By Dr. David Laing Dawson
Our approach to suicide prevention over the past 30 years has been tiresome, costly, and futile. Through this period the incidence of suicide did not decline. In fact, it increased among teens and youth.
Our Suicide prevention programs can so far be summed up as:
1. Public awareness (let’s talk)
2. Getting every doctor, counselor, teacher to ask every patient, client, student if they have been thinking about suicide.
3. Attempts to de-stigmatize suicide (“dying by suicide” rather than “committing suicide”).
4. Omnipresent media advice to not do it but call this number instead. And in case dialing 7 digits was daunting we will shorten it to 3.
This has not made the slightest dent in the incidence of suicide over those thirty years. It may even have caused an increase in the impulsive suicides of youth, and distracted mental health workers from the job of identifying and treating mental illness. And a negative answer to the question “Are you planning to kill yourself?” has become the dominant reason many mentally ill people are being prematurely discharged from hospital.
Imagine applying this approach to death from heart failure or cholera.
Instead we might take a close look at medical, epidemiological, sociological, historical, and cultural data to devise a far more effective approach. Let me give this a start:
1. Culturally the stronger the stigma against killing oneself the lower the incidence of suicide. So let the stigma remain. It is a nasty thing to do to your family. (This does not preclude compassion or empathy)
2. Some suicides have always been rational choices to end suffering from untreatable, terminal illnesses . Our acceptance of MAID indicates most of us agree with this statement.
3. We have extensive data on the demographics and causes of suicide. Let us use this to devise specific programs targeting specific populations, while acknowledging that some suicides will remain unpredictable, surprising, or the consequence of complex social problems and not easily amenable to intervention or prevention.
Let me look at a few of these high risk demographic groups.
1. People who have been recently discharged from emergency, short term and long term mental health and Psychiatric inpatient care.
A possible intervention: the development of transitional care teams, able to provide treatment and support within hours of discharge rather than the current long wait for an outpatient appointment. And involvement of family caregivers in every phase of hospitalization, treatment and discharge.
2. Schizophrenia, bipolar disorder, and depression. People with these illnesses are at a ten fold risk of suicide.
So instead of the emphasis on suicide prevention in the whole population let’s put our energy and resources into good, thorough, comprehensive, and long term treatment of these illnesses. (note that a significant study post-mortem of bipolar people who died by suicide found that all, all of them had stopped taking their medication)
3. A subset of 2 consists of males age 35 to 65. These are men who develop (usually) depression (often associated with losses and alcohol) who, unlike females who seek help or let their distress be known, suffer in silence or anger. I’m not sure how we can target this group other than trying to make male health care and mental health care for men more acceptable and accessible. Note that while many women’s health studies and programs have been initiated in recent years, the males of this world are, with a few exceptions, far less healthy than the females – we have higher rates of everything except where it is anatomically not possible. Identification of, and treatment for depression in this gender and age group could reduce the incidence of domestic violence, murder/suicide as well as suicide.
4. Though teens and youth are not the highest risk demographic, a suicide at this age is always tragic. And the suicide incidence at this age has been creeping up. It has gone up rather than down despite (or because of?) an abundance of awareness programs. We already know that when anti-smoking campaigns were introduced in our High Schools the percentage of teens smoking increased.
Some of the suicides in this age group are the result of the serious mental illnesses listed in point 2 above. So a focus on detection and treatment of these illnesses in this age group is warranted.
The adolescent brain is susceptible to catastrophizing shame, particularly within a peer group. It also is short on perspective and an awareness of a future when present concerns will become unimportant. Hence teenagers are prone to terrible impulsive decisions and terrible reactions to temporary failings and passing slights.
The safety railings for this are not phone numbers for helplines, suicide or mental health awareness programs, or once a week appointments alone with counselors, but rather the means of impulsively inflicting great self harm not being immediately available (guns of any kind, potentially lethal pharmaceuticals, father’s Mercedes, bridges without safety nets), involved, available parents, time away from peers and social media, and for teachers, family doctors, psychiatrists, therapists, and counselors to always include parents.
The adolescent brain needs a parent to provide perspective, relief from the onslaught of peer opinions and social media distortion, a sense of a different time both past and future, some boundaries, as well as safety, love and support.
5. Indigenous and first nations
The rate of suicide in this population is generally higher than the general population but varies dramatically between reserves and communities. Much research, study and suicide prevention programs have been initiated. Reading the literature one finds conflict between an individual mental health emphasis vs. a more sociological and historical emphasis. Colonialism, loss of land, loss of culture and language, and inter-generational trauma are often blamed.
But overall, what is clear to me is that those reserves and populations that have become more economically independent, relying more on generated income than government grants, have lower suicide rates. The more successful and independent the reserve, the lower the suicide rate.
People need activities, purpose, and future possibilities. Young people need activity, purpose, and future possibilities, within an organized structured community.
It is all well and good to blame colonialism, residential schools, and loss of culture, and to advertise “trauma-informed” crisis lines of 7 digits or 3, but high rates of suicide will persist among the youth on reserves until those reserves develop, achieve, some economic (work, capitalism, enterprise) independence, and thus create a foreseeable future for their adolescent population.