Key to suicide prevention

Public, private partnership:

Lionel Wijesiri

In the past two decades suicide has emerged as an significant public health problem in many countries. Internationally, over one million people die by suicide each year. In Sri Lanka currently over 4000 people die by suicide annually. We had 8449 reported suicides in 1995 and although it has now decreased by 48 percent, the figure is still alarming when compared other countries in the region. We are losing far too many; every suicide profoundly hurts those left behind.

It has been estimated that there are three times as many suicide attempts as suicide deaths. Suicide attempts range in intent and medical severity from the mildly self-injurious to the determinedly lethal. At a personal level, all suicide attempts, regardless of the extent of medical severity, are indications of severe emotional distress, unhappiness and/or mental illness.

It is clear that Sri Lanka still has a crisis of suicidal behaviour among its young and middle aged people. Doing something about this situation is the responsibility of every part of Sri Lankan society, be it private or public.

In every case we are aware of where rates of death by suicide have been lowered, assertive and sustained government actions have played a critical role. It means that the government, too, has an important role to play as well - as do Provincial Councils and other public representative bodies to reach the desired goal.

Mental health problems

Research findings suggest that a range of social, personality, childhood and related factors make contributions to risks of suicidal behaviour. However, by far the largest contribution comes from mental health problems. These findings imply that any pragmatic prevention strategy must involve approaches that aim to improve the detection, treatment, management and prevention of these disorders in the population.

The most common of approach is through population-based approaches that encourage positive mental health, improved public understanding of mental illness, and improved detection, treatment and management of mental disorders. Two approaches may be of particular use: initiatives focusing on the better recognition, treatment and management of depression; and parallel programs designed to address alcohol and substance-use disorders.

Research findings also suggest that an important step in reducing the number of people who are vulnerable to suicidal behaviours is through programs that reduce the number of children exposed to unsatisfactory or disadvantaged environments that lead to the risk of later suicide attempt. There are a number of strategies by which this target might be achieved, including population-based programs designed to reduce social inequity and social discrimination. Such programs may make an effective contribution to suicide prevention by providing an equitable social environment in which other, more targeted, approaches to suicide prevention would have their best chance of success.

Three more approaches are also available: first one, focuses on the development of general mental health programs, which aim to foster good mental health skills to promote resiliency and address the psycho-social needs of those exposed to stress and adversity; second one lies in school-based competency-promoting and stress-reducing programs to reduce the risks of mental disorders and behaviours with which suicidal behaviour is associated; and the third lies with the provision of family support and early intervention programs targeting at-risk families and designed to improve early-childhood exposure to family disadvantage and to optimise childhood and adolescent life opportunities.

Multi-sector approach

The effective prevention of suicide will likely require a multi-sector approach that integrates both individual-level and population-level programs to minimise the circumstances that encourage suicidal behaviours. The risk factors for suicidal behaviour are similar to those for a range of related adverse psycho-social outcomes. Therefore it is unlikely that significant reductions in suicide rates will be achieved without corresponding reductions in the rates of depression, substance abuse (including alcohol and drug abuse), and domestic violence.

The multi-sector approach implies that there is a need to develop a public-private partnership to address these complicated issues.

This partnership needs to co-ordinate the government agencies and integrated public and private sectors for the success of the operation. An approach that addresses an array of problems with common risk factors will have a better chance of ensuring that prevention programs become embedded across a range of local, regional and national activities than an approach that attempts to focus on suicide as a single social issue. Such partnership structures will require adequate, sustained government and community support and resources to ensure that reductions in suicide rates are pursued using scientifically developed and well-evaluated programs. Specifically, there is a need to ensure sustained funding for suicide research and prevention.

Approaches

Few suggestions come across the mind to be evaluated by the partnership.

l The low rate of suicidal behaviour among elders can be attributed to the strength of the culture they grew up in, which provided them with very strong coping skills. The elevated rate of suicidal behaviour among young men and women in Sri Lanka today can be attributed in large part to high levels of unresolved historical trauma in our society - the legacy of stress and pain from events that occurred due to the terrorist war.

l Since the people who are prone to suicidal tendency first speak to about thoughts are their family members or friends, it is critically important that we raise the level of 'Suicide alertness and intervention' skills among the entire population so that people in distress can be identified - and encouraged to seek help.

l Since many people do require help from trained counsellors, we need to provide more training to both the medical professionals working in Sri Lanka and to the individuals and groups that provide lay counselling in the communities.

l Since high rates suicidal behaviour cannot be understood in isolation from the high rates of other social determinants in our society - early dropout from school, alcohol and drug abuse (especially among youth), overcrowded housing, sexual abuse (both in childhood and later in life), unemployment and poverty, violence - all levels of government must try much harder to address those underlying social determinants of elevated rates of suicidal behaviour in Sri Lanka.

l 'Early childhood development' prevention and intervention programs (e.g. home visitation programs for young mothers, programs that help children learn how to better regulate their emotions, etc.) have been demonstrated to have had a positive impact in other jurisdictions. A holistic, culturally appropriate approach to improving the lives of young parents could help prevent many kinds of problems from occurring later in life.

l We need to know more if we are to make a difference. All initiatives undertaken in the name of suicide prevention could be carefully evaluated to determine whether they are effective (and cost-effective) or not. Issues relating to suicidal behaviour in Sri Lanka need to be researched, and the research findings need to be communicated to the society.

The role of the community

A policy issue that clearly requires careful thought relates to achieving a balance between perspectives emphasising the role of the community in suicide prevention, and perspectives focusing on the development of effective professional services. To date, Sri Lankan policy has been heavily weighted to the community model with a lesser investment in the areas of professionally led services.

These policy investments may need to be revisited in the light of the strong evidence about the role of mental health issues in suicide prevention, the increasing focus on genetic and biological factors in the causes of suicidal behaviour, and the growing investment in approaches to suicide prevention that centre on primary care providers, mental health services, establishing 'chains of care' within such services for those who are suicidal, clinical research, and systematic and appropriate evaluation of all suicide prevention and intervention programs.