IAN WEBSTER. It’s not mental illness, but despair

Aboriginal and Torres Strait Islanders have got it right when they frame the conditions we label as mental illness as issues of social and emotional well-being. They do not consider the endemic problems in their communities, as mental illnesses.

“It’s despair, not depression, that’s responsible for Indigenous suicide”, wrote Tim Carey and Rob McPhee in the Conversation on 14th of December and posted in Pearls and Irritations on the 18th. They accepted mental illness as part of Aboriginal and Torres Strait Islander suicide but there are other factors – isolation, unemployment, poverty, family conflict, incarceration, hopelessness, childhood abuse and homelessness.

The Senate inquiry into rural and remote mental health, reached a similar conclusion: that suicide in Aboriginal and Torres Strait Islander communities is not mental illness, but despair. The evidence from frontline Aboriginal and Torres Strait Islander organisations was that there are many life-problems – individual and community, arising from the historical breakdown in culture, contributing to the high rates of suicide. (Senate, December, 2018)

Similarly, opioid (and other drug) addictions, alcohol addiction and suicide in the US are being described as ‘dis-eases of despair’. The clear implication being that solutions to these epidemics are not medical, or health system reform, but lie elsewhere in social and cultural change.

The tragedy of suicide in Aboriginal and Torres Strait Islander communities is the impact on young men, and increasingly young women, representing the huge loss of potential for the future of young lives.

Canadian researchers, Chandler MJ and Dunlop WL, in “Cultural Wounds demand Cultural Medicines“, describe how half the 200 plus First Nations communities in Canada have zero suicides yet alongside them are communities with rates 1000 times the national average. Those marked by community-level efforts, claiming ownership of their past, control of their civic futures and cultural continuity (language, culture, women’s role, educational practices and childhood safety) had no suicides. For these researchers, suicide is not a “private problem”, when “depression is as common as clay”, and it demands culture-based community-level initiatives. Lessons of this kind are being implemented by Aboriginal and Torres Strait Islander leaders in Australia.

Where countries have strategies to prevent suicides, they are community and public health programs. They aim to connect individuals and communities, improve understanding, promote informed public discourse and media reporting and provide social support, such as for those bereaved by suicide. They aim to protect young people and vulnerable persons and to align government and non-government programs in preventing suicide – all sectors of government have a role to play.

But the Australian suicide prevention strategy has two main problems: firstly, suicide prevention is funded as a subset of mental health programs and, secondly, the key role of alcohol and drug policies is neglected.

Splitting suicide prevention from mental health

The subservience of suicide prevention to mental health is evident in the Fifth National Mental Health and Suicide Prevention Plan, August 2017. This is despite the Plan saying, “The causes of suicide and suicide attempts can be complex and multifaceted. While some mental illnesses can be linked to an increased risk of suicide, not everyone who dies by suicide will have a mental illness. The causes of suicide and suicide attempts can be complex and multifaceted.

Up until 2017, there was a semblance that suicide prevention embraced more than mental health approaches to include social, cultural and structural issues framed in public health and community development terms. Suicide prevention policies were not necessarily linked to mental health policy and programs, for example, in reducing the means of suicide – at ‘hot spots’, motor vehicle CO emissions, access to barbiturates, access to guns – and in GP initiatives and media reporting.

This vision for suicide prevention needs to be re-captured.

Alcohol and drugs

The second missing part of the suicide jigsaw, is the role of alcohol, drugs and addictions.

Alcohol is toxic to communities – it breaks down relationships and social and cultural norms. These breakdowns are powerful factors in the occurrence of suicide in exposed communities – in impoverished people of inner and outer urban areas and in rural and remote regions. Intoxication massively increases the risk of suicide.

Alcohol has a major role in suicide deaths as it does in deaths and hospitalisations from injury, liver, cardiovascular and cerebrovascular disease and psychoses. These harms are an order of magnitude greater in Aboriginal and Torres Strait Islander communities in which, on average, alcohol and drug use is double that of the general Australian population.

These are social and public health problems, not primarily mental health problems.

The medicalization of human predicaments, defining them as mental disorders, rather than recognising their social and structural trajectories, impairs society’s ability to respond to the epidemics of ‘dis-eases of despair’.

Nowhere is this needed more than in Aboriginal and Torres Strait Islander communities as proposed in Pearls and Irritations by Tim Carey and Rob McPhee, Deputy CEO, of the Kimberley Aboriginal Medical Service.

Ian Webster AO, Emeritus Professor of Public Health and Community Medicine was chairperson of the Australian advisory councils for suicide prevention from 1998 to 2014 and a National Mental Health Commissioner from 2012-2014.

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Ian W Webster AO is Emeritus Professor of Public Health and Community Medicine of the University of New South Wales. He has worked as a physician in public and regional hospitals in Australia and UK and in NGOs dealing with homelessness, alcohol and drug problems and mental illness.

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