. There appears to be no other explanation why Indians should have such high rates of "other violent deaths". But their proneness to violent death by suicide is well ~ o w ~ , ~ . ~ hence the exJ O planation put forward here that these undetermined deaths are mostly

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Asia-Pacific Journal of Public Health 1995 Vol. 8. No. 3 misclassified suicides satisfactorily explains the excess of Indian undetermined deaths.. Furthermore the reduction in rates occurred about equally for both sexes as well as all age-groups, including children and adolescents'! suggesting that a common factor is at work in this reduction. This problem of misclassification of suicides has long been recognised and official national suicide statistics have been criticised as unreliable, misleading and invalid'. The Malaysian experience is not unique. It has been argued thus far that deaths due to violence of unknown causes are mostly due to suicide. If this reasoning is accepted then a Corrected Suicide Rate may be calculated by combining the published suicide rate with the rate for undetermined violent deaths yielding a probably more accurate representation of the suicide problem. There is a possibility that this combination might somewhat overestimate the suicide rate (for example by including the undetermined deaths of very young children), but nevertheless may be a better representation of the true suicide rate than the presently reported figures. This Corrected Suicide Rate shows a rise after 1982 and a peak between 1985 - 1987 (Figure 8). This peak period coincides with the most serious economic recession Malaysia has faced in recent years. This is not surprising because it is well known that in times of economic difficulties suicide rates increase. Hence, the true suicide rate for Malaysia in the 1980s is probably between 8 13per 100,000 population and not 1.5 per 100,000 as has recently been reportedlo. Interestingly, the race distribution of this corrected suicide rate shows a remarkable trend that has been noted in a district in Ma1aysialz. There is an increasing rate of suicides among Malays - from about two per 100,000 in the early 1970s to about six per 100,000 in the late 1980s, almost a three-fold increase (Figure 9). There is a smaller increase for the Chinese but not much change in the Indian suicide rate. Present mortality data involving calculation ofrates are thus thrown into doubt because of the twin problems of low certification rates (less than 40%) and, even when the deaths are certified, inaccuracies and improper methods of indicating causes of death. Collection of mortality data in the Ministry of Health is manual and the need for training and supervision of all categories of staff involved in this process is obvious. medical schools give particular attention to this aspect of training, and junior medical officers are supervised more closely in the reporting of deaths.

References
1. Kreitman N. Suicideand Parasuicide. In: Kendall RE, Zeally AK, editors.

19931743-60. 2. Holding TA, Barraclough BM. Undetermined deaths: Suicide or Accident? Br J Psychiatry 1978;133:542-9. 3. Murphy GE. Suicide and Attempted Suicide. In: Winokur G, Clayton PJ,

Companion to Psychiatric Studies. Edinburgh:Churchill Livingstone,

Conclusion A reduction in the officially published suicide rate in Malaysia has occurred largely because of a misclassification of suicide as undetermined violent deaths. This occurs to some extent in other countries as well, but the data above indicates that such a misclassification has occurred on a large scale in the West Malaysian data. Hence, presently reported Malaysian national suicide statistics are not reliable. The true mean crude suicide rate for Malaysia is estimated (though this carries a risk of some overestimation) to be between 8 - 13 per 100),000since 1982. Indians in West Malaysia have twice the suicide rate of the Chinese and Malays combined. There appears to be an increase in the suicide rate among Malays in the late 198Os, a three-fold increase that is not matched by the other races. Reliable statistics are absolutely essential for rational planning of medical services both in the preventive and curative' fields. Where mortality statistics are concerned, Malaysia is very handicapped. It would be useful if

editors. The Medical Basis of Psychiatry, 2nd edition,Philadelphia: WB Saunders & Co., 1994. 4. Teoh JI. An analysis of completed suicides by psychological postmortem. Annals Academy of Medicine
5. South East Asia Medical Information Centre (SEAMIC) Health Statistics, 1985. Tokyo. 6. Malaysia, Dept of Statistics,Vital Statistics. West Malaysia series 19661990. Kuala Lumpur. 7. Chia BH. Suicidal Behaviour in Singapore. SEAMIC PublicationNo 24. Tokyo: Southeast 8. Asian Medical Information Centre. International Medical Foundation of Japan, 1981. 9. Lo WH, Leung M. Suicide in 1 long Kong. Aust N Z J Psychiatry
1985: 19:287-92. 10. Barraclough B. Differences between national suicide rates. Br J Psychiatry 1973;122:95-6. 11. Kok LP, Tsoi WE Epidemiology of Suicide in Singapore 1940-1989. ASEAN J Psychiatry 1991; 1:817. 12. Maniam T. Trends in Deaths due to 1974;3:117-24.

6:94-100. 13. Maniam T. Changing Patterns of Sui-

Injuries among Children and Adolescents in West Malaysia, 1971 1990. Malaysian J Child Health 1994;

cides in Cameron Highlands. Malaysian J Psychiatry 1994;2: 48-58.

185
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