What would you say is the potential of approaches such as biomarker-based screening or stratified medicine in tackling suicide rates?

I come from a developing country, where we don’t have such a sophisticated measure for stratified medicine, or the technology to do biomedical research and to look into the biology of suicide in depth. Actually, suicide is underreported in my country, because of the stigma, because of the social pressure, because of the religion. My country is Muslim and Islam prohibits suicide and considers it a sin. There’s a verse in the Koran “you don’t have to kill yourself because your soul belongs to God, to Allah”. So many patients I have met, they say “we think of suicide, we have suicidal ideas and intentions but we don’t do it because of religion”. On the other hand, there are a sizeable number of patients who commit suicide. But we don’t have a precise, official number for this because it is misreported as an accident. In our country, violence is an everyday occurrence, so it isn’t easy to differentiate between suicide and homicide.

What characteristics of mania with depressive symptoms do you think are to blame for the higher risk of suicide seen in sufferers of the condition?

In a country like ours, a developing country, or an Arab-Muslim country, suicide risk factors usually present in bipolar patients who discontinue their medication. I have been practicing psychiatry for 30 years, and I think the most important factor for relapse is discontinuation of medication. Drug adherence is the number one problem that we face in our country. We prescribe medication, but there is no system for appointment and follow-up, so very, very low numbers of our patients come back to us. We’ve just lost them. Either they take the medication on their own or they go to a faith healer, or they go to other psychiatrists who we have no connection to.

What special precautions would you take to lower the risk of suicide in patients diagnosed with mania with depressive symptoms?

In my experience, the most important factor, or preventive factor, is to maintain the treatment and to keep the patient under observation, to instruct the family to bring the patient to the nearest mental health services centre or a hospital or even to a primary health clinic when they see very early signs of relapse. We do have a problem though - a huge number of our patients will go to faith healers, who don’t support maintaining drug treatment.

The other preventive or protective factor is the presence of social support. In developing countries, I think there is more social support than in Western countries. I mean, patients live with their family. They are not abandoned; they have fathers, mothers, husbands, brothers and sisters. We do have this family cohesion, which I think is good for mentally ill patients.