Today is World Suicide Prevention Day, endorsed by the World Health Organisation (WHO) and by the International Association for Suicide Prevention (IASP). The latter encourages pro-life activities and lighting a candle by our windows tonight as a way to remember those who, in the words of outgoing WHO Director-General Margaret Chan, succumb to this “preventable tragedy”.
One person commits suicide every 40 seconds worldwide (800,000 suicides per year), which is probably a considerable underestimate of the size of the problem as many such deaths are not reported due to shame and inadequate data collection. Only 60 countries have good-quality vital registration data on suicide (WHO, 2017).
Suicide and self-harm are the most stigmatised and concealed mental health challenges. Keith Hawton, director of the UK’s National Suicidology Research Centre, describes suicide as “a highly complex issue with a range of causes at both the individual and contextual levels”, (British Journal of Psychiatry, June 2017).
To date this year, 14 Maltese and Gozitans reportedly died a lonely death, probably suffering in silence and without anyone realising what they were going through. This makes it about half the expected number of suicides this year (28 in total). Seven years’ data collected by Crisis Resolution Malta (CRM), the only 24/7 crisis resolution and home treatment team established in 2010, reveals that, on average, 30-40 males and females die by suicide annually.
WHO also states that for every suicide, at least six people are directly affected by this crisis. Locally, this amounts to about 168 individuals (28 x 6) annually. These loved ones are themselves at risk of lifelong mental health problems with all the burden that this entails on themselves, on society and healthcare. Of serious concern is the fact that these individuals are at increased risk of committing suicide themselves as they spend a lifetime tormented by endless, unanswered questions about their loved one’s death. Suicide thus inflicts a transgenerational legacy of pain and suffering.
WHO also reports that for every person who commits suicide, about 20 self-harm. In essence, this amounts to more than 4,000 potential victims directly or indirectly affected by suicide and self-harm in Malta per year. Besides, self-harming once renders a person a hundred times more likely to repeat this act in the next 12 months compared to the general population. Hence, attempted suicide should not be dismissed, and measures must in place to avoid repetition.
Affecting all social classes, suicide peaks beyond middle age. It also peaks in adolescents and young adults, being the second commonest cause of death after physical trauma in this category. Risk factors include socioeconomic downturn, social isolation, male sex, drugs, gambling, alcohol, bullying and gender issues. Depression is the commonest mental health risk factor for suicide and is the leading cause of disability worldwide, exceeding heart disease and cancer (WHO, 2017). Keith Hawton also mentions “lack of help at times of crisis” (i.e. lack of a crisis team) as a further risk factor (British Journal of Psychiatry, 2017).
Locally, few provide long-term care for these people. Even fewer cater for those who grieve the loss of their loved ones or those who are traumatised by people known to them who self-harm. CRM, in fact, reports that crises are sadly the most unaddressed and under-resourced locally. Experience shows that despite initial goodwill and scattered services, the enthusiasm fizzles out. National anti-suicide projects are non-existent.
CRM has been campaigning to have a national suicide prevention strategy since 2010, in keeping with WHO recommendations. We forwarded a draft strategy to the Health Department in 2015. It embodies the latest evidence-based research, applied in a stepwise fashion, and focuses on six objectives: 1. Reduce the risk of suicide in key high-risk groups; 2. Tailor approaches to improve mental health in specific groups; 3. Reduce access to the means of suicide; 4. Provide better information and support to those bereaved or affected by suicide; 5. Support the media in delivering sensitive approaches to suicide and suicidal behaviour; 6. Support research, data collection and monitoring.
It isn’t the first time that we ‘knocked’ at somebody’s door as he was planning to kill himself
Crisis teams are the tip of the arrowhead poised to implement and manage such strategies, according to WHO and Hawton. These teams are so important that our local Mental Health Commissioner, John Cachia, stated in his 2016 annual report (and told this newspaper) that “crisis intervention services must become an integral part of the emergency response services at Mater Dei Hospital”. The report notes “with concern that crisis intervention services were effectively non-existent in 2015”. Sadly, little has changed since due to lack of funds and resources. Other than CRM (which often does pro bono work), there is no other 24/7 service.
Crisis teams save lives and prevent hospital admissions: CRM estimates that it sees about 25 people a week who present in crisis varying degrees of suicidal ideation. Thankfully, not all have the same intent to take their lives, but it nevertheless highlights the gravity of the issue.
In order to stem this potential loss of life, CRM runs a busy 24/7 national crisis line (a key component of a prevention strategy) at no charge. We are humbled that we have managed to save many lives, discreetly and without fanfare also thanks to the efficient police force and Facebook’s tracking service. It isn’t the first time that we ‘knocked’ at somebody’s door as he was planning to kill himself, after spotting his location through his IP address, while a crisis team member was engaging him online. Occasionally, we even receive calls or messages from people as far away as Canada or Latvia seeking support, and we liaise with crisis teams there to save lives.
The strategy also includes setting up a national surveillance system in Malta and Gozo, which consists of crisis telephone lines and webcams located at sites where people jump to their deaths. These measures, which are long-established abroad, are among other strategy requisites endorsed by Hawton’s centre, including school and work-based awareness programmes, social media help, removal of ligature points in hospitals, and erecting barriers. Kudos go to Mosta local council for setting up barriers at their locality’s bridge. Police sources tell us that the number of suicides last year dropped from the expected nine to two. The same applies for the erection of nets at our prisons which saves lives every month.
Besides, revolutionary magnetic stimulation therapy reverses suicidal ideation within hours and is an evidence-based and painless treatment that is easily applied by any crisis team. This can make the difference between forced admission (with all its associated negative connotations) and supervised outpatients follow-up.
Hawton’s research proves that non-sensational, responsible media reporting is also a way to reduce suicides and is known as the ‘Papageno effect’, whereby offering crisis line numbers and expert advice in newspaper articles diminishes suicides. This is contrary to the popular notion that talking about suicide makes people want to commit suicide. People in crisis want to remove the helplessness they are going through and not actually kill themselves. They crave a listening ear to ‘kill’ the pain, not themselves (IASP, 2017). The ‘Werther effect’, also researched by Hawton, is copycat suicide behaviour due to unnecessarily graphic articles about suicides. This may increase newspaper sales but sadly also increases the suicide rate.
Hawton advocates that crisis teams should adopt WHO’s Brief Intervention and Contact (BIC) method for people who were discharged home from hospital after a suicide attempt. In essence, this evidence-based approach diminishes suicides by having a one-hour individual information session pre-discharge and nine follow-up contacts (phone calls, internet contact or home visits) post-discharge (British Journal of Psychiatry, 2017). CRM’s success in saving lives is precisely because it has been doing this since its inception principally through its Facebook page (Crisis Resolution Malta) and crisis line (+356 9933 9966).
Furthermore, this strategy must prioritise the person’s psychosocial needs and “focus on the particular circumstances, characteristics and meanings that seem likely to have precipitated this suicidal ideation and destructive behaviour” (British Journal of Psychiatry, 2017).
Taking care of self-harmers, suicide survivors, their loved ones and the relatives of those who succumb to suicide is also vital. This strategy endeavours to meet the WHO target to cut the suicide rate (at present six per 100,000) by 10 per cent in 2020. Involving stakeholders is imperative.
However, people are not mere statistics, as those who work in the field will attest. Ask any crisis professional who attends the funeral of a person who committed suicide. The shrieks of the pale widow, toddler in tow, standing listless by the coffin, held upright by her distraught brothers screaming: “Għaliex ħallejtna waħedna? Għaliex m’għedtlix?” (‘Why did you leave us alone? Why didn’t you tell me?’), remain etched in the mind of even the most hardened professional. What do you do to appease the pain? How can you help heal the lifelong hurt?
This challenge cannot remain unaddressed locally. People keep dying uselessly every month. Life is beautiful and we need a strategy to spot and help those in need. What if one of your loved ones were involved? Would you care about suicide then?
Mark Xuereb is a psychiatrist who manages crisis teams and is a visiting university lecturer.