There is strong evidence that people with substance use problems often also have other psychiatric disorders such as depression and psychosis, that in turn is linked to suicidal behaviour. Those who do not receive help are at a higher risk of committing suicide than the general population.
More than 1 in 10 South Africans have a lifetime diagnosis of a substance use disorder – higher than European countries. South Africa’s youth are particularly at high risk of alcohol, marijuana, and tobacco use. In the country about 40% of the people who commit suicide are under the influence of alcohol at the time of their death. And studies from other low and middle-income countries show that substance use is a clear risk factor for suicidal behaviour.
People with substance use problems therefore need effective and accessible mental health care. In developed countries, like the United States, the United Kingdom, and Australia, governments have created national suicide prevention strategies.
They use multilevel interventions like improving access to mental health services for high risk groups, creating public education campaigns, and improving the capacity of health care workers to recognise and respond to suicide warning signs.
But in low resource settings – like South Africa – this is not the case. There is no national suicide prevention strategy in South Africa. There are also many factors that impede suicide prevention in the country. This includes a lack of intersectoral collaboration and the lack of person centred psycho-social care at a community level. Effective suicide prevention for people with substance use problems requires integrating psychiatric care along with psychological and social services.
As part of our research, we asked mental health care providers working with suicidal people with substance use disorders in Cape Town about their perception of barriers to suicide prevention.
Our findings suggest that one of the biggest barriers to suicide prevention is the fact that psychiatric services and substance use services are often not integrated. As a result, people who have substance use disorders do not receive the psychiatric, psychological, and social care that they need to prevent them from engaging in suicidal behaviour.
These structural challenges with the provision of services, along with situation and contextual factors such as poverty, inequality, and interpersonal conflict, create a fertile ground for putting people with substance use problems at high risk of suicide.
Without integrated care and intersectoral collaboration, it will continue to be difficult to prevent suicide in people with substance use disorders.
Limitations
In South Africa and globally, suicide prevention strategies have largely been framed within a biomedical paradigm. This assumes that suicidal people are mentally ill and simply require psychiatric treatment.
This approach focuses on individual risk factors, and improving access to psychiatric care. Although strategies like this are important they do not always serve the needs of people with substance use problems who are suicidal.
Part of the problem with strictly biomedical approaches to suicide prevention is that they do not recognise that people with substance use problems often face a range of serious social, economic, contextual, and interpersonal challenges.
People who have substance use problems can seek help at treatment facilities. But there are many challenges that make accessing these facilities difficult.
Firstly, there is a shortage of services that provide effective care. In South Africa, for example, there are only 75 treatment facilities registered with the Department of Social Development. These facilities served only 8787 treatment seekers in the second half of 2016.
Secondly, substance use treatment services are often woefully under resourced.
Thirdly, people have trouble accessing treatment because of financial and geographical barriers. For example, in the Western Cape province, only about 50% of people receiving treatment for substance use, access care at state sponsored facilities.
The resource constraints mean that most treatment facilities have to limit the amount of care they can provide each person. Many facilities are also forced to provide brief interventions that only focus on substance use, without addressing any of the other social and economic problems that might be linked to substance use.
Integrated care is key
Our study highlights the range of factors that prevent health care workers in South Africa from providing effective care and preventing suicide among people with substance use disorders.
Poverty and inequality prevent many patients from accessing facilities. Furthermore, breakdown of families, unemployment, social isolation, exposure to trauma, homelessness, and stigma all contribute to high rates of suicide among people with substance use problems. These are important factors that need to be addressed as part of any national suicide prevention strategy.
Health care providers said that they felt powerless to address these problems which fall outside the realm of the health system. Yet, these factors have a significant impact on people’s mental health.
Our study showed that health care providers working with people with substance use disorders need to be supported to do their difficult work. Health care providers described their work as emotionally provocative and said they felt overwhelmed and distressed providing care to suicidal patients. Sometimes they felt powerless to prevent suicides. Those who were supported by colleagues said this helped them to do their work without becoming overwhelmed, despite its challenges.
Multilevel strategies are needed
The World Health Organisation has recommended that suicide prevention interventions should target high risk groups. This is important given that substance use is a major public health problem in South Africa.
The responsibility for preventing suicide in people with substance use disorders may need to extend beyond the health care system and treatment facilities. Better intersectoral collaboration, more integrated health services, and addressing contextual factors are required to effectively prevent suicide in people with substance use disorders.
Clearly there is a need to provide more care for the carers, so that the professionals who do the difficult work of providing mental health care services are adequately supported.
Our research also draws attention to the need for mental health care providers to be well trained in providing evidence based interventions for suicide prevention and problems associated with substance use.