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Suicide prevention takes more than ‘treating depression’

Suicide prevention in Australia is often represented as, first and foremost, about recognising and getting help and treatment for depression. Everywhere, we are given the message that depression leads…

Treating mental illness does not necessarily prevent suicide. Image from shutterstock.com

Suicide prevention in Australia is often represented as, first and foremost, about recognising and getting help and treatment for depression. Everywhere, we are given the message that depression leads to suicide. A search of suicide prevention websites, media reporting, and popular debate turns up repeated calls for awareness about depression.

There’s no doubt that mental illness, especially depression, is a risk factor for suicide. Researchers estimate between 30% to 90% of people who die by suicide have some form of mental illness.

But those estimates also tell us that many people who take their own lives are not mentally ill. Life history and personal circumstances – such as relationship breakdowns, business failure, or unemployment – can play a strong role in the development of suicidal behaviour, irrespective of whether or not that behaviour is accompanied by mental illness.

Suicide is the culmination of complex interactions between biological, social, economic, cultural and psychological factors operating at individual, community and societal levels.

Simply treating mental illness, without addressing the context in which illness has occurred, does not necessarily prevent suicide. Or, as one experienced mental health nurse put it in a conversation with me:

A patient of mine rang and said “that’s it, the antidepressants aren’t working anymore, I can’t go on” … I’d known him for a while and I said, “what else is going on?”

Turns out that what had really got to him was his business was finally picking up, but he couldn’t afford to hire the workers he needed to get the jobs done … his suicidal thoughts didn’t come from depression, they were because some practical things needed to happen, and he couldn’t make them happen.

Personal circumstances such as relationship breakdowns can play a strong role in the development of suicidal behaviour. Image from shutterstock.com

Connections between mental illness and suicide vary across different demographic groups. Among younger people, for instance, suicide is often linked with school, family, or relationship problems, rather than psychiatric illness.

There are also cultural differences at play: while mental disorders are often associated with suicides in European and North American people, this is not the case in Asia. Varied cultural understandings of mental illness may contribute to part of this difference - but they cannot explain all of it.

Why such a heavy focus on mental illness?

Millions of research dollars have gone towards exploring connections between mental illness and suicide. So when we address mental illness, we are trying to take evidence-based action that can reduce one important risk factor for suicide.

Unfortunately, the relentless focus on depression means we have less research evidence around other contributors to suicide than we do for mental illness. We have created a cycle where we focus on mental illness because we know it relates to suicide, and we know it relates to suicide because we have focused on it.

As a result, suicide prevention programs are typically administered through mental health branches of health departments. Suicide prevention policies are often “tacked on” to mental health policies. Other risk factors and contributors to suicide get a mention, but they are generally relegated to the sidelines.

This in turn makes it difficult to develop rigorous preventive strategies that step outside an “interventionist” medical model, in which suicide is seen as the result of illness.

Framing suicide within a medical model oversimplifies an incredibly complex human behaviour. Focusing on mental illness helps us feel that we are doing something about the “wicked problem” of suicide, but in practical terms it can mean people at risk of suicide may not get the “right” information or the “right” types of help.

For young people, suicide is often linked with school, family, or relationship problems, rather than psychiatric illness. Image from shutterstock.com

There is also the risk of misdirecting scarce resources. For instance, although awareness campaigns are often held up as a suicide prevention measure, we have no direct evidence that years of government-funded depression awareness campaigns have impacted on Australian suicide rates.

Differentiating suicide from mental illness is not just a theoretical debate. It has tangible implications for suicide prevention strategies. When communities at high risk of suicide are identified, for example, the default response is usually to “send in more mental health services”.

But what if the real problem is financial insecurity and stress, brought on by a failing industry on which a whole community relies? Or entrenched social disadvantage? Or loss and bereavement?

Responding adequately to these suicide risk factors calls for a whole-of-life approach that crosses different sectors, agencies, and actors. Ultimately, achieving real change in this area requires more than lip-service and platitudes. It requires a new paradigm in suicide prevention that places suicide – not depression – at its centre.

Join the conversation

7 Comments sorted by

  1. Mike Brisco

    Scientist at Flinders University of South Australia

    Fair point, yes, environment does matter, Consider a hypothetical

    If depression kicks in - but I am free to potter round the house, do odd jobs, catch up with people, rest, sit in the sun - things go one way

    If depression kicks in - and I must be at work - doing things required of me, at a pace set by others, to the expectations and requirements of others -- things might go very differently.

    Yes, environment matters: I get the point.

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  2. Kris McCracken

    logged in via Facebook

    Any effort to address the widespread availability and problematic use patterns of alcohol in Australia will go some way to making a dent in the numbers. Research has demonstrated that about half of adult and adolescent suicides may be impulsive, with little preparation or premeditation. The role of alcohol in this should be obvious. That is, intoxication - especially heavy intoxication - increases disinhibited, impulsive and aggressive behaviours and also affects cognitive processing and problem-solving…

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    1. Russell Edwards

      logged in via email @gmail.com

      In reply to Kris McCracken

      Perhaps if suicide is the frequent result of disinhibition, as a society (does such a thing still exist?) we should look at what is being inhibited. If disinhibition leads to suicide, perhaps under the rose-coloured, propagandised, unalcoholic glasses is a meaningless life of daily wage slavery struggle which is unameliorated and perhaps even exacerbated by the trappings of luxiuriance that act to disguise the misery of the day to day grind of the masses who don't even comprehend that the economic system enslaves them for the extraction of surplus value.

      Just maybe?

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  3. Kaye Hargreaves

    Retired

    Samara, you say that complex social and economic factors are involved in suicide, which I think is certainly true - but you say this as if this is not the case with depression. Depression is also the interplay of many complex factors. You say we can't address suicide by "simply" treating depression. Well, unless your psychiatrist is an idiot, the treatment of depression will never be simple. The medical model has become a code word for something that oversimplifies and misses the point. But the best medical treatment is given by someone with a lot of options in their toolkit. In downplaying the impact of depression, you don't explain how it is that one person's response to being retrenched might be to start a small business, while another's might be to take their own life. Losing your job is a huge stress, but the issue is not only the fact of job loss, but how you deal with it. Similarly with relationship breakdown and the other risk factors.

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  4. Marshall Perron

    Ret. politician

    Samara your piece is very relevant to the euthanasia debate (VE). Opponents to VE usually claim that anyone who wants to die must be depressed and therefore in no state to make a decision to die.

    It is reasonable for an individual with a terminal illness to be depressed. Particularly so if their prognosis is severe debilitation, suffering and indignity as the body shuts down. To claim that with good palliative care and modern painkilling drugs their depression will go away and their desire for death will go away is just wishful thinking.

    Rational suicide exists and it is time our society acknowledged that fact and allowed those who face inevitable death and seek to relieve suffering thru death assistance to do so peacefully and with dignity.

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  5. Luftmensch

    logged in via Twitter

    As a psychologist I have become disillusioned with the clinical branch of psychology and it's almost entire focus on the reduction of symptoms as a way to treat mental health problems. I agree that there is scientific evidence that strongly suggests that mental health needs to be seen from the complex interactions of biopsychosocial model. But all too often treatment is tailored to the biopscho leaving out environmental factors.

    There is an interaction between the individual and the environment…

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  6. Kate Munro

    Manager Suicide Prevention Lifeline Newcastle & Hunter at Lifeline Newcastle & Hunter

    What an interesting article - thank you Samara. Working in the area of suicide prevention I remain focused on the suicide not the mental illness. This complex issue is never easy - especially when we try to 'medicalise' it or set it in a reseach paradigm. Working driectly with people who are thinking about suicide and those who are bereaved by suicide I am constantly reminded that I must focus on their needs and what might help to keep them safe and feel supported. I believe most people thinking about suicide want help to live and I don't need to have a disgnosis to be able to listen to their pain and why they want to die. I will contiue to work on breaking down the fear,stigma and myths surronding suicide and to support the people who are left behind trying to understand what happened.

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