IAN WEBSTER: Preventing suicide

The 10th September is recognised as World Suicide Prevention Day.

“The burden of suicide does not weigh solely on the health sector; it has multiple impacts on many sectors and on society as a whole. Thus, to start a successful journey towards the prevention of suicide, countries should employ a multisectoral approach that addresses suicide in a comprehensive manner, bringing together the different sectors and stakeholders most relevant to each context”. Director-General, WHO Preventing Suicide: A global imperative, 2014.

The Australian strategies for the prevention of youth suicide and, in all age groups, had the task of reaching the groups at high risk and proposing universal prevention approaches for the whole population.

Australia is not homogeneous; there are different populations– each with their own substrates for suicide. In children and young people, the path to suicide is vastly different from old age, which in turn differs from middle-age; and there are differences between men and women.

The risk of suicide is increased in – Aboriginal and Torres Strait Islanders, prisoners and others involved in the criminal justice system, armed service personnel and veterans, the LGBTI community, certain occupations, rural communities, middle-aged and elderly males – are groups with increased risk of suicide.

Most people believe that suicide is caused by mental illness (up to 90%) and that preventing suicide is a task for mental health services. This view is held by mental health professionals, advocate organisations and governments. In 1998 I accepted the framing of suicide as a mental health problem as the evidence, then available, attributed 28 to 98 percent of suicide to mental illness.

But majority of people with a mental disorder do not engage in suicidal behaviour. National surveys show that 1 in 5 people in Australia have a mental disorder of some kind each year and ABS data record 11.8 suicides per 100,000 population over the same period – a thousand-fold difference between disorder and suicide.

In the common mental illnesses suicide is rare. In the less common psychotic illnesses – schizophrenia and bipolar disorder – the life-time risk of suicide is of the order of 5 to 10 percent, similar to the life-time risk in heavy alcohol and drug users and comparable to the risk in older people with physical health problems.

The causal role of mental health problems in suicide comes mainly from ‘psychological autopsies’. This research collects information about the likelihood that a decedent had been mentally ill before death. There are problems in research design and process – different definitions of mental problems, selection of informants, immediacy of events and bias, al-be-it unintentional, in the investigators. It focusses on mood and behaviour to the neglect of situation factors and runs the risk of attribution bias.

Leading suicide researchers, Louise Pouliot and Diego De Leo, said of ‘psychological autopsies’:

“…the current emphasis on psychiatric disorders in published research needs to be balanced by a better analysis of socioenvironmental contributors to suicide…” and, “efforts in this direction will promote a truly ecological approach to understanding suicide, and will assist in the development of better preventive strategies.

Plainly, mental disorder and suicide are related, and this determines much of the treatment received by people with mental illness, but, by default, this relationship becomes extrapolated to the whole population to prevent suicide.

Unfortunately, these extrapolations lead to the expectation that by investing in mental health services population suicide rates will be reduced. But the policy can’t deliver as a minority of suicides have had contact with a psychiatrist or a mental health service; whereas 80 percent or more have seen a GP in the 3 months prior to death and many more have attended a general hospital than a mental health service.

The belief that suicide is a mental health problem is powerfully influential. So much so, that doctors in the community and hospitals see suicidality as the responsibility of psychiatrists and mental health services, neglecting their own potential and responsibility to intervene.

It also means suicide prevention is seen as a sub-set of the mental health system – almost exclusively focussed on depression as the primary cause. This approach neglects attention to wider and more effective strategies – universal, selective and indicated – which deal with social, cultural and public health issues.

The 2014 WHO report, Preventing Suicide: A global imperative, said:

“No single factor is sufficient to explain why a person died by suicide: suicidal behaviour is a complex phenomenon that is influenced by several interacting factors − personal, social, psychological, cultural, biological and environmental. While the link between suicide and mental disorders is well established, broad generalizations of risk factors are counterproductive…Many suicides occur impulsively in moments of crisis and, in these circumstances, ready access to the means of suicide…can determine whether a person lives or dies. Other risk factors for suicide include a breakdown in the ability to deal with acute or chronic life stresses, such as financial problems. In addition, cases of gender-based violence and child abuse are strongly associated with suicidal behaviour. …Suicide prevention efforts require coordination and collaboration among multiple sectors of society, both public and private, including both health and non-health sectors such as education, labour, agriculture, business, justice, law, defense, politics and the media. These efforts must be comprehensive, integrated and synergistic, as no single approach can impact alone.”

Between 1998 and 2014 this was the approach of Australian governments but in September 2013 this changed with the election of the Abbott Government. The Gillard Government had appointed the National Mental Health Commission (NMHC) to report annually on the nation’s mental health. The new Minister for Health, Peter Dutton, to whom the NMHC now reported, and not the Prime Minister as initially planned, directed the NMHC to downscale its reporting on the nation’s mental health and to focus on the efficiency and delivery of mental health programs, with suicide prevention as an embarrassing afterthought.

The NMHC continued valiantly, but the blush of excitement of a wider societal perspective was lost. The focus inevitably shifted to service provision, costs and individualised treatments, important as these may be for those affected but of minimal impact on population well-being.

The suicide prevention strategies of the – UK, NZ, US and other countries – are public health and community-orientated programs. Without exception, they stress the role of communities, connectedness, understanding, responsible media and public discourse and social support. They all promote factors to protect vulnerable persons, especially young people. And they attempt to engage all sectors in society and to align government and non-government programs to be consistent with suicide prevention objectives.

Australia’s national suicide prevention strategy was recognized as being at the leading edge of these international initiatives. That vision needs to be recaptured if we are to have an impact on suicide statistics and the loss of valued lives and human potential.

Ian Webster AO, Emeritus Professor of Public Health and Community Medicine  at UNSW was chairperson of the Australian advisory councils for suicide prevention from 1998 to 2014.

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