Contributed by Paul Southworth:
As always, first come the statistics. Suicide is thought to kill about a million people a year and by 2020 this is expected to increase to more than 1.5 million with 85% of suicides occurring in low- and middle-income countries. Between 10 and 20 times as many people attempt suicide as succeed and with 5 to 6 people affected by an individual’s suicidal behaviour, somewhere in the order of 100 million people are directly affected by suicidal behaviour each year. On top of this, and what these numbers cannot tell, is the enormous suffering of those who wish to end their life and of those who lose their loved ones and/or caregivers to suicide or suicidal behaviours.
From all this, we can safely say that suicide is an enormous public health issue. But is suicide itself a global health issue? There are many definitions of ‘global health’ floating around, so I should define what I mean by it here. By ‘global health’, I mean those health issues which can best be dealt with internationally, with cooperation across governments and international organisations directing or supporting international and within-country schemes. Methods of suicide, rates of suicide and cultural attitudes to suicide all differ greatly across the world. Even in a country as small as the United Kingdom, the suicide rates are very variable. In Scotland, for example, suicide rates among those under 18 years old are as high as 5.2 per 100,000 whereas in England and Wales the figure is just 1.4 per 100,000. To address this as a ‘global health’ issue, it is important to have a flexible set of aims and priorities and not a restrictive one-size-fits-all strategy which, in reality, fits no-one.
In 1993 the World Health Organization (WHO) proposed the following five broad priorities to pursue: (i) control of gun possession; (ii) detoxification of domestic gas and car emissions; (iii) control of availability of toxic substances; (iv) toning down news reports about suicide; (v) early recognition and treatment of psychiatric disorders. The inclusion of changes to news reports as a key priority in the WHO strategy is probably an overstatement. While there has been evidence to suggest that responsible news reporting can prevent some suicides, it is thought that there is contribution of the media in only 1-2% of suicides. I believe that, nearly 20 years later, we should rethink and renew our priorities. I am not an expert in this field and I do not pretend to know better than Global Mental Health experts what to do. Nevertheless, I have below drawn up a brief list of priorities to generate discussion over what we can do globally to reduce suicide.
1. Encourage treatment of suicide as a health matter, not a criminal matter.
I have deliberately placed this as the first priority because of its huge impact upon the others. Suicide and attempted suicide are still illegal in a large number of countries, including many African countries and Islamic countries. This is often driven by religious, social and cultural beliefs and norms. The social response to suicidal behaviours in some areas can be very severe:
“In Uganda, some reports indicate that suicide victims do not receive a decent burial; their families and the survivors of suicide attempts are shunned; and those who are employed do not have their terminal benefits paid to the surviving family members.”
Obviously moves to destigmatise suicide would require a big change in the culture of these countries, but decriminalisation and medicalisation of suicide and attempted suicide could certainly help propel this forward. It is difficult to see any great downsides to legalisation. If the worry is that acceptance of suicide as legal might increase suicide rates, this does not seem to be borne out by the evidence. Indeed South America, where suicide is not illegal, is thought to have some of the lowest suicide rates in the world. It is also worth remembering that it has only been 50 years since suicide was decriminalised in England and recent decades have seen successful suicide prevention strategies there. This BBC article describes some tales of what happened to attempted suicides before decriminalisation.
2. Better reporting of suicide and suicidal behaviour.
The first thing you’ll notice about the map above is how astonishingly little data there is on suicide in Africa. In fact, there is no country-wide data on suicide for more than half of the world’s countries, most of which are resource-poor countries in Asia and Africa. The most recent WHO report (Violence and Health in the WHO African Region 2010) offers an excellent overview of the available data, but most of their data comes from South Africa, with only four countries providing country-wide data (Mauritius, Sao Tome & Principe, Seychelles and Zimbabwe). For such a large and diverse continent, this is obviously a poor representation and extrapolation is difficult. Poor reporting is likely intimately linked with the first point, with political, religious and cultural reasons given for this paucity of data. In rural parts of India, where suicide is illegal, it is estimated that underreporting of suicide may be as much as 9- or 10-fold. Getting good data is vital to developing local and regional suicide prevention strategies. Without knowing the nature of the problem, it is exceedingly difficult to find solutions.
It is also very important to have a standardised definition of what constitutes suicide. This may sound pretty obvious, but different countries have different rules for determining when a death is declared a suicide. Some countries require external evidence of intent, such as a suicide note, while others require only judgement of intent. Furthermore, globally there is even less data on attempted suicide. How much of the variation between countries is due to success rates in treating those who have attempted suicide; how much to differences in chosen methods; and how much to rates of suicidal behaviour? It is very difficult to say. Greater reporting of suicidal behaviours and unsuccessful suicide attempts could give a greater understanding of suicide prevention strategies worldwide.
3. Greater recognition of good mental health as key to good health – early recognition and treatment of psychiatric disorders.
In a recent article, I lamented the disproportionately low attention received by mental illness as a global health problem and suicide could be described as perhaps the most dramatic outcome of poor mental health. Psychiatric illness is an important factor in suicide. Evidence from so-called ‘psychological autopsy’ studies suggests that over 90% of people who commit suicide had recognisable psychiatric illness at the time of death. Furthermore, the presence of depression in those who go on to commit suicide appears to be a universal across cultures, rather than a construct of Western psychiatric practices.
The nature of necessary mental health services will vary greatly by country and region, depending on culture, resources etc. However, what is clear is that all countries are under-treating mental illness with no country thought to be treating more than a third of those who experience mental illness and that number substantially lower in more resource-poor countries.
4. Where feasible, control of methods of suicide
The control of methods of suicide made up three of the WHO’s five strategies for suicide prevention in 1993. I have left this priority for last because of the diversity of suicide methods around the world. The priority given to each control method will differ greatly between countries. For example gun control is a much bigger concern in the US (where it is the chosen method of 60% of male suicides and 36% of females) than in Japan (0.2% and 0.0% respectively). Similarly, there is a huge problem in many resource-poor countries with suicide by ingestion of agricultural pesticides, reaching approximately 90% of suicides in El Salvador as well as in rural areas of Malaysia; while such a problem is almost non-existent in most of the so-called “developed” countries. Further, in those parts of the world where the most common suicide methods are hanging, falling, cutting etc. the control of suicidal methods is likely to be much less plausible or effective. Nevertheless, it is clear that tighter controls on guns and toxic substances could have a large impact on global suicide numbers.
Taken together, I believe these priorities form an effective framework for both reducing suicide rates and gaining a greater understanding of suicide and suicidal behaviours worldwide. Furthermore, by learning about suicide around the world, it is likely that we can gain insight into different ways of dealing with and preventing suicidal behaviours both medically and at the community level. It is already known that approaches from resource-poor countries to some mental illnesses can be more effective than “Western” approaches, such as with schizophrenia. It is entirely possible that the same could be true of suicidal behaviours. By countries working together rather than separately, we can be more than the sum of our parts and develop more effective ways of reducing suicide. As I have said previously, I am no expert in this area, but I hope that by drawing up a list of priorities like this, we can stimulate discussion of what I believe to be an under-appreciated global health problem.