Suicide is misunderstood because a medical model is being applied, meaning doctors are incorrectly treating it as an illness of the mind, argues Professor Said Shahtahmasebi, Director of the Good Life Research Trust Centre and editor ofDynamics of Human Health. Shahtahmasebi has conducted years of research to try to better understand suicide trends and find an effective prevention model. Utilizing his grassroots, community-empowering model, one region in New Zealand went from having one youth suicide a month on average to having two suicides in an 18-month period.
In light of the fact suicide rates are unacceptably high (New Zealand has the highest rate of teen suicide in the developed world), Anti-Media asked Professor Shahtahmasebi why suicide rates have increased despite a redirection of massive resources to mental health services.
AM: In your opinion, what are some of the underlying problems with the way suicide is being treated?
Over the last 20 years, I have repeatedly challenged the conventional wisdom about suicide, emphasizing that suicide rates follow a cyclical pattern (the sequence of downward and upward movements of suicide rates). Instead of concentrating efforts on breaking the cycle, decision makers, mental health services, and researchers claim credit for lowering suicide rates when the cycle is on the downturn, then demand more funding to continue with the same services. But when the cycle is on the upturn, they claim suicide is a very complex issue with many socio-economic and environmental risk factors and that they, again, require more funding to extend the same service to more people.
This may be fine the first time. However, after many decades of research and psychiatric intervention, the reality is that suicide prevention is really more of the same, with an approach centered around looking for signs of mental illness and then referring individuals to mental health services. But each year, the strategy of ‘more of the same’ is costing more in terms of both lives lost and monetary burden.
Suicide is not a mental health problem. Not many people with mental illness or depression commit suicide, but some suicidal people undergoing psychiatric intervention do. Current estimates suggest about one-third of all individuals who have killed themselves had previous contact with mental health services but still went ahead and completed suicide.
On the other hand, between two-thirds and three-quarters of all people who end their lives have no contact with mental health services, which means we don’t know anything about their state of mind. Further, psychological autopsy studies linking mental disorder to suicide have been challenged and discredited.
AM: So how can psychiatrists and politicians still claim suicide is the result of mental illness?
A study [pdf] I conducted in 2003 using patient records from a psychiatric/mental health hospital showed that out of those who sought psychiatric help and completed suicide, only 16 percent had depression recorded as a diagnosis or had it mentioned somewhere in their medical notes. Thirty-three percent had a different classification, including schizophrenia, alcohol or drug abuse, paranoia, or personality disorder, and 17 percent had “other.” Astonishingly, 33 percent did not have a diagnosis at all.
Therefore, about 50 percent of the patients had no mental illness diagnosed at the time of suicide.
The research suggests that psychiatrists and politicians can no longer claim that suicide is the result of mental illness.
AM: So what is actually known about those cases who had no contact with health services?
The whole notion of ‘look for signs of mental illness and refer’ to prevent suicide defies logic and is counter-intuitive.
First, it assumes that only people with a mental disorder commit suicide. This is not true. Second, this method ignores the majority of people who may be suicidal and in need of help. Third, by associating suicide with mental illness, people who experience suicidal thoughts or behavior potentially avoid seeking help. Fourth, if signs are detectable, then prevention has failed, and it is time for effective interventions. Fifth, psychiatric intervention has failed to prevent a large proportion of all suicide cases who were referred to mental health services.
For example, official government documents show that in New Zealand, prescriptions for antidepressants have more than quadrupled since 1997, yet the suicide rate has continued in a cyclic upward pattern, now reaching an all-time high of 579 this year.
If mental illness is the cause of suicide, shouldn’t we be observing a continual reduction in the number of suicides given the amount of resources being put towards mental-health-based treatments and the increase in antidepressant use?
So it is not only ‘more of the same’ in suicide prevention action plan but also ‘more of the same’ in rhetoric: at every cyclic upturn, ministers and their ‘experts’ claim suicide is ‘unacceptably’ high and that mental health services must be strengthened.
‘More of the same’ is symptomatic of a lack of accountability.
AM: How does your proposed model differ from the current status quo?
The philosophy of preventing suicide through mental health intervention is no longer tenable. Psychiatric research declaring mental illness the cause of suicide has been challenged and discredited. In a recent publication, the World Health Organization (WHO) lists mental illness causing suicide as one of the many myths, and as a result, they have modified their guidelines.
There is no doubt that mental health services must be supported effectively to deliver efficient services and to improve health outcomes. However, mental health services cannot prevent suicide.
The problem is exacerbated by an uncritical media that pushes the medical model and refers to proponents of the medical model as the “experts.” The truth is that we do not understand suicide because all of our efforts have been focused on treating mental illnesses that may or may not exist.
In other words, if an individual is referred to mental health services (whether they are self-referred because of a suicide attempt or by a health professional), the intervention looks to establish a mental disorder, such as depression, for which medication can be prescribed. So, in the process of treatment, ‘suicide’ per se is effectively taken out of the equation and ignored, and a completely different issue is treated as a result of the misdiagnosis. Treating a condition that does not exist explains the reason why a significant proportion of all suicide cases who received psychiatric treatment went through with suicide (about one third).
Through the process of raising research funds, I realized several points. Firstly, it is futile to wait for the government to take the initiative and act in the interest of the public. Secondly, suicide prevention does not require major funding and can be operationalized with few resources. Third, uncritical and flawed suicide information is contributing to misinformation in the public domain. Fourth, so long as suicide prevention remains highly politicized, ‘more of the same’ is the only suicide prevention action plan available to the public.
In order to achieve a change in direction, suicide prevention must be de-politicized. A sure way of achieving this is to engage the public. This can be achieved by providing the public with quality and appropriate information about suicide and human behavior.In 2010, our grassroots approach to suicide prevention was rolled out in the Waikato and Kawerau in New Zealand through a series of training workshops. The philosophy behind the grassroots approach is that we, the public, cannot wait for signs of mental disorder to manifest and then seek psychiatric intervention. The aim is to prevent people getting to the stage where they feel that suicide is a viable option.
A couple of very important outcomes from the workshops were: first, we received many personal comments from suicide survivors (parents who had lost a loved one to suicide). By teaching them about adolescent development and adolescent behavior, we were providing them with alternatives to dealing with their teenaged children. For example, it’s no use telling a teenager to pull themselves together or that there are plenty more fish in the sea when they are going through a break-up because, at that point in time, the break-up means everything to them. Showing sympathy and empathy have been proven to be far more effective. Because of this, many personal comments came our way along the lines of: “Had they known this information then their loved one would probably be alive today.”
Second, participating communities formed suicide prevention groups enforcing prevention rather than intervention. The groups developed locally-based suicide awareness activities designed to inform and to prevent.
“For the approach to be successful it had to address the needs of the participating communities as perceived by them. The frontline health workers that we contacted indicated their greatest need was for information, training, and for upskilling in order to be able to deal with youth and adolescent issues. The resulting outcome was a pilot project offering training workshops.
“The frontline health workers organized the community workshops including locating venues, facilitating publicity, and inviting local dignitaries and other community members (e.g., police, teachers, social workers, counselors, young people, and the general public). The project intended to empower communities to plan and make decisions at the family and community level by increasing their awareness of adolescent issues. In this context, the role of the researchers was to facilitate training workshops and basically play a support and mentoring role. All the community projects and activities that followed were designed and developed at the grassroots level by the communities themselves.”
The frontline health and social workers in the participating communities reported that suicide — youth suicide, in particular — had substantially declined. This is a trend that continues to the present date.
The communities also have reported that they are much more confident in engaging in problem situations and preventing them from becoming suicide crises.
The workshops were also funded through local institutions and charitable trusts, a Fulbright grant, frontline workers, and volunteers. Attendees included social workers, mental health frontline workers, police, coroners, psychiatrists, GPs, teachers, church representatives, youth, the general public, and suicide survivors. Unlike the medical model, the grassroots approach is an inclusive strategy.
I guess the concluding message is that if the public is sick of ‘more of the same’ suicide intervention strategy, then the grassroots must mobilize and take action… after all, it is the grassroots who know their communities better than the ‘experts’ or government decision makers.