A man standing on the banks of a river sees a child in the water crying for help. He takes off his clothes dives in and pulls the kid out. No sooner has he done that when he sees another child in the river near to drowning. Again he dives in and heroically saves a life. But then there is another and another, so he stops and asks himself “Why are these children ending up in the river?” He decides rather than continuing to pull children out, he needs to move his efforts upstream to stop them falling in.
It is hard not to feel like that man when you are a psychiatrist. The Michigan Perfect Depression Care project demonstrates how good we can be at stopping people dying from suicide: we are pretty good at pulling children out of the river.
But even in an open access health service, like the British National Health System, only a minority (25-30 percent) of people who die by suicide will have seen someone for a mental health problem in the last year.
In many high income countries less than 50 percent of people with mental health and addictions problems get any treatment.
Michigan has decreased suicide risk, but only for those who get care. If we want to decrease the rates of suicide we need to increase the number of people in distress who get treatment and support as well as decreasing the social factors that make people suicidal. An ounce of prevention is worth a ton of cure.
But suicide prevention is not straight forward. Suicide is linked to complex social, psychological and cultural factors and is often not predictable.
An individual who takes their life usually has a number of different issues at play. Though they may take their life after what are known as “loss events” such as being made redundant, divorce or going to prison, there are often background factors such as bullying, social isolation, financial problems, mental health and addictions issues that contribute.
When you look across a population the rate of suicide is influenced by massive social change. But, just like for individuals, the impacts are not always predictable.
Sociologists have been trying to understand suicide rates for over 100 years. Emile Durkheim described four different types of suicide:
- Egoistic, where a person has a long period of feeling like they do not belong and are not integrated into society;
- Altruistic, where people who are well integrated may sacrifice themselves for the good of the society, such as a suicide bomber;
- Anomic, where an individual or society is in moral confusion because the expectations of life or rules of society have changed; and,
- Fatalistic, where a person may decide death is better than the constant abuse or oppression they face.
He argued that social change may affect suicide rates in countries differently because of their history, the way the culture deals with challenges, and their societal structure.
And that is what we find, for instance, the Asia Economic crisis in the 1990s was been linked to a sharp rise in suicide in South Korea, but researchers have been unable to find similar peaks of suicide in Hong Kong, Japan, Singapore or Taiwan.
Similarly, over 1 million Russians have died from suicide since the dissolution of the Soviet Union – but over the same time suicide rates decreased in some former Eastern Bloc countries.
The best predictors of suicide in Eastern Bloc countries between 1984 and 1994 are the rate of democratization, alcohol consumption, and social disorganization. But even these factors only predict changes in the suicide rates in 16 of 28 Eastern Bloc.
And economic changes by themselves were not a good predictor of suicide rates. It seems that social change rather than economic hardship is an important factor.
When countries develop suicide prevention strategies they usually think of the individual or, perhaps, at risk groups like veterans. But focus on the bigger picture, focus upstream on developing policies that help decrease the impacts of social change may be imperative if we are to decrease rates of suicide in a changing world.