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.
WHO Global Map of Suicide Rates
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.
This is an excellent article, Paul. Thank you so much for sharing this!
Well researched Paul. Your numbers make WHO strategies appear misguided.
A great article, Paul. I think that there will be better recording of suicide, and attempted suicide, once there is a better approach to dealing with and accepting the presence of suicide in a population. So point 1 will directly feed into point 2. Thanks for the links and I was always confused by why individuals who failed to commit suicide were then punished. It makes no sense and probably made things worse for the person. A few quotes from the BBC page you link to, that stand out for me:
“What was happening in the late 50s and early 60s was that attitudes shifted from suicide as wrongdoing or sin to the medicalisation of suicide, recognising that the majority of individuals attempting suicide or dying [from suicide] were in a great deal of distress,”
“From the middle of the 18th Century to the mid-20th Century there was growing tolerance and a softening of public attitudes towards suicide which was a reflection of, among other things, the secularisation of society and the emergence of the medical profession,” says Dr Wright, co-author of Histories of suicide: International perspectives on self-destruction in the modern world.
and what I didn’t know before, was this fact beside the text:
“Samaritans began in 1953 with Chad Varah, an Anglican vicar.
His first duty was to bury a 14-year-old girl. The girl had started menstruation, but, having no one to talk to, believed she was gravely ill and took her own life.
Reverend Varah vowed he would help others and set up Samaritans which later became the world’s first 24-hour helpline service.
It has 18,500 volunteers and 200 branches in the UK and Ireland.”
Issues of religion/secularism and cultural approaches to mental health/suicide is interesting, and like you, I’m not well versed to make too many comments on that, other than what I’ve grown up with, what I read in the news and my own interpretations. It’s not entirely positive.
A question for you, should you have come across anything on this: What role does the community play in reporting suicide or suicidal tendencies? Is there something with regards to education that can better prepare individuals to notice declining mental health in others as well as in themselves? With knowledge at our fingertips and a window into other peoples cultures, perhaps there will be a sea change in the way some communities now view suicide/suicide attempts?
Hi Jameela,
In response to your question about the role of community in reporting suicide & parasuicide behaviours -I’ve some experience in this area in the U.K. as a medic. The U.K. Centre for Suicide Prevention, based at the University of Manchester, is a national centre for the collation and coordination of research on suicide in the U.K.. The centre has become an excellent focal point for research & additionally works on an advisory level with the U.K. Department of Health and globally.
Research into suicide in the U.K. has been greatly helped by the creation of a national confidential inquiry into suicide in mental illness, commissioned by the U.K. health departments (http://www.medicine.manchester.ac.uk/mentalhealth/research/suicide/prevention/nci/). The inquiry investigates every suicide by people with known mental illness (similar to the ‘psychological autopsies’ mentioned in the article) the confidential aspect aims to remove the impact of stigma/fear of whistle-blowing in professionals.The enquiry looks into the role of medical professionals and crucially, the context of the victim and the community they were based in.
I’m aware of other ongoing U.K. research which looks more specifically at individual factors surrounding suicide & suicide attempts. One study of note uses qualitative methods to study both suicide attempt survivors & people close to them, looking at both factors that contributed to the attempt & the person’s experience, including the impression of those close to them. The aim of this research is two-fold, to better understand the psychology of attempts & also to identify characteristics/behaviours common in suicidal people. I think community based research like this is vital from a public health perspective to add to the strategies already in place to educate the public on how declining mental health & suicidality can present.
On a more individual level, a great deal of effort is spent in Psychiatry to educate both patients and their carers/ friends & family on both prevention & early recognition of declining health. Additionally, there is a large shift in Psychiatry to direct resources into community mental health to facilitate early intervention, prevention & treatment with improved access to a wider range of support.
Although I don’t have a great deal of experience of mental health strategies on a more global level I think these approaches could be translatable on a more global level, the C.S.P in particular is already involved in the global discussion on suicide.
Ruth
When you factor in war torn areas, debilitating disease and/or migration, figures for suicide may become muggy…it IS complicated to get numbers and ultimately evaluate the success of any initiatives that deal with improving the lives of people, who are mentally ill and their surrounding support networks.
Thanks, Paul, for your timely and insightful article. I agree fully with points 1 and 3 as increasing the understanding and appropriate treatment for depression and other mental illnesses are the cornerstones to decreasing suicide. As a mental health professional who worked in an emergency assessment capacity as well as a therapist for many years, I have reservations about attempting to “attempting to control methods of suicide.” I believe if it was possible to control the current most common methods of suicide, then other methods would just become the most common (i.e. jumping from a high building or in front of a moving car – which is terribly hard to regulate). I think focusing on trying to control the methods of suicide, instead of on the people suffereing from depression or other illnesses, only diverts attention away from better understanding and treatment. The only point I would add would be to promote community based education and support programs (as well as peer-to-peer, advocacy and family support organizations) potentially allied to the medical treatment community. As numbers, methods and cultural implications of suicide are so variable, communities can be a truly powerful ally in support of their own members.
Thanks for your comment Amy. I completely agree with you that community is key in suicide prevention. Being integrated into one’s community with a strong support system is certainly very protective against a number of mental illnesses
As for the control of suicide methods, I partly agree. I left this as the last of my priorities precisely because it is dealing with the symptom and not the cause. I also agree that there is some degree to which regulation of suicide methods will simply cause people to change methods. However, this is not entirely true. There is evidence that removing so-called “easier” methods of suicide reduces suicide rates. The pesticide problem in poorer countries provides some useful examples. In Sri Lanka, reductions in suicide have coincided with restrictions on imports and sales of the most toxic pesticides.
Further, by switching common methods of suicide to less effective ones, we can gain more time to treat people and bring them into mental health programs. For example, studies suggest that there is no greater suicidal intent in those who intentionally ingest toxic pesticides than in those who intentionally overdose on prescription drugs (as is much more common in richer countries which have greater regulation of pesticides). However, the former are much more likely to succeed in their suicide attempt. Thus by reducing availability of more effective methods, we can effectively reduce suicide rates and bring the attempted suicides into mental health programs (see here for more details: http://ije.oxfordjournals.org/content/32/6/902.long ).
Having said that, it is of course vital that there are strong support systems available both in communities and in health systems to help those who have attempted suicide or are contemplating suicide; so I completely agree that this should never stray from the forefront of our strategies.
Thanks Paul for the very valuable information. I fully agree with your priorities and attempt to pull the suicide issue into (global) mental health policies and area.
See full text at http://www.who.int/bulletin/volumes/86/9/en/
SUICIDE PREVENTION, A FIVE COUNTRY INTERVENTION STUDY
According to WHO estimates, yearly deaths from suicide exceed 800,000,
occurring in almost all age groups.
In this research article from the Bulletin of the World Health Organization
, Alexandra Fleischmann and colleagues report the results of a multicountry
intervention study to test brief intervention and contact with suicide
attempters against treatment as usual. Those in the study were randomly
assigned to treatment as usual or brief intervention and contact. Survival
at 18 months was significantly higher in the intervention group.
“The brief intervention and contact treatment modality included, in
addition to treatment as usual, a 1-hour individual information session as
close to the time of discharge as possible and, after discharge, nine
follow-up contacts (phone calls or visits, as appropriate) according to a
specific time-line up to 18 months (at 1, 2, 4, 7 and 11 week(s), and 4,
6,12 and 18 months), conducted by a person with clinical experience (e.g.
doctor, nurse, psychologist). The individual information session was
conducted according to
a written protocol which all sites adhered to. It included information
about suicidal behaviour as a sign of psychological and/or social distress,
risk and protective factors, basic epidemiology, repetition, alternatives
to suicidal behaviours, and referral options.”
Although conducted in developing countries, the study results are of wider
interest. Any intervention which is affordable in developing countries will
also be affordable in industrialized ones.
For anyone interested, The Lancet have just published a series on suicide. Their emphasis is on restriction of highly lethal methods of suicide, such as handguns and pesticides, as a strategy for suicide prevention (priority no.4 in my article). http://www.thelancet.com/series/suicide
Thanks for sharing the article. The issue of suicide is rarely discussed. Mental health in general is blatantly ignored as a global health issue. It’s nice to see that more and more, people are becoming aware of it and are open to talking about it and to finding solutions.