The Journal’s concerns about suicide

The world has changed since the Australian and New Zealand Journal of Psychiatry’s (ANZJP) first issue was published in 1967. Drugs, AIDS, wars, migration and economic crises (for example) changed lives. Altered circumstances can affect mental health and degrees of stress, anxiety and depression. The present commentary is focussed on suicide. For the last 50 years, the Journal has facilitated discussion of why people kill themselves or self-harm, and what can be done to stop it happening, giving particular attention to what happens in Australia and New Zealand.

Goldney (2013) helped celebrate the College’s 50th birthday by providing a review of ANZJP publications concerning suicidal behaviour. Suicide was of major interest in 7.4% of the articles published in 1967–2012; he cited 29 of the 342, doubtless wishing he could cite more. The ANZJP has published more on suicide since then. Commendably, one issue in 2015 and another in 2016 (as in several previous years) were focussed mainly on suicide, thus highlighting the Journal’s awareness that the topic needs continuing attention.

The Journal provides an ongoing forum for presentation of data concerning patterns of suicide in Australia and New Zealand. Discussion has centred on reasons for changes in those patterns. Hassan and Carr (1989) quoted Durkheim when commenting on striking fluctuations in Australian male and female suicide rates in 1895–1985. They profiled some of the sociological factors which appeared to have influenced suicide rates. Male suicides during the Great Depression were viewed as at least partly a result of erosion of the (then) customary male role as the economic provider of the family. The overall male rate was 24.0 per 100,000 in 1930; in 1944, it was 9.9 per 100,000.

Attention has been drawn to extraordinary changes in age patterns of suicide in both Australia and New Zealand since the 1960s, suicide rates of males in their 20s having reached peaks in the 1990s but halving since that time. Also since the 1960s, suicide rates of older men have fallen dramatically – except among those aged over 85 years. Why? What caused the fall? In Australia, the initial male peak has now shifted to middle age (attributable to a cohort effect). Suicide rates of most male and female age-groups increased between 2013 and 2015 (male up 16.7% to 19.4, female up 10% to 6.1 per 100,000). Australian and New Zealand female rates have remained relatively low across the age-range for decades.

Since the 1980s, suicide rates of younger indigenous people in both countries have risen much higher than those of same-aged non-indigenous populations. In Australia, the overall male and female indigenous rates are now (alarmingly) 31.8 and 11.9 per 100,000, respectively. The Journal can and should contribute to protest and advocacy.

How do differences between populations around the world relate to their suicide rates? Why is suicide proportionally much more common among women in China and India than in Australia, New Zealand and the United States? What does this tell us about the causes of suicide? Why has there been such a substantial recent fall in the male suicide rate in Japan? Documentation of patterns elsewhere in the world tends to be in overseas or international journals. By seeking to publish more about suicide patterns in overseas countries and comparing them with those in Australia and New Zealand, the ANZJP would facilitate broader discussions among its readers concerning precipitants of suicide.

Many papers in the Journal have focussed on prevention of suicide. Krysinka et al. (2016) concluded that the greatest impacts on suicide reduction have resulted from psychosocial treatment, general practitioner training, gatekeeper training and reducing access to means. The ANZJP has published data demonstrating that restricting access to firearms, carbon monoxide poisoning and places from which to jump have led to decreased suicide rates. Method substitution may follow, but commonly after a delay. In certain Asian countries, use of charcoal-burning was popularised (partly by media) as a suicide method in the early 2000s, leading to astonishing increases in suicide rates – most notably in Korea. Restricting access (as was done for pesticides in Sri Lanka and elsewhere in Asia) has led to big reductions in rate.

The recent increase in Australian suicide rates has led to frustration regarding perceptions of limited responses to preventive effort and calls for a new national strategy aiming to cut the suicide rate. However, before rushing into a new approach, there is good reason for examining why suicide rates have decreased or stayed low in various sub-populations. The above-mentioned reduction in late-life suicide rates has been ongoing – and we can debate whether this has been due to improved mental or physical health management, or for socioeconomic reasons or what. Suicide rates among younger non-indigenous Australian males have decreased substantially since 2000. Why? They have increased in cohorts who are now middle-aged.

In order to review strategies in Australia and New Zealand, we need to focus again on who dies by suicide and why. What provokes persisting anguish in these individuals, and why them? Why the increasingly high rates among younger indigenous people in both countries? If the answers have already been provided in this Journal, we should act on them.

There is good reason for suspecting that psychache (anguish, emotional turmoil, mental perturbation) precedes most suicides (Shneidman, 1993), and that this arises from a complex interplay of factors. Pridmore (2015) concluded that

suicide may be the result of a mental disorder, or a single socioeconomic stressor (such as public disgrace), but more often it is the result of a number of stressors, one of which may be a mental disorder, with other possibilities including unemployment, relationship failure, drug and alcohol use, and painful emotions such as shame, guilt and sadness.

In China, it appears that a large proportion of suicides are impulsive, in response to relatively brief periods of anguish. Impulsive pesticide consumption is commonly lethal. Can we accept that emotional turmoil commonly does not fulfil Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for ‘mental disorder’? Studies show that Chinese suicide decedents are less likely to have had definable mental disorders than people in Western countries who die by suicide. The Journal facilitated debate about Pridmore’s views and the importance of mental disorder in relation to suicide. Mental illness is clearly a factor in some cases. In others, socioeconomic disaster (maybe with consequent severe anxiety/depression) was the precipitant. A narcissist’s loss of self-esteem may lead to suicide. Acute feelings of guilt, remorse or shame may lead to intolerable anguish (think Judas Iscariot). Whether or not the feelings are persistent and severe enough to think a diagnosis of ‘mental disorder’ is appropriate, psychological or environmental interventions may well be more effective than medication in averting suicide. It is vital that we look at what is right for the individual – and that we ensure there are opportunities to intervene in time. The Journal has a responsibility to provoke such discussions, which are relevant to the world, not just Australia and New Zealand.

The ANZJP clearly has a local role – to promote discussions about mental health issues that have particular relevance within Australia, New Zealand and the local region. However, there are good reasons for expanding discussions in order to compare our own with overseas data, opinions and ways of managing psychiatric conditions. We have much to learn from others and they from us.