Moreno later directed the local mental health board to convene and review the circumstances of the incident and suggest steps to strengthen the mental health and psychosocial support services (MHPSS) at the more than 20 isolation and treatment units in hotels, inns, and campuses throughout the city so that suicide prevention is better enforced.

The board is a multi-stakeholder body and adjunct to the local health board mandated under the Local Government Code and composed of mental health care professionals, non-government leaders and persons with lived experience of mental illness, with advisory and recommendatory tasks under the office of the local chief executive, particularly on mental health policies. It was formed in 2015 through an executive order aligned with the national government’s Mental Health Action Plan, 2015-2021 at the Department of Health, in consonance with the Mental Health Global Action Plan (mhGAP) of the World Health Organization (WHO). These policies at the global and national levels of governance seek to empower local communities and healthcare professionals to do their share in sustaining a mental health service program amid a dearth of psychiatrists and psychologists in poor and developing countries like the Philippines.

Seismic

That seismic one-death-too-many moment also marked a dark milestone in the Oro government’s Covid response more than a year after a community quarantine was declared on March 19, 2020, and as hundreds of frontliners were mobilized to prevent the spread of the virus. City hall employees manned barangay health centers, hospitals, ports, airports, and roadside checkpoints to transport individuals to isolation units, cook meals for the confined or disinfect roads and buildings.

As breakthrough infections rose among frontliners, community transmissions increased, causing three-digit reports of cases. In a few weeks, the number of active cases would breach the thousandth-mark, most of whom were housed in the isolation units as the hospitals raised the code red status, or all beds occupied. In less than two months, Cagayan de Oro suffered the worst surge of Covid cases and was declared under an Enhanced Community Quarantine (ECQ). At its peak, there were more than 3,000 active cases in a single day.

(Jaymee Leonen, director of the Psychosocial division of the Cagayan de Oro City Social Welfare and Development Office.)

Mental health support

The Bayanihan: We Heal as One National Covid Response Act stipulates that isolation units and treatment facilities must be provided with MHPSS (mental health and psychosocial support services).

These tasks fell mainly on the shoulders of the understaffed and underfunded psychosocial division as the city health office focused on dealing with Covid cases, plus other health programs on major diseases. The Mental Health Act also mandates that the CSWD psychologists and social workers must provide post-disaster stress debriefing and psychological first aid to populations hit by calamities like this disease outbreak.

Solutions

By the end of that week in May 2021, loopholes were addressed as two dedicated hotlines were made available exclusively for those who were housed in the government facilities, including those Covid positive but asymptomatic, or exhibiting mild or moderate symptoms.

Previously, three other lines provided counselling on mental health-related issues such as domestic violence and referrals to in-depth therapies.

These lines are on top of other measures, including keeping infected persons together in wider ward-like  spaces such as dormitories in groups of 10 instead of keeping single individuals solitary in separate bedrooms. Nursing staff went on monitoring rounds at night and dawn, more watchful of specific at-risk individuals like youths, the immunocompromised and those living with mental health disorders.

The WHO, along with scientists and medical professionals, had warned of a spike in mental health problems, such as cases of suicidality, which had  worried officials as early as prepandemic January 2020.

Pre-pandemic data show 800,000 die by suicide globally. The significance of addressing suicide-related crises is highlighted by the inclusion of suicide rate  as an indicator of mental health and well-being in the Sustainability Development Goals (SDGs). Under SDG #3, suicide rates are targeted to be reduced to a third of 2016 data by 2030.

In an article in The Journal of Public Health, Prof. Jeff Clyde Corpuz of De La Salle University rang alarm bells as historically, suicide rates rose during disease outbreaks as the 1918-19 influenza epidemic in the US and the 2003 severe acute respiratory syndrome (SARS) in Hongkong.

Corpuz also wrote that the Philippine Statistics Authority (PSA) saw a 25.7 % rise in deaths by self-harm in 2020, the start of the pandemic, compared with 2019 data.

CSWD data show suicide rates in Oro increased slightly from 2.3% in 2020 (18 cases) to 2.45 (19 cases) in 2021. In Northern Mindanao, with 123 cases in 2021, suicide rate was calculated at 2.5%, an increase from the previous year’s 2.0%.  The PSA however noted that the country’s suicide rate remained at 2.2% from 2016 to 2019.

Below 20

“The trends (in Cagayan de Oro) show that they are getting younger. Ga kabata. The youngest is a nine-year-old,” Leonen told a forum in September 2021.

Her insight presaged the WHO findings released in a briefing paper in March 2022.

"Suicidal behaviors among children and young adolescents aged 20 and below were on the rise globally even as global suicide rates were stable in the early part of the pandemic," WHO experts concluded.  

Dr. Ginger Ramirez, who monitored youth suicides in the country, also saw a sharp rise (58 %) in the number of youth suicides from January to October 2020, compared to 2021 data of the same period.

But a March 2022 WHO briefing paper said available national data from several countries showed no increase in suicide rates in the early months of the pandemic even with rising prevalence among the young.

Faultline

A critic of the city government’s Covid-19 response strategies, however, insisted that these are only stopgap measures.

“The real faultline lies in the use of private commercial establishments like hotels instead of empowering barangays and neighborhoods to establish community-based facilities as envisaged in the Bayanihan Act.

“We are not used to leave our sick and ill alone. That is so Westernized. Our culture is more caregiving. Isolating the sick like this in a strange environment invites despair and depression, and alienation and anomie. We give them attention and presence which are denied (the infected) due to the viral contagion,” she said, adding that Covid funds were centrally handled by city hall, leaving most barangays empty-handed and disempowered throughout the pandemic.

(The mayor was contacted for comment and this story will be  updated as soon as he replies).

Leonen said the trends in previous years indicate that more children as young as nine were reporting suicide ideation, attributing it to the pandemic impact on family life and social relationships. “Distressed parents beget distressed children.”

Disruptions

Meanwhile, awareness of the exclusive crisis hotlines was further enhanced by placing the contact phone numbers in leaflets handed out to clients as they checked into facilities.

But these lifelines were disrupted around late July till early September when the lines were burned to communicate with cash-strapped families competing to receive cash grants to stave off hunger as the local economy was on a standstill because of the ECQ status. The lines were flooded with calls and text messages from thousands of angry citizens who felt discriminated and excluded from the controversy-ridden distribution of the cash grants.

Leonen begged for sobriety and compassion for the caregivers as surreally, the phone messages turned into  online abuse, filled with obscenities and threats, which spilled into the discussion threads of the psychosocial division’s Facebook posts.

As this was happening, those confined at the isolation rooms and wards could no longer avail of the counselling services. “I kept on calling the numbers since day one, but someone would have pushed the end button. It happened for days,” Rowena Taperla, 28, a young professional and former cultural worker, recalled her experience when she was confined for 10 days at an isolation unit.

Despite their unavailability, the exclusive lines were still announced and shared for several weeks during the daily briefings. Obviously, there was a disconnect between the CSWD and the information staff hosting the briefings as the latter was not informed of the disruption of services. The mixed-up was corrected only in September.

24/7

Asked for suggestions on how to improve the lifeline, Taperla said the service and the other hospital-based telehealth services must be made available 24 hours a day, seven days a week. Presently, telehealth services are only available during office hours, 8 am-5 pm, Mondays to Fridays.

Under the Mental Health Act , suicide prevention hotlines are mandated to follow this 24/7 dictum.

“The night makes people more vulnerable,” Taperla explained when asked why she thought night duty is necessary.

Quoting the writer Diane Ackerman who volunteered for the night shift of a suicide prevention center in the 1990s, she further said,” As Ackerman observed, ‘people are most alone at night. They drink until they fill their minds with darkness forever. They have the pre-dawn crazies…If they can just get through till daybreak, the gloom might just break a little, and familiar people and routines offer hope.”

Fortunately, other private volunteer groups are filling the gaps by providing telehealth services via social media such as the Cagayan de Oro Mental Health Hour and Kamusta Youth Online Chat.

So far, only the DOH Kamusta Ka Hotline phone and social media lines are truly 24/7.

Three shifts of trained counsellors are manning three lines. By September 2021, the latest data indicated that around 15,000 calls had been received by the service, or around 25 calls per day, which could last for at least five minutes to an hour.

Lifelines

But Maria Dolores Mercado, DOH-10 regional coordinator on mental health, also urged that family members and friends can become lifelines themselves, as force multipliers, to be listeners and witnesses so that patients may not rely on crises lifelines. “If we cultivate the art of listening to these people, the call lines should serve as only the last resort,” she said.

“Usually these people would tell people their stories, their fears, their problems. They need a listening ear.”

“If any of your friends or a family member tell you they are suicidal, take them seriously. Do not dismiss them as ka-dramahan or just a mere joke. You must listen without judgment. Give them options, show and convince them they are not alone,” she suggested.

Aftershock

Another aspect that needs to be addressed is “postvention,” an activity that reduces the risk of suicide and debriefs the surviving and grieving family and friends in the aftershock of a sudden completed suicide. Persons whose attempt to end their lives did not succeed might also need support to process their situation.

As licensed social worker Ken Norton quoted, “It is said that a suicide dies but once and yet the survivors of the lost lives die a thousand deaths in the aftershocks of grief, guilt and shame.”

Postvention is considered “the third leg to the three-legged stool of addressing a suicide crisis,” aside from prevention and direct intervention but it is rarely included in programs such as this.

Better

Today, primary vaccinations in the city has reached beyond 100% for the target sectors. Booster shots continue to be administered to target groups. The schools have reopened for face-to- face, in-person classes.

The isolation units and temporary treatment facilities are now in back-to-normal business, serving tourists and travelers in hotels and inns. But the city’s infirmary in Barangay Lumbia, the JR Borja General Hospital and Treatment Facility in Barangay San Simon–- built and or refurbished with pandemic funds and other private hospitals — had increased bed spaces in preparation for a future surge.

Daily Covid-positives are either zero or in low single digits. There are barely a 100 active cases, mostly in isolation in their homes.

Leonen said the Sanggunian has approved, as its swan song before their term ended in June, the much-awaited Mental Health Ordinance, which is a community-based service delivery program under the City Health Office.

The ordinance  operationalizes the policies for local government’s roles laid out in the RA 11036.

With this legislation comes appropriate funding for more staff and counsellors to man the lifelines and serve the communities; more funding for training barangay health workers on psychological first aid and suicide prevention, and building facilities and providing free psychotropic medicines and mental health-care insurance for the mentally ill in barangays.

The implementation of the Mandanas ruling this year, in which local government units (LGUs) get a share of national tax revenues, heralds a bigger budgetary hoard for the LGUs and ensures better-funded mental health projects.

#Hawidlaum

But this September, ironically, suicide cases clustered during and after September 9, Suicide Prevention Awareness Day.

Eight completed suicide incidents and two attempts within a week brought mid-year incidences to 16, with 10 attempted cases. With three more months to go before yearend, it is predicted that the number of suicides in 2022 will far exceed last year’s 19.

Leonen and Mercado agree that a challenge remains that of reining in the media as their coverage of suicide cases, especially of radio stations, become more of a sensationalized feeding frenzy that violates ethical protocols and risks social contagion or copycat cases.

But Leonen trusts that with frequent reminders from mental health advocates and champions within their ranks, the media will carry on its tasks to rally people to choose #hawidlaum: holding on to hope.

#Hawid-laum: Did socmed radio trigger Oro's suicide cluster in September?  

Last of two parts

Cagayan de Oro – As the world marked the annual Suicide Awareness and Prevention Day on September 10 this year, a series of suicide incidents swept across Cagayan de Oro.

By the end of the month, the wave of eight cases within nine days - - from the September 10-18 - - catapulted the year's total to 23. This number of cases has surpassed 2021's tally of 19 suicide incidents, with still three months to go before the year would end.

But as quickly as the wave rose, during most of the month's second half - - between September 19 and 30 - - there were only two cases.

What caused the sudden spike and the equally sudden decline?

Maria Dolores Mercado, mental health program coordinator at the Department of Health-Region10 non-communicable diseases cluster, says exposure to exaggerated live broadcast coverage that extends from traditional to social media, could be a major factor.

In different forums in recent months, Dolores, a psychiatric nurse and college instructor in psychiatric nursing, had always called out the local broadcast media for its sensationalised  coverage of these events as this, according to her, could result in more "copycat" suicide cases in the city.

"This is called the Werther phenomenon," she said, quoting the latest Department of Health administrative order that sets guidelines for the ethical and responsible reporting and portrayal of suicide in mass media and the cultural arts.

She discussed this at a forum among journalists and in an online public service program at Oro Broadcast Services on October 8.

The Werther effect, first mentioned in 1982 by David Phillips, references Werther, the protagonist in Goethe's novel, "The Sorrows of the Young Werther", who killed himself because of unrequited love.

In 1774,when it was first published, many young men, who has read this epistolary novel, killed themselves.

Many studies suggest that "media reports about people who have died by suicide can influence vulnerable people as is associated with higher rates of suicide," according to the Canadian Association of Psychiatrists, in its 2018 re-issue of a policy paper on suicide reporting guidelines.

Mercado revealed, without citing figures, that in Northern Mindanao, suicide cases had  gone down this year as it had gone up in Cagayan de Oro.  

"Adtong 2020,medyo misaka ang atong mga kaso (Northern Mindanao). Sa 2021,misaka pa gyud. Niubos na siya karong 2022. Pero half of the year pa man ang datos nga nag-abot." (The suicide cases somehow went up in 2020. In 2021,it went even higher. The cases went down this year but the data we have comprise only those in the first half of the year. ")

Region 10 is comprised of Misamis Oriental, Misamis Occidental, Lanao del Norte, and Camiguin.

But she further pointed out that suicide rates in the city had been always high, correlating it to the sensationalised, on-the-spot coverages of suicide crises.

"Pero daghan gyud cases diri sa Cagayan de Oro. Mao siguro kay diri ra man gud nga sensationalised kaayo ang pag balita." (The suicide rates had always been high in Cagayan de Oro. It is probably due to the sensationalised reporting. ")

She recalled how at one time, she heard the news as she was riding a taxi.

"Diha gyud time nga nagsakay kog taxi nga gusto na nako ignan ang driver nga adtoan nato na. Kay sobra ka sensationalised ug ka detalye." ("There was a time while I was riding in a taxi and was listening to the news on the radio and I had this urge to tell the taxi driver to bring me to the radio station to give the anchor a piece of my mind.")

More than 50 studies worldwide indicate that several factors could aggravate the Wether impact, including the duration, amount, and prominence of coverage. Also considered are the detailed description of the method used, dramatic images, and repetitive/extensive coverage.

Papageno Phenomenon

If radio stations, with traditional and digital platforms, are a factor behind the surge in suicides, did they also contribute to the decline in cases after September 18th?

They probably did.

On September 18th, at around 8 p. m, a young man was seen at the edge of a protruding concrete platform holding the  deck at Ysalina Bridge across the Cagayan de Oro River.

A staff of a food delivery service company stopped by, climbed down to the platform, placed his arms over his shoulders, and talked to the young man in those crucial minutes.  

Relatives of the young man as well as a rescue team from Barangay Carmen came by later.  

"I saw him from afar as I was crossing over the bridge on my way to deliver a basket of fried chicken wings  to a hospital staff. I also saw a woman trying to get the attention of the young man, raising both hands but the man would not turn around and instead was just at the edge, looking down on the river," Ace Tristan Dy of Grab Food Delivery, said.

We were strangers to each other but somehow we understood each other,Dy reflected.

He said he had no training in rescuing people but his mother had often told him that he had the gift of persuasive speech. He attributed his calmness and intuitive skills to Buddhism, which is a long-time family practice.

In a few minutes, the young man agreed to go with his relatives.

Aside from traditional media coverage, the Facebook pages of at least 5 radio stations shared  these moments of rescue captured in photographs by the Sangguniang Kabataan of Barangay Carmen.

From September 18, there were but just a single report of an attempted suicide till the first week of the next month.

The decline could be what is called the Papageno effect.

Since a seminal study by Thomas Niederkrotenthaler, evidence is growing that mass media can play a positive role in suicide prevention by showing that there are alternatives to suicide, which bring hope to people in crises.

The phenomenon is named after Papageno, the character in the opera Magic Flute, who lost his love and contemplated suicide but was convinced by three boys to choose to live anew.

The station DXCC of the Radio Mindanao Network, among those which shared the story in its traditional broadcast as well as in its Facebook page, has a policy to cover suicide responsibly, thus it  reported the rescue extensively. Other radio stations like Magnum Radio, DXKO, Bombo Radyo and iFM Idol Radio also shared the posts.

Annaliza Amontos Reyes, program director at DXCC, said that their reporters are always reminded to follow the code of ethics of the Kapisanan ng mga Brodkaster sa Pilipinas (KBP) , of which the station is a member.

The KBP has a code of ethics which provides guidelines in how to report crises situations,among others. But it still does not have particular guidelines in covering suicide.

When a suicide occurs and coverage is deemed necessary, Amontos-Reyes said that they (reporters) emphasize suicide prevention.

"We interview a psychologist so our listeners are educated what to do when faced with similar situations. And how we can help those who are suicidal."

As for sensationalised coverages as part of the strategy to beat others in the ratings game, she admonished a do-no-harm policy as more important.

" Bisan pa makataas sa ratings pero makadaot sa kadaghanan, dapat I-minimize. "

" Dili kay mas daghan pang komentaryo bahin sa nahitabo o sa pamilya kay sa pag-educate." (Instead of providing more commentary (than news) on the survivors or the family, we must educate (our listeners),she stressed.

"Focus ta sa pag educate. Unsaon nato malikayan ang suicide, unsaon nato pag tabang sa mga suicidal. Mas kinahanglan nato ang pag educate, "

 ("Let us focus on the goal to educate. On the preventive measures. On how we can support those who are suicidal. We need to stress more on how to educate.") 

(This story was produced with a Health and Governance fellowship from the Philippine Press Institute (PPI) under the auspices of the Hanns Seidel Foundation-Philippines (HSFP). The contents of this story are the full responsibility of the journalist.