Stellenbosch University: Suicide prevention requires actions, not just words

World Suicide Prevention Day was observed on Saturday 10 September. In an opinion piece for the Mail & Guardian, Prof Jason Bantjes (South African Medical Research Council / Institute for Life Course Health Research) writes that talking about suicide will not be enough to prevent it in South Africa. Purposeful actions are needed to reduce suicide rates.

Read the article below or click here for the piece as published.
​Jason Bantjes*

World Suicide Prevention Day (10 September) provides another opportunity for more public conversations about a global public health issue which results in approximately 703,000 deaths a year worldwide. But what more is there to say about suicide that has not already been said? And what is the point of talking about suicide prevention unless we are willing to act?

People have been talking about suicide and suicide prevention for ages. Although suicidal behaviour has been understood in different ways at different times in history, the practice of suicide prevention has evolved into an evidence-based science and there is growing consensus among professionals about best practice to reduce suicide rates.

Suicide has been variously constructed as a personal choice, an existential crisis, a spiritual matter, a moral failing, a criminal act, a symptom of mental illness, and more recently as a human rights issue. Ancient scholars wrote about suicide and thought deeply about when, if ever, suicides were justified. Since at least the 5th century AD religious leaders have actively counselled against suicide and in Europe in the 10th century AD laws prohibiting suicidal behaviour were established in a misguided effort to curb suicide.

The first academic suicide prevention conference was held in 1908 and suicide prevention centres and suicide helplines have been around since the 1950s. In 1968 the American Association of Suicidology was born and the field of suicidology (i.e. the scientific study of suicide) was officially founded. In the past 70 years the field of suicidology has rapidly expanded with several academic journals now entirely dedicated to the subject.

The proliferation of suicide research has shown that suicide is preventable and that zero suicides may not be an unrealistic pipedream. We are far from clueless or helpless to reduce suicide rates and we have a fairly good idea of what needs to be done.

Effective suicide prevention strategies include promoting access to evidence-based treatment for mental health problems, training primary care physicians to recognise and treat depression, equipping health professionals to recognise suicide warning signs and intervene in a suicidal crisis, educating young people about depression and suicidal behaviour and actively following up with psychiatric patients after discharge or a suicidal crisis. Other strategies, like gatekeeper training and internet and helpline support, seem promising but have not been researched as thoroughly yet.

The media has an important role to play in suicide prevention. The evidence suggests that by adhering to responsible reporting guidelines, the media can help to reduce suicide rates and a contagion effect associated with irresponsible coverage.

Restricting access to lethal means is a very effective prevention strategy, especially control of analgesics (i.e., medications that relieve pain) and poisons, as well as interventions at locations frequently used for suicide by jumping. In Sri Lanka, for example, suicide mortality was reduced by 21% between 2011 and 2015 by banning several pesticides (paraquat, dimethoate, and fenthion) known to have the highest suicide case fatality rates. And there is evidence to suggest that interventions focused on establishing barriers and nets in places where people frequently jump to their death are associated with a 28% net decrease in annual suicides by jumping.

We also know that to be effective, suicide prevention efforts require inter-sectoral collaboration and should include systemic interventions at a community level. Suicide prevention at a population level requires interventions to reduce poverty and unemployment, address gender-based violence, create safe communities, reduce social isolation, increase belonging, and establish bully-free schools.

We know that substance use is strongly associated with suicidal behaviour, and interventions to reduce hazardous substance use are integral to any national suicide prevention strategy.

Alcohol, for example, increases the likelihood of suicidal behaviour through multiple mechanisms. First, as a central nervous system depressant, alcohol intoxication can increase impulsivity and psychological distress, which are well-established risk factors for suicide. Second, alcohol dependence precipitates and exacerbates symptoms of mood disorders, which are strongly associated with suicidal behaviour.

Third, alcohol dependence can have a serious negative impact on work and relationships, reducing social connection and support. It can result in frontal lobe executive dysfunction, which, in turn, impairs problem-solving ability and future orientation, all of which are further risk factors for suicide. A recent systematic review of alcohol interventions on suicidal ideation and behaviour concluded that interventions to limit an individual’s consumption of alcohol led to significant reductions in self-harm.

Although we know a great deal about what needs to be done to reduce suicide rates at an aggregate population level, it is much more difficult to prevent suicide at an individual level. There are many reasons for this, including the fact that mental health professionals struggle to predict who will complete suicide and we don’t always see the warning signs, except retrospectively. We can identify groups of people who are at elevated risk of suicide but even the best statistical prediction methods based on current scientific evidence are only slightly better than the chance at predicting which individuals will attempt or complete suicide. This can sometimes create the impression that “suicides come out of nowhere”.

If we know what needs to be done to reduce suicide rates at a national level, why are we still talking about it? It is easier to talk than to do the difficult work of mobilising resources, changing attitudes, strengthening our public mental health care system, increasing access to effective treatments for mental disorders, creating safer schools, building communities where people can find a sense of belonging, ensuring that mental health care is an integral part of our primary health care system, reducing poverty and ending sexual violence. This year’s World Suicide Prevention Day is an ideal opportunity for us to stop talking and to start acting purposefully. Actions do speak louder than words, after all.