Suicide hurts people

Snowdon (2017) raises many fine questions. Some suggestions, but no answers, follow. ‘If wishes were horses, beggars would ride’ (early 17th century English proverb). We all wish suicide could be eradicated, but that does not mean the eradication of suicide is possible (and it certainly does not mean that we know how to do it). Given that we have little idea how to do it, the National Mental Health Commission’s (NMHC, 2014) call for a 50% reduction in suicide over the next decade beggars belief.

The Journal, being of the ‘hard science’ disposition, favors suicide studies of a statistical bent. But what we learn on Day 1 in statistics class is that if you take enough variables (say, two genders, marital and employment status and half a dozen age brackets) and look at them often enough, you will soon come up with statistically significant but meaningless results.

Suicide has been known in every ethnic group in every region of the world throughout history. Contem-plation of these facts brings us face to face with the reality that suicide is a profoundly human response, which is not going to be eradicated (or even reduced) without fundamental change.

The annual suicide rate of Lithuania is around 40/100,000, while that of Greece is around 4; the annual suicide rate of South Korea is around 35, while that of Malaysia is around 2. Such facts were reported by Durkheim in 1897, and unavoidably indicate that cultural factors (attitudes and customs) have a huge impact on suicide behavior.

Perhaps the greatest mistake in the field in the last two centuries was the conclusion that all or almost all suicide is the result of mental disorder. Max Planck stated, ‘A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and are replaced by a new generation growing up that is familiar with it’. There is now clear evidence that mental disorder is only one of the triggers of suicide, but the ‘myth’ (so branded by the World Health Organization [WHO], 2014) survives.

The problem with the myth that suicide is always the result of mental disorder is that it causes all prevention efforts (and associated funds) to adopt a clinical/treatment orientation. However, we know on comparison of the suicide rates of the different nations of the world that cultural factors are most influential—the clinical/treatment approach can have little impact on cultural factors. Similarly, the clinical/treatment approach can have limited impact on unemployment and separation/divorce.

A very high suicide rate among indigenous people in contact with a dominant population is reported in Australia and New Zealand, and many other regions around the world (including North America and Greenland). There is no better evidence of the influence of social, economic and educational factors, as well as substance use, on suicide rates.

In this Journal, Krysinska et al. (2016) recently wrote, ‘a new idea has emerged that a multilevel, multifactorial systemic approach is needed to comprehensively reduce suicide risk’, and that various strategies need to be made available simultaneously. The chosen strategies are reduced access to lethal means, responsible media reporting, community awareness activities, gatekeeper training, school-based prevention programs, additional training for family doctors and frontline staff, and psychotherapy and follow-up for individuals following suicide attempts. The effects of these strategies when practiced alone are yet to be proven (Cramer and Akpinar-Elci, 2016), and there is nothing to suggest they will work better in concert. However, such psychosocial interventions probably have advantages over the purely medical model approach.

To eradicate suicide, we need to eradicate loss and distress, and change our culture. Clearly, the eradication of loss is impossible. It may be possible to reduce distress, or the impact of distress, by providing support/therapy, but a certain amount of distress is inevitable and may even bring benefits (personal growth).

Culture includes customs—the action responses to circumstances. Suicide is a possible response/solution to upsetting circumstances. To reduce suicide, we need to reduce the tendency of people to opt for the suicide solution.

Smoking was not reduced by treating smokers, but by public health activities which made the practice socially/personally undesirable. Rather than stifle discussion about suicide, the topic needs to be frequently and openly discussed. Smoking was branded a health hazard—we need to openly state that suicide hurts family and friends, reduces the national wealth (human capital) and is a permanent solution to a temporary problem. We need to redefine ‘responsible reporting’ and encourage the public, not just the think tanks, to think about the problem.