COVID-19 WEBINAR 18: SUICIDE PREVENTION
By Anna Watkins
The Lancet Psychiatry, Mental Health Innovation Network, MHPSS.net and United for Global Mental Health organises a series of regular webinars designed to provide policy makers and the wider health community with the latest evidence on the impact of COVID-19 on mental health and how to address it.
18th August: Suicide and suicide prevention in the time of COVID-19
Chair: Niall Boyce, Lancet Psychiatry
- Murad Khan, International Association of Suicide Prevention
- Cassey Chambers, South Africa Depression and Anxiety Group
- Chris Caulkins, IASP Lived Experience Special Interest Group
- Michael Eddlestone, University of Edinburgh
The recording of this webinar can be found here.
Murad Khan: We always need to look at suicide prevention from a public health and a human rights perspective; terminology and government policy are hugely important in suicide prevention, by enabling people to seek help.
Cassey Chambers: COVID-19 has severely increased the demand for our services, policies need to include mental health provision and suicide prevention now more than ever.
Chris Caulkins: We need to learn from people with lived experience in order to increase our understanding and empathy. We also need to educate people that people who have attempted suicide are not dangerous and treat them with care and consideration.
Michael Eddlestone: The easiest way to reduce suicide rates is by removing access to lethal pesticides; 15-20% of all suicides worldwide today are still caused by pesticides.
Niall Boyce, Lancet Psychiatry
This is an exceptionally important topic in the field of mental health. It is often used to diagnose the state of a nation’s mental health which can be a useful measurement tool but equally has some significant disadvantages. The level of interest in suicide and suicide prevention is evidenced by the high number of registrations for this webinar - almost 1000 people. The subject of suicide prevention was the theme of the first volume of Lancet Psychiatry.
Why is the illegality of suicide such a barrier to suicide prevention? How does it stop us finding and treating those who need support?
Murad Khan, IASP
Unfortunately whilst suicide is decimalised in majority of countries there are 40-45 countries where it is still a criminalised activity, including quite a few of Islamic countries. Islam goes further than other religions in condemning suicide. This stops people coming forward to seek help, and makes it difficult to address self harm, it also impacts the ability to collect data on suicide.
The phrase to ‘commit suicide’ implies it is a criminal act; even the language we use is shaped by its history.
Yes, terminology is very important; the term ‘commit’ suggests it is wrong or a crime. A person who is contemplating suicide is under huge stress and his or her ability to make informed decisions is likely to be significantly hindered. We should not add to this stress by punishing them, but instead look after them compassionately as someone who needs help. We always need to look at suicide prevention from a public health and a human rights perspective. The illegality of suicide has very little deterrent when someone is in that state of mind, it just means they are less likely to seek help. It is time to repeal the laws.
Why is it so hard for the law to change?
In a country, such as mine - Pakistan - where religion plays a very important part of society, there is a belief that if someone dies by suicide then you are denied entry to heaven. People have also taken this approach to those who self-harm or attempt suicide, and this often leads to a fine or imprisonment. It is a very sensitive topic and people are scared that to decriminalise suicide believing it will make it more common. In societies like this mental health has low importance, so it is not something discussed in the public domain. Suicide and suicidal behaviour is not discussed either as an individual act or in a holistic way.
Cassey, how has COVID-19 affected suicide in South Africa?
Cassey Chambers, South African Depression and Anxiety Group
SADAG provides free counselling. Due to the lockdown in South Africa we had to close everything and move to working remotely. We have moved from receiving 600 calls a day to around 1400 a day, and it is growing every day. The mental health impact has been huge for many South Africans - we have had over 4 months in lockdown - and the demand for our services is still growing.
It has been important to be able to properly understand challenges and impact. In April we conducted a survey of 1200 people in South African on their perceived levels of anxiety, stress, and depression. 49% of people in the workplace had symptoms of some form of pre-PTSD. People not using the services reported feeling stress every day. Even before COVID-19 there had been a huge strain on underfunded and under-resourced mental health services, and during COVID-19 the lack of resources has become even more apparent.
How do you investigate and evaluate what works?
For us it is really important to show evidence; by doing a lot of research and online surveys, as well as monitoring call volumes and issues on a daily basis. We use data from our helplines as well as case studies of the challenges faced from our callers to gather examples of lived experience, such as accessing treatment, and medication stock outs. During COVID-19 everything has been virtual and we have seen a huge uptake in resources accessed online. We have over 200 support groups which are now being turned into online groups.
Turning to the experience of individuals and particularly lived experience what should be considered in this instance? The way we care for people experiencing suicidality is important.
Chris Caulkins, IASP Lived Experience Special Interest Group
Lived experience is important to increasing understanding of where people are coming from, this includes learning from people who have experienced suicidal ideation. We need to educate people that we (who have suffered mental ill health) are not dangerous – we are more likely to be a victim of a crime than a perpetrator. I have suffered repercussions from speaking about my experiences. People with mental ill health are often perceived as damaged or there is something wrong with them. As part of my work in the ambulance service I respond to a lot of calls to suicide attempts; I believe my lived experience gives me more empathy and helps improve my response and my ability to do my job.
Now we are going to talk about suicide as a public health issue, and using public health measures to prevent suicide. Michael as an expert in suicide prevention through pesticide regulation, please tell us a bit more about why access to pesticides is such an important factor in suicide prevention?
Michael Eddlestone, University of Edinburgh
In the early 1950s pesticides were not used and really rare, but with the agricultural Green Revolution pesticides - and these very toxic substances - were brought into households. At this time suicide rates shot up, not because more people wanted to die but because the poisons available to them were lethal. Today 15-20% of all suicides worldwide are caused by pesticides. Most people who survive drinking pesticides do not go on to try any other form of suicide. In Sri Lanka the ban of eight pesticides in the 80’s and 90’s resulted in more than a 70% reduction in total suicides. The rate of self poisoning stayed the same or even went up - people were still harming themselves - but [thanks to a reduction in 8 highly toxic pesticides] people were no longer dying. Instead they survived to get the support they needed from their family, community and health services.
Bangladesh, South Korea, Jordan, China, India have all successfully reduced access to highly toxic pesticides and seen a marked fall in deaths. Controlling access to pesticides is really important for suicide prevention, and fundamentally it is a ‘low hanging fruit’ [a simple but effective policy intervention]. By reducing circulation of pesticides that are highly toxic to people, we can stop the deaths of people with a low intention to die.
This busts the myths about suicide being something that people will attempt multiple times until they find a way to die. Instead the evidence suggests that if you control the lethal methods then you save lives. What does pesticide control mean?
There are three levels to this:
Work with patients to try and stop them dying after they have taken pesticides.
Work with communities to make sure they control and lock away pesticides
But the most effective way is to make pesticides safe; if you drink them they are safe. It is hard to predict when and who will self-harm [this way you address anyone who tries using pesticides].
What are successful ways to reduce national suicide rates?
The country needs a comprehensive national suicide prevention strategy; with different elements including restricting pesticides, but also good surveillance systems to measure the impact [of different interventions]. Very few countries that have this. Examples of countries from the non-Western world include Iran which has a very good surveillance system, I reviewed their programme and they have built a programme where data is uploaded within a month which is extremely important. Sudan, Namibia, Switzerland, Republic of Korea also have good strategies and clear targets. You really need leadership with a strong internal advocate.
What are the best strategies to adopt when advocating for the government to change the law?
There are a range of strategies that can be used. De-stigmatisation is very important; advocacy means engaging with all stakeholders including people in education, the justice system, law enforcement agencies etc. to develop a groundswell of support and pressure on the government to make changes. The last country that has been successful in ending the illegality of suicide is India and we can learn from this.
As Murad said, suicide prevention means involving stakeholders at every level. Is there any specific guidance or measures to address suicide during the pandemic? What needs to be done going forward?
We need to emphasise the importance of public health information and make sure that mental health wards and services are still running for people with mental health issues. One thing we found in South Africa is we didn’t have enough beds for adolescents – the most at risk age – normally they are put into an adult ward which is fraught with problems. We need to prioritise mental health during COVID-19 and ensure there is a suicide prevention strategy followed during this time. In South Africa we are seeing a psychological demand; a demand for mental health professionals, NGOs and the government to put in teams and strategies now, ready to deal with it in the months to come.
Have you seen rises in suicide in communities?
Yes, it has highlighted the importance of getting help. But video counselling lacks the essential human contact and it is human contact that people lack. During COVID-19 we need to stop talking about social distancing: it is physical distancing we need but combined with social connectivity. This is a particular problem among the elderly in my area of the US. Elderly people in senior living complexes are unable to see visitors, their travel is restricted, and they are severely lacking social engagement. Therefore there is an increase in loneliness. More broadly we have seen 11% increase in fatal overdoses and 16% increase in non-fatal overdoses. There is also an increase in domestic violence and child abuse. There are a lot more risks to mental health during lockdown.
We are hearing a clear message from the panel that suicide prevention needs to be part of the COVID-19 strategy now, especially pre-emptively knowing that economic problems are associated with increased rates of self-harm and suicide.
Pesticides are made by private companies and sold to consumers so how can we make pesticide control a reality?
There are people who believe we don’t need chemical pesticides and are looking to reduce them. Meanwhile the pesticides causing most suicides are a small number. The question is how to make self-harm safe; people use self-harm to communicate hurt or anger. This is a global question of how to use pesticides; we need to know which countries don’t know which pesticides are causing problems? Identifying those countries and governments and promoting the FAO guidelines to them on how to remove highly toxic pesticides will help change policy and result in far fewer people dying. This is one key thing which will make a huge difference.
Question from the audience. If people know more about ways to die by suicide then will more people will take their lives?
It is a myth that if suicide is talked about then more people will take their life. There needs to be a balance and clear public understanding of how people can get help. The discussion has to be balanced - you have to balance the discussion around suicide with suicide prevention and how to address the problem. We have enough evidence from lived experience advocates and researchers that, for example, with pesticides the suicidal intention may not be there but if it is an easy option to self harm then it becomes the only option for people.
Do these sorts of worries about how suicide is communicated affect your work?
Yes, it's very important to control the narrative about how we are talking about suicide. Especially in South Africa when we are talking about these concepts around mental health - for a lot of the culture this is not recognised - for example there is no Zulu word for depression. We need to work with the press and media on responsible reporting and how we talk about it, where and when. We need to share how to get help and we see that leads to more people reaching out for help.
Recommended reading Samaritans guidance on media reporting.
Some people have talked about alcohol restrictions as a method of preventing suicide. Chris what do you think?
One study in the US has found that approximately 29% of people who die by suicide are positive for alcohol, not necessarily intoxicated but have been using alcohol. We know that alcohol decreases your inhibitions and increases your impulsiveness; but restricting alcohol is a concern, as there is worry about alcohol withdrawal. In the US liquor stores were designated as an essential business during COVID-19, because people in alcohol withdrawal can suffer badly with seizures and die. An alcohol cessation programme is very difficult to do without sufficient mental health and physical health support.
Yes exactly, these things have to be thought about very carefully and need to fit into the national economic and cultural context.
Round up question – 280 characters or less. What is the biggest priority right now for suicide prevention?
Murad Khan: Number 1 is connectedness and reaching out to people; engaging family, friends and colleagues.
Cassey Chambers: LMICs need to make health accessible for all – especially during the pandemic to make it part of the strategy for COVID-19 response.
Chris Caulkins: I agree with Murad – social connection is the biggest thing we can do. We need physical distancing not social distancing, it is often found that an adequate relationship is more important to long life than moderating eating or smoking.
Michael Eddlestone: Agree with the above.
Niall Boyce: Suicide is a devastating experience and it is very easy to feel helpless. But you are not helpless and everyone can do something.
Next week’s webinar (25th August) is on workplace mental health and the week after (1st September) is on substance misuse. Please email email@example.com, you can view all recordings here.