Tackling suicidal ideation
It is critical that suicide prevention initiatives are person-centred and place those requiring support at the centre of the process. By Justin Frewen and Dr. Anna Datta.
Over one million people end their own lives annually, accounting for 1% to 2% of total global mortality. Ten to 20 times more people attempt to end their lives each year. The WHO estimates that by 2020 total suicides will rise to 1.53 million annually, equivalent to a fatality every 20 seconds or suicide attempt every 1-2 seconds.
The 2007 HSE report, Mental Health in Ireland, revealed that suicide was one of the three most important mental health problems faced by Irish adults along with alcohol and depression.
The HSE's National Office for Suicide Prevention's (NOSP's) reported that 424 Irish people took their own life in 2008, far in excess of the 276 lives lost on Irish roads that year. Men accounted for over 78% (332) of these suicides against 92 women. Suicide peaks amongst young males from 20 and 24, while women are at most risk in their early 50s.
There are some positive indicators. Ireland´s suicide rate, taking population growth into account, is at its lowest since decriminalisation in 1993 and is the sixth lowest in the EU. However, Ireland has the fourth highest rate of suicides amongst young men behind Lithuania, Finland and Estonia.
Although recorded suicides have decreased steadily since 2003, the statistical significance remains unclear. For instance, while recorded suicides fell from 460 to 424 between 2007 and 2008, undetermined deaths rose by over 50%, from 119 to 181. As the President of The Irish Association of Suicidology, Dan Neville, explains:
"There is always a question in relation to undetermined deaths and suicide. It has always been accepted that the official suicide statistical rate does not fully reflect the true level of suicide."
Although there is no universally accepted definition of suicide, it is generally considered a deliberate act of fatal self-harm with greater or lesser self-destructive intent. Suicidal behaviour is understood as a continuum ranging from suicidal thoughts to suicide attempts and completed suicide.
There is no clearly identifiable unique factor leading to suicide. Motives can entail a range of psychological, social, environmental and biological elements that may have occurred over an entire lifetime. Though the suicide attempt may result from a single incident, it generally follows years of suicidal ideation, behaviour, plans and potential warnings. Suicide is frequently preceded by a sense of separation and/or alienation, together with a loss of purpose aggravated by a feeling of suffering from which there appears no escape. In roughly half all suicides, there has been at least one previous attempt.
In addition to the considerable human cost of suffering associated with suicide, there are also substantial economic costs.
In a 2007 paper, Kennelly calculated the total annual costs of suicide at €900 million in 2001 and €835 million in 2002, or just under 1% of Irish GNP. Human costs, the value individuals place on their lives beyond their work capacity, account for the lion´s share of these costs at 70%. Indirect costs, lost output or production as a result of suicide, amount to approximately 28% while direct costs, including financial expenses associated with suicide, comprise the remainder.
Although these costs require further research, they indicate the substantial economic benefits to be realised in preventing suicide and tackling suicidal behaviour.
A range of overlapping and integrated suicide prevention programmes is required, perhaps comprising general education campaigns with more specific ones targeted at high-risk groups like young males. Primary care and specialist mental health care services should cooperate closely to support high risk groups in the community.
Preventing suicidal behaviour necessitates high levels of participation, coordination and cooperation by health, social and education services, businesses, and voluntary and health promotion organisations. Family, friends and work colleagues can also play a crucial role, as they are often the first to realise the difficulties a close one or colleague is experiencing.
However, most important of all, it is critical that suicide prevention initiatives are person-centred and place those requiring support at the centre of the process. In addition, community resources, knowledge and capacities should be utilised to as great an extent as possible.
Negative social determinants such as poverty, unemployment and under-employment, and low educational levels, increase the risk of suicidal behaviour.
Research by the National Suicide Research Foundation (NSRF) showed that during the Celtic Tiger years, unemployed men and unemployed women ran a significantly greater risk of suicide and undetermined death, 2-3 and 4-6 times respectively. The NSRF Research Director, Dr. Arensman, has emphasised the need for specific suicide awareness raising interventions for people dealing with the unemployed community.
Tackling negative social determinants is therefore imperative to reduce overall suicide rates.
As the WHO emphasises: "Suicide prevention requires intervention from outside the health sector and calls for an innovative, comprehensive multi-sectoral approach, including both health and non-health sectors."
Tackling the overall rate of suicide will require investment in suicide prevention programmes in the health and other relevant sectors.
In 'From Neglect to Respect´, the Irish Mental Health Coalition highlight the need to allocate sufficient resources to the NOSP, HSE and other voluntary agencies engaged in suicide prevention. This would require a major policy shift away from the current underfunding of mental health, as evidenced by the decline in the proportion of the overall public health budget allocated to mental health from 10.6% in 1990 to 5.3% in 2010. Failing to do so will result not only in many potentially preventable cases of suicide but also have considerable economic consequences.
Information and Counselling Support
If you believe you know someone who may be experiencing suicidal behaviour click here to visit the Samaritans for further information.
For information on counselling and support services available to those recently bereaved by suicide, the HSE´s NOSP have a directory available – You Are Not Alone: Directory of Bereavement Services – available online at http://www.nosp.ie/not_alone_directory.pdf