Said Shahtahmasebi, Ph.D.
The process of policy formation is by default a political one. The main reason is that national and local resources are finite but more importantly controlled by politicians. The fact that politicians are elected by the public and have unlimited access to a wide range of scientific tools and/or scientists to seek evidence in support of a decision ought to be reassuring. However, the reality is that these facts actually cloak personal ‘political’ preferences and hence the process of decision making.
An exploration of suicide prevention policies of the past provides a good example. Although, suicide is often referred to as a major public health concern, suicide prevention is classed as a mental illness issue and formulated under mental health policy. The current guidelines in New Zealand (NZ) prevent public discussion and debate on suicide and suicide prevention and advise us to look for signs and direct all our concerns to mental health or psychiatric services. It appears that depression and mental illness are the signs for suicidality. Those who receive mental health services for showing the signs are then treated with antidepressants for mental illness and not for suicide.
There is a downside to this approach. Waiting for signs to develop and manifest is rather too late and does not prevent suicide so the approach becomes interventionist. This approach ignores those who do not exhibit signs either because they do not have symptoms or are good at hiding their symptoms because they know what treatment awaits them. Current estimates suggest that between two-thirds and three-quarters of all suicide cases do not come into contact with mental health services.
In addition, suicide trends over a long period suggest a cyclic effect, i.e. each cycle exhibits a peak and trough. Furthermore, conflicting suicide trends (by age, by sex) suggest that there is a lagging effect in cycles between the sexes and similarly between age-groups. When the cycle is following a downward trend the authorities (researchers and policy makers) claim success and demand more funding to reinforce the same policies for the other age-groups. But when it is the reverse, they claim that suicide is a complex issue and needs more funding to increase access to mental health services and to investigate the various mental illness and social contributing factors. Such a response is perhaps the worst consequence of the interventionist approach and has led a suicide prevention policy that each year offers more of the same but at higher social and economic costs.
Health service data from UK and NZ, and research on suicide survivors (those bereaved by suicide of a loved one) suggest that this approach is not working. For example, some individuals who received treatment for depression/mental illness subsequent to a failed attempt were found deceased following discharge from mental health units. For some individuals the process of treatment-discharge with no suicidality and suicide attempt were repeated several times before their final demise.
In New Zealand, there is additional evidence that there is an urgent need to rethink our approach to suicide and suicide prevention. In 2011, the Chief Coroner, stated that current approaches are not working and a new approach is needed. He also commented on the secrecy surrounding suicide by stating “I have suggested that there may be room for a gentle opening up of the restrictions on media reporting of suicide, but we need to consider all viewpoints – especially those of families – so we can make informed decisions.”
But perhaps the most concrete evidence in New Zealand is the doubling of prescription of antidepressants. The government’s own reports show that antidepressant prescriptions doubled between 1997 and 2005 and doubled again between 2005 and 2012. But over the same period suicide rates increased from 540 deaths annually in 2007/2008 to 558 in 2010/2011. The decision by the Associate Minister for Health to side step suicide survivors when initiating a meeting to discuss suicide reporting very firmly reinforces the top-down interventionist view that only the Government’s selected experts have a valid opinion.
It is unfortunate that despite the evidence, the politics of suicide prevention is still to cure a mental illness cause and basically provide more of the same.
A new approach must break free from the assumptions of the past. Indeed suicide is a complex process and there is no statistical evidence for any one factor, be it medical, social, economic, or environmental, to be causing suicide. It must be acknowledged that suicide is the result of a personal decision making process and we must understand more about this process which is a human behaviour. Like other decisions, we must empower the public to choose life instead of death by removing the obstacles and taboos so that individuals feel safe and free to seek help with their decision making process. To do this we must depoliticise suicide prevention policy making.
Clearly, depoliticising a process is not an easy task. By default it will involve ways of introducing new ‘blood’ in the process to make sure the evidence is seen and taken on board. This is high level politicking and is beyond most academics and the public. But there is another method of depoliticising the process by adopting a grassroots approach.
The grassroots approach involves understanding the needs of a community and then empowering the community to address their needs. In terms of suicide prevention, a simple question ‘what do you need to stop youth suicide?’ was put to health and welfare liaison workers in communities with a high youth suicide rate. The answer was the same for each community: we do not understand suicide and need more information about youth.
In 2010, Waikato Institute of Technology (Wintec) funded a visit to New Zealand by Professor Hatim Omar, the founder and Chair of Kentucky ‘stop youth suicide’ campaign to give a number of workshops on youth development and suicide, as well as report on the progress of the campaign in Kentucky. As a result, a number of communities who participated in the workshops set up their own groups and identified issues that the group could do to involve youths and let the young people know that their community cares. A second visit, funded by Fulbright, Wintec, Trust Waikato and participating communities, followed at the end of 2011.
The Community suicide prevention groups worked according to their understanding of their population. Some worked speedier than others. The net effect was that community partnerships began to flourish. Perhaps the biggest coup was the partnership with the local media which has been supporting the groups and reporting on suicide prevention activities. For example, one group organised a week where they had a suicide prevention festival and closed off the main road with organised activities to increase awareness and demystify suicide. The information packs they provided included a list of available services plus ‘shout out’ cards where individuals can record the contact details of one or more friend/family as the first port of call in case of difficulties. The festival was a great success and was supported by the local media. Others managed to organise a dedicated cell-phone line for youths to call when having issues/difficulties especially if they did not want to use the national service.
The most interesting results is that the communities are talking about and debating suicide publically, they have worked hard to resource their suicide prevention activities, they understand that intervention does not prevent and lower suicide rates – to prevent suicide and lower suicide rates the whole community must get involved. They feel empowered that they are taking action that means something to them rather than being told to intervene, they are encouraging the community to talk to each other: parents with their children, children with their parents, with relatives, with others in the community. They feel empowered to engage the community by empowering the youth by engaging schools, up-skilling young people, youth becoming part of the prevention, and engaging community groups (e.g. YMCA, Salvation Army). Interestingly, they reported that a number of lives had been saved by just talking and using the ‘shout out’ cards. Finally, in the area with highest youth suicide where the community set up a week of suicide awareness festival, youth suicide fell from an average of one a month for the previous years to 2 (one youth and one adult who was receiving mental health services) during 2012.
1. Shahtahmasebi, Said (2013) De-politicising suicide prevention. Under review.
2. Shahtahmasebi, Said (2012) Youth suicide prevention at grassroots. Int J Child Adolesc Health 2013;6(2): forthcoming.
3. Shahtahmasebi, S. (2011) A review and critique of mental health policy development. Int J Child Health Hum Dev 2012;5(3):255-64.
4. Shahtahmasebi, S. (2006) “The Good life: A holistic approach to the health of the population” TSWJ-Holistic Health and Medicine, 1, 153-168.