September is Suicide Prevention Awareness Month – a time to raise awareness, reduce stigma, and encourage an informed response to this global mental health emergency. Suicide is the second leading cause of death among youth aged 15-29. Twenty-three South Africans complete suicide every day, and another 460 attempt to end their lives daily. For people living in conditions of adversity – poverty, unemployment, food insecurity, violence; all conditions pervasive in our communities – the risk for suicide is heightened. 

We know a fair amount about who attempts or completes suicide, the risk factors involved, and the associated psychiatric disorders. Suicide is regarded as a phenomenon of mental disorders: 9 out of 10 persons who die by suicide are found to suffer from a mental disorder. These disorders often go unnoticed and undetected. Moreover, men and women differ in their suicide behaviour: men are four times more likely to complete suicide, while non-fatal suicide behaviour is more common among women. More recently, we have started to recognise the role of contextual factors, particularly experiencing so-called “catastrophic” events, in increasing suicide risk. The taboo around mental illness and especially suicide, forces it underground, and results in persons contemplating suicide to remain silent about their thoughts or experiences.

Even though we understand many of the factors linked with suicide, we still struggle to preventing it from happening. There are two main reasons for this. Firstly, suicide is primarily and most often an act of impulse. Secondly, in South Africa and other low- and middle-income countries, treatments are often reactive to a suicide event rather than preventative or proactive. Notably, no research trials on suicide prevention have been conducted in South Africa, leaving a major gap in evidence-based suicide prevention and treatment.

The notion that someone is thinking of hurting or killing themselves is overwhelming, even for experienced clinicians. Eight out of 10 people who die by suicide had contact with a primary healthcare provider within one year of their death. Yet, in South Africa, primary healthcare providers typically have minimal training in mental health. Psychiatrists and psychologists are few and far between in these settings and deciding if someone is at-risk for suicide often falls on a provider in the local system deemed most equipped – usually a general practitioner. High-risk persons may need referral and admission to a psychiatric unit, while lower risk persons might benefit from anti-depressant treatment, and referral to a social worker. Sadly, only a minority of people will report suicidal thinking and receive the necessary life-saving care. There are pockets of support available in communities, such as help lines, support groups, and school-based programs, but more needs to be done. Crucially, how can we better care for those who present to services with suicidality from ever making a fatal attempt?

Answering this question is complex and requires a multi-faceted approach. Firstly, primary prevention or community-based care requires greater awareness among persons in homes, schools, and groups. Mental illness and suicide are highly stigmatised, and we need to do more to promote stigma-reducing language, programs, and methods, that will open the door for people who experience mental illness, stigma, and suicidal thinking to seek help sooner. One of the drivers of stigma is ignorance, and there is evidence to suggest that improving public knowledge about a specific condition, in this case suicide, can reduce the effects of stigmatisation. If we improve knowledge about suicide in schools, universities, healthcare facilities, and even in the general population, we can equip staff, clinicians, and peers to provide better suicide treatment and support. Through sensitising staff, we can develop and implement clear guidelines on assessment and treatment of suicide, with packages of care targeted towards different levels of risk and tailored to individual needs: women in abusive relationships might need a different intervention (such as a place of safety) compared to a lonely, anxious teenager needing one-on-one counselling and peer support. 

Secondly, specific suicide-directed therapies need to be investigated. There is a rich literature in behavioural science which we can draw on. One example is cognitive behavioural therapy (or CBT), whereby a person’s negative thoughts and re-enforcing behaviours are addressed in a directed and supported manner. In the model of depression, a person may develop negative patterns of thinking about themselves, the world, and their future. These thoughts arise spontaneously and are known as negative automatic thoughts. These thoughts are coloured by the stressful and overwhelming experience and develop into cognitive distortions. An example is “catastrophisation”. This plays out when people hear bad news or experience a stressor, and tend to think the worst. They deeply personalise the event, and run it through to a conclusion. The result may be a feeling of entrapment, which becomes reinforced when the person is isolated or has no interior mechanism to challenge the false idea. Single options of escape then emerge and may take the form of suicidal thinking or behaviour. To address this using CBT, the therapist or provider must allow the person to express the stress, the ensuing fear, and the cognitive distortion (in this example, catastrophisation) they are experiencing. Once the faulty thinking is identified, the goal of CBT is to show the person that the negative thought was based on incorrect underlying assumptions (for example “my partner broke up with me because I have no value in general”). The incorrect assumption, and the following negative thoughts are challenged by the therapist, using the person’s own language and experience, and eventually they are taught to self-challenge when negative thoughts and feelings occur. A suicidal person feels trapped, often a burden to others, ambivalent about living, and negatively perceived by others. Alternative realities, agency, and growing self- and other support are key interventions to address these. CBT is a highly technical intervention, but it can be task-shared to non-psychologists in an effective way, and our Group has shown this. Nurses, for example, can be trained and supervised to guide clients to understand their illness, develop ways to activate themselves from boredom and apathy, and also to challenge many incorrect ways of thinking.

Suicide, and particularly interventions for suicide, remain an area of critical public health interest. Yet, there are several barriers to conducting this type of research. People with suicidal thoughts and behaviour are deemed a difficult population to investigate, and studies conducting research in this area are at risk of including persons who attempt or complete suicide – serious adverse events for any investigating team to manage. For these reasons, and probably others, researchers have been loath to venture into recruiting suicidal persons into intervention studies. 

It is time for researchers and clinician-scientists to overcome these barriers and address the global mental health emergency that is suicide. We need to extend the reach of primary prevention efforts among at-risk individuals. Importantly, we need to strengthen healthcare systems by enhancing knowledge and skills and finding evidence-based approaches that can be cost-effectively delivered to those who need it the most. In this period following the COVID-19 pandemic, and the ensuing stress, unfortunately the need will only be greater. The time to act is now.

To read the original piece, follow the link: https://www.dailymaverick.co.za/article/2022-09-08-suicide-in-south-africa-tiome-to-tackle-stigma-of-this-global-emergency/