|Year : 2021 | Volume
| Issue : 3 | Page : 165-170
Debate: Suicide is a Societal, not a Mental Health or Even a Public Health Problem
Digvijay S Goel1, Brian Dennis1, Alok Sarin2
1 Consultant Psychiatrist, Southland Hospital, Invercargill, Invercargill, New Zealand
2 Department of Psychiatry, Sitaram Bharatia Institute of Science and Research, New Delhi, India
|Date of Submission||28-Oct-2021|
|Date of Decision||18-Nov-2021|
|Date of Acceptance||22-Nov-2021|
|Date of Web Publication||23-Dec-2021|
Digvijay S Goel
Consultant Psychiatrist, Mental Health, Addictions and Intellectual Disability Services, Southland Hospital, Invercargill
Source of Support: None, Conflict of Interest: None
In this debate the focus is on suicide which is a complex maze, wherein multiple parameters intersect. The first part of the paper questions many basic premises which have been taken as given in the discourse of suicide and currently form the substrate of conversations around suicide. The basic premise is that this societal problem has been expropriated by health professionals. They have assumed ownership without having the wherewithal to address the many contributory factors to suicide – social, economic, cultural, and moral. Suicide prevention plans are ritually rolled out despite a consistent record of repeated failures. There is a need to move against the tide and reimagine the subject in light of macrolevel evidence. The second part posits that for an issue as complex as suicide, it is important to think inclusively rather than looking for simplistic answers in either/or way, and the larger societal, economic and even political issues will need to be factored in.
Keywords: Mental health, public health, real-life, societal, suicide
|How to cite this article:|
Goel DS, Dennis B, Sarin A. Debate: Suicide is a Societal, not a Mental Health or Even a Public Health Problem. World Soc Psychiatry 2021;3:165-70
For the Proposition
D S Goel, Brian Dennis
| Introduction|| |
The mere mention of New Zealand evokes images of an idyllic land of great natural beauty, of fjords, snow-covered mountains, pristine rivers, magnificent landscapes, rolling hills, and incredible beaches made for swimming and surfing. At the beginning of the 20th century, it became the nursery of the then-revolutionary concept of the modern welfare state, imagining cradle to grave care for all its citizens. It was also the first country in the world to give women the vote, years ahead of the United States of America and other western nations. Over the past several decades, it has evolved into a vibrant multicultural society that has done more than most other countries to restore the dignity, inclusion, and well-being of their indigenous people, the Maori. The country has low unemployment rates, robust social security networks, universal education, and an excellent public health-care system, free at the point of delivery. Serious crime is infrequent and murders make national news.
The country has been struggling for years with demons of its own: High rates of domestic violence, child sexual abuse and increasing suicides, despite numerous, well-resourced government initiatives to address these shocking statistics. High and increasing suicide rates, particularly among the young, pose a major challenge to the government which has been ritually rolling out suicide prevention plans every 4 years, with little effect. These repeated failures have provoked national angst and a growing sense of frustration, which in turn has led to the inevitable blame game, with the mental health services being targeted as the most convenient fall guy. It is quite another matter that most of the suicides happen in persons who have had no contact with mental health services. We believe this myth is one of psychiatry's and public health's many self-inflicted injuries.
We posit that suicide is a societal, not mental health, nor even a public health problem.
| Data|| |
New Zealand has by far the highest youth suicide rate in the developed world, and this has been so for quite some time. More teenagers (15–19 years) commit suicide in this country than in any other of the 41 Organizations for Economic Cooperation and Development (OECD) and European Union countries. The rate, 15.6 suicides/100,000 people is twice as high as in the USA and almost five times that of Britain.
In the year 2017–2018, the country's annual provisional suicide number was once again the highest since records began, rising for the fourth consecutive year to a record 668 deaths. Male Māori continues to be disproportionately represented in these statistics, making up 97 of the 668 deaths in the year. The country's Chief Coroner, Judge Deborah Marshall went on to caution, “We can't ignore the social determinants of suicide, including poverty, violence, and the legacy of colonization. We won't see a shift in our suicide rates until we start to address these factors.”
| One Hundred Years of Suicide in New Zealand|| |
This landmark epidemiological study sheds light on the longitudinal trends of suicides over a century, 1889–1988. The male rate has remained markedly higher than the female rate, almost 5-fold in the early 1890s to <2-fold in the late 1960s. The female rate climbed from a low of about 3/100,000 in the early 1890s to about 6/100,000 around the time of the Great Depression in the 1930s and has remained remarkably consistent since that time at between 5 and 6.5/100,000. The male rate rose steadily from the late 1890s to 1911–1916 and then stabilized until the dramatic increase in the late 1920s and early 1930s coinciding with the Great Depression. The rate fell until the mid-l960s, but since then the male rate has risen at an increasing rate, but the last available figures (1988) show that the male rate has not quite regained the 1930s zenith. These data clearly indicate that powerful socioeconomic and perhaps political forces have been at play, rather than any startling variations in mental morbidity or the vastly augmented availability of psychotropic medications and mental health services over the past several decades. Another notable fact relates to the method of male as well as female suicides over the years, with hanging being the most common, followed by vehicle exhausts in males and overdosing (“self-poisoning”) among females. Since ropes, motor vehicle and over-the-counter medicines are freely available, the often-promoted strategy of limiting access to the means of committing suicide is not a feasible option in suicide prevention.
| Back to the Future|| |
In his remarkably prescient treatise, El Suicido, Emile Durkheim had drawn similar inferences well over a century ago. His most significant contribution was undoubtedly the concept of anomie, a sense of alienation resulting from eroded social cohesion, as during periods of serious social, economic, or political upheaval, like in post-Soviet USSR or during the recent COVID-19 pandemic. He had observed that more socially integrated and connected persons are less likely to commit suicide; as social integration decreases, people are more likely to commit suicide. He attributed the lower rate of suicide among Catholics to stronger forms of social control and cohesion among them than among Protestants. Interestingly, soldiers commit suicide more often than civilians and, paradoxically, rates of suicide are higher during peacetime than during wartime. Unfortunately, “the nuance and richness of Durkheim's insights that have been largely lost in modern suicidology, despite being foundational to all sociological theories of suicide – even those that have moved beyond his model.”
| Flawed Narrative|| |
For over half a century, an “insidiously harmful myth” equating suicide with mental illness has been promoted, among others by the World Health Organization, “Unfortunately, suicide all too often fails to be prioritized as a major public health problem…. However, suicides are preventable. With timely and effective evidence-based interventions, treatment and support, both suicides and suicide attempts can be prevented.” This simplistic formulation is being increasingly challenged, “If mental illness were the source of most suicides, the men of Japan (26.9 suicides/100,000 people) would have almost twice the rates of psychopathology as the men of New Zealand (14.4/100,000); India (21.1/100,000) would have four times as many mentally ill citizens as Spain (5.1/100,000); and the people of Saudi Arabia (0.4/100,000) would have virtually no mental illness at all.” There is growing realization that “Suicide is not simply a medical “problem,” or even a public health “problem”–it is a complex cultural and moral concern that is deeply embedded in social and historical narratives and is unlikely to be greatly altered by any form of health intervention. We need to understand that medicine does not have all the answers to such complex problems.
The wide variations in suicide rates across the world do not correlate with the availability of mental health services and resources. Australia, Canada, the USA, and India have similar suicide rates/100,000 male population, but there are wide disparities in their psychiatrist-to-population ratios, ranging from 9.2/100,000 population in Australia and 12.4/100,000 in the USA/Canada, to a mere 0.3 psychiatrists/100,000 population in India. Most Latin American countries have lower suicide rates despite having fewer psychiatrists (4.4/100,000), whereas the lowest suicide rates are reported from the parts of the African continents which have just 0.056 psychiatrists/100,000 population.
The paradox becomes even more glaring in India, a federal union of semi-autonomous states and union territories with widely varying economies and health-care systems. Again, the hugely different suicide rates do not accord with the availability of mental health services. Bihar, one of the poorest states in India with the weakest health care and mental health-care systems has the fewest suicides. Whereas Kerala, at the other end of the health-care spectrum has the highest suicide rates. Compounding the conundrum is the fact that Kerala also has the highest proportion of Catholics in its population, the highest levels of female literacy and the lowest maternal and infant mortality rates in the country.
| What Then is Driving High Suicide Rates?|| |
This remains a million-dollar question. While indicative statistics are available from several sources, questions remain. The National Crime Records Bureau in India and the USA Centers for Disease Control and Prevention data indicate that real-life issues, rather than mental health disorders are the principal drivers of most suicides.
These findings have reignited the debate on whether the rise of suicide is a public health problem or a societal issue and has triggered yet another blame game. Questions are being asked, provoking one observer to pose this rhetoric query, “Is it too many guns? Or too few mental health professionals? Or a broken health delivery system. I am not so sure that suicide is a medical problem. Certainly, it can be spread by a vector, in this case the ubiquitous media. With more exposure, suicide has become if not the norm, a socially acceptable management option for an unhappy life. The increase in the suicide rate is the symptom of a sick society”.
There is no denying the fact that societal factors or sickness play a critical role. A classic example how real life and societal attitudes intersect is the student suicides in India. Learning has always been respected and highly prized since times immemorial. Brahmins, the twice-born, sat at the apex of the caste hierarchy not because of wealth or power but owing to their monopoly of knowledge. In modern and more egalitarian India, the pursuit of higher education has been democratized. The real-life stories of a poor fisherman's son from a coastal hamlet in South India who became one of its most loved presidents, to a tea-seller's son who became the Prime Minister of the largest democracy in the world have inspired millions to rise above the poverty line and realize their aspirations to reach the summit. Several Indian-origin CEOs of leading global companies are the products of this socioeconomic ferment. Parents virtually invest all their savings and even mortgage their future to provide their children with the best possible education in the hope that they would make it to the top educational institutions like the Indian Institutes of Technology or National Eligibility Cum Entrance Test in the teeth of cut-throat competition where millions of students compete for a few hundred or thousand seats. Given this background, the sense of shame and guilt, of having failed their parents' expectations and financial sacrifice drives some to suicide. Failure, inevitable in the face of such impossible odds, extracts its inevitable toll which has little to do with diagnosable mental health disorders.
There is yet another emotive issue that evokes recriminations and a great deal of political heat worldwide, often ignoring the fact that global economic forces, beyond the control of national governments, are the main drivers of farm distress. The situation in New Zealand is no different and a spate of farmers' suicides has triggered an ongoing and divisive debate, with the mental health grenade being tossed around in the ensuing blame game, In a small country with a mainly commodity-based economy, large and often unforeseen fluctuations in global commodity prices have drastic consequences for the farm sector. New Zealand is the 2nd largest milk producer in the world (second only to India) and when the price of milk solids in the international markets goes down, the pay-outs by Fonterra, the giant farmers' cooperative, go down as well, bankrupting many. The introduction of robust business management practices in the farming sector, rather than mental or public health interventions, is far more likely to be effective in ameliorating this real-life distress.
The aforesaid paradigm was brought into sharp focus by a decade-old landmark study by Jacob et al. where the key findings are that “psychosocial stress and social isolation, rather than psychiatric morbidity, are risk factors for suicide in rural South India.” The evidence supporting this line of reasoning has been articulated more recently by Rao et al. through the columns of the Indian Journal of Psychiatry.
At the macro level, the role of global economic factors like growing income inequality within and between nations, measured by the Gini index, as a factor in determining suicide rates, has attracted increasing attention, and there is a growing body of evidence to support this proposition.,, Framing such suicides through the mental health or public health prism trivializes the role of the very real socioeconomic distress driving people to end their lives.
| Role of the Media and the Suicide Contagion|| |
Marilyn Monroe's tragic suicide in August 1962 had received extensive news coverage and there was an outpouring of sorrow across the world at a promising life cut short. There was, also, a spate of suicides and the suicide rate in the United States jumped by 12% compared to the same month in the previous year. This lead the New York Times columnist, Margot Sanger-Katz to observe, “Mental illness is not a communicable disease, but there is a strong body of evidence that suicide is still contagious. Publicity surrounding suicide has been repeatedly and definitively linked to a subsequent increase in suicide, especially among young people. Analysis suggests that at least 5% of youth suicides are influenced by contagion. People who kill themselves are already vulnerable, but publicity around another suicide appears to make a difference as they are considering their options. The evidence suggests that suicide “outbreaks” and “clusters” are real phenomena; one death can set off others. There is a particularly strong effect from celebrity suicides.”
The advent of social media has acted as an incredibly lethal force multiplier in this regard. Not infrequently it acts like a dark echo chamber where negativity resonates. The release of the Netflix show, “13 Reasons Why” has been implicated in increased youth suicide rates. In another tragic instance, a Malaysian teenager committed suicide after her Instagram followers “voted for her to die.” This pernicious dimension has the potential to do incalculable harm. The genie is, however, out of the bottle and even governments find themselves helpless in this regard. Despite tightening regulatory mechanisms, such as these are, the violators always manage to stay one step ahead, aided, albeit unintentionally, by well-meaning advocates of free speech.
| Conclusion|| |
Over a century after Durkheim had conceptualized suicide as a social epiphenomenon, it was reimagined as a mental health problem, amenable to medicalized public health interventions, modeled on the lines of those which had successfully eradicated endemic diseases such as smallpox and polio. The social, cultural, and economic dimensions were gradually subsumed and then amputated from the discourse. This has diverted attention from the core issues to a quest for convenient, quick-fix solutions. The debris of failed suicide prevention plans bear witness to the inherent fault-lines in the current approach. Suicide is a societal, not mental health, nor even a public health problem. The powerful social, economic, and political forces driving high suicide rates are themselves endemic. Growing income inequality, terrorism, climate change, droughts and food shortages, and economic migration are some of the many challenges facing the world. Populism is replacing pluralism, globalization is giving way to protectionism, economic prudence to fiscal expediency, and political wisdom to electoral gimmickry. Instead of suicide prevention, the focus should be on enhancing resilience, on inculcating life skills and problem-solving abilities among school children, in reviving and reinforcing the organic support systems within the community.
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Conflicts of interest
There are no conflicts of interest.
A Critique of the Position
Thank you to Dr Goel for offering this subject for discussion. I find myself, as often in the past, in the truly interesting place, of both partly agreeing with what Dr Goel says, and simultaneously disagreeing with it. To approach the matter of the debate from a different perspective, let me come to the issue differently. What is the basis of my discomfiture with the line of thought that Dr Goel so articulately and forcefully advocates? Is it that he is saying anything wrong? If what he says is so patently correct, why indeed did it create so much discomfiture when the presentation was first made? Is it either wrong, or so stunningly correct and so far ahead of its time that it is incomprehensible to the lesser mortal?
If we think historically, this is perhaps, as pointed out, what the sociologist, Emile Durkheim was saying in the late 19th century (1897). According to Durkheim, suicide is not an individual act nor a personal action. It is caused by some power which is over and above the individual or super individual. He viewed “all classes of deaths resulting directly or indirectly from the positive or negative acts of the victim itself who knows the result they produce.” Having defined the phenomenon, Durkheim dismisses the psychological explanation. Many doctors and psychologists develop the theory that majority of people who take their own life are in a pathological state, but Durkheim emphasized that the force, which determines the suicide, is not psychological but social. He concluded that suicide is the result of social disorganization or lack of social integration or social solidarity. Although Durkheim's theory of suicide has contributed much about the understanding of the phenomenon because of his stress on social rather than on biological or personal factors, the main criticism of the theory has been that he has laid too much stress only on one factor, namely social factor and has forgotten or undermined other factors, thereby making his theory limited and only one sided. We may, here, be on the verge of repeating the same mistake.
I think we may move from here, to what I think of as the main problem with thinking in medicine, and specifically in psychiatry. Let us for the moment call this binary thought, or the “either-or” syndrome.
However, before we do that, if you would indulge me, let us take a small digression, and talk of stories. A story that has fascinated me forever so long has been the Ramayana. In his wonderful essay, “Three Hundred Ramayanas: Five Examples and Three Thoughts on Translation” Ramanujan (1991), makes the point that in the telling of a story, using the same anchor points, one can build very different, and often contrasting narratives. As Ramanujan says, “the story is essentially the same, but the weave, the texture, and the colors are very different.” Moreover, this essentially is the point of this remarkable essay-there can be no one monolithic version of a complex layered story, there can and will be different versions, and those versions, to make coherent sense, will have to “speak to each other.”
In that sense, when we speak of something as complex as suicide, then, looking for simple or simplistic answers may be somewhat difficult. Any cursory reading of any psychiatry history will show us how easily we fall into these patterns.
A case in point is the history of the mental hospital. There was a time when the care of the mentally ill was neglected. Homeless mentally ill people were on the streets. As “asylums” for care, mental health institutions were created, where it was possible to be both “mad and safe.” Essentially these were started as acts of caring or philanthropy. However, with a typical mix of human enterprise, industry and cupidity, there came a time in the West there were mental hospitals across the length and breadth of countries, in what is called “the great confinement.” Like all institutions, unsurprisingly, this crumbled. The hospitals became places of squalor, abuse, and neglect. This was contributed to by and perpetuated by a variety of factors. The veering of belief, toward the social and cultural factors contributing to mental illness, the advances and limitations of psychopharmacology were some of the factors that led to the decline in the standards at the mental hospitals.
It may, here, be good to remember that even as far as the mental hospitals are concerned, there are many diverse and often contrasting narratives, and many stories to be told.
However, the fact remains that many institutions had indeed become places where gross violations of human rights occurred. This, in turn, led to the care of the mentally ill being neglected. This led to a justifiable outrage, and this was followed by the Great De-institutionalization. Homeless mentally ill people are on the streets. And in jails. This in turn has led to the care of the mentally ill being neglected.
What should be the learning from these rather grim stories, and how long do we go on repeating them? The answer may perhaps be in moving away from the binary, or the “either-or.”
Maybe we need institutions for some folks, and maybe we need community care for some. Maybe we need to plan the community care better and more thoughtfully. We certainly need to plan those institutions better and more thoughtfully. However, I think we need to be clear that we certainly need both. If there has been one true learning from the patterns of pivoting, it is that we need institutional care perhaps in an ongoing fashion for some people, and we need to think about how most people will transition from institutions to reintegrating with the community.
We need, perhaps, to go beyond the outrage and think more inclusively.
This brings us to the other point that we need to perhaps raise here-when it comes to the planning of policy, what the policy makers ask of us is simple. They want simple, easy to implement, nonambiguous answers, in bullet points preferably. The real world is complicated, messy, nonbinary, layered. The last thing the policy-maker wants is a layered, complex building of narrative with existence of many possible tellings of the tale. Hence, we get reduced into simplifying things and into “dumbing them down.”
Suicide is a complex, tragic, multistoried devastating final punctuation mark to many different stories. Is there a possibility of ever reaching a zero-suicide state? Has it ever been reached? The answers are obvious. In a sense, the battle analogies, and “wars on suicide” are equally problematic, because these are unwinnable wars, but it is a problem only if we think of them as wars. Think of the “war on disease.” If we think of it as war, it is a war we are all destined to lose. My point is we may not want to think of it as “war.”
So, in a sense, with all due respect, looking at the social aspect is necessary, and for far too long has mainstream medical psychiatry neglected it. It is unarguably important and vital. To that end, I think Dr Goel's rather valiant efforts at re-instating the social perspective in suicide prevention certainly needs to be lauded.
The problem, however, is in the “pivot.” We may not want to shift from the “medical” to the “social,” so completely that we forget the “medical.” In many ways, talking about the effects of medication, of treatment, of the benefits of something like lithium carbonate in treating suicidal ideation in people with affective disorders, would be in so many ways, merely stating the obvious. The difficulty would be in embracing the “social,” so completely that we discard the 'medical' models, and perhaps equally disastrous.
Which brings us to the next issue: How do I layer my lenses? Medicine is very fond of what it calls “paradigm shifts,” a term I remember fondly from days of training and residency in these very hallowed halls of the All India Institute of Medical Sciences, where the current debate is happening. The question is however, what does it mean? Do I relinquish earlier learning for the shiny new tool? (Let us, for the moment, forget that here the “shiny new tool” is actually a century old). Or do I, somehow, try to keep in my consciousness the awareness that in the complexity of the human condition, the biological, the psychological and the larger world, or the social will all have influence? Is there something called a “Bio-Psycho-Social” or like many other concepts is this only meant for lip-service in medical residency?
It has taken a global pandemic to remind us of the importance of public health. Does it need a continuing spate of suicides to remind us of common sense?
I leave the question with you.
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Conflicts of interest
There are no conflicts of interest.
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