Suicide prevention hampered by mental health stigma
Paul Yip calls for more action to tackle society's ignorance and prejudice towards mental health and suicide, to help those in crisis and reduce the burden on families and communities
Today is World Suicide Prevention Day, co-sponsored by the International Association for Suicide Prevention and the World Health Organisation. First observed in 2003, the theme of this year's event is "Stigma: A Major Barrier to Suicide Prevention". According to the WHO, suicide is a major public health problem in high-income countries and an emerging problem in low- and middle-income nations.
It is among the top 20 causes of death in the world, with some 800,000 suicides each year, many of them young people. That's around one death every 40 seconds. The number of suicide deaths each year exceeds the number of lives lost to homicide and war combined. These staggering figures do not include suicide attempts, which occur much more frequently.
A large proportion of people who commit suicide suffer from mental illness. Recent estimates suggest that mental disorders will become the second leading cause of the global disease burden in the next two decades, making it the most important category of ill-health - above even cancer or heart disease.
The impact on someone suffering from mental health problems can be even greater than for commonly diagnosed cancers. Yet a significant number of people suffering from mental illness who commit suicide did not contact health or social services prior to their death. In many cases, there are insufficient services available to assist those in need at a time of crisis, while some are reluctant to get help.
This lack of access to appropriate care is one factor that magnifies the stigma associated with mental illness and with suicidal thoughts and behaviour. This type of stigma, deeply rooted in most societies, can arise for different reasons. One is a simple lack of knowledge.
This can be addressed through community-based education programmes targeted at specific groups within society; by age, educational level, religious affiliation, and so on. The goal is to increase public awareness of the characteristics and treatment of people with mental illnesses and suicidal behaviour, and of the treatment available to help individuals with these problems.
Studies by our centre suggest that only 25 per cent of those who commit suicide try to get help beforehand. Reasons include not knowing about the service, believing it will be of no use, or being discouraged by the long waiting time in the public system and the unaffordable cost of private psychiatric treatment.
But knowledge is not enough to combat the stigma. Negative attitudes towards individuals with mental illnesses and suicidal tendencies are common in many communities. Often, education has no effect on such prejudice. Indeed, many health professionals who feel uncomfortable dealing with these people often hold negative attitudes about such patients, resulting in a failure to provide optimal care and support for people in crisis.
Changing such attitudes requires a long-term effort to alter the underlying cultural values of a community and a parallel effort to change the treatment norms of health care professionals. Our centre is working with local hospitals and non-governmental organisations to develop programmes to improve the follow-up support for patients who self-harm and who have been admitted to hospital.
Stigma is also the underlying motive for discrimination in the form of inappropriate or unlawful restrictions on the freedoms of individuals with mental illnesses or suicidal behaviour. Such restrictions can be evident at a personal, community or institutional level.
One extreme example is the criminalisation of suicidal behaviour, which still occurs in many countries. Discrimination can prevent or discourage people with mental illnesses or suicidal thoughts or behaviour from seeking professional help or from returning to their normal social roles after receiving treatment.
Clearly, criminalisation can be a powerful deterrent to individuals in crisis who desperately need access to care and support without being judged or penalised. Suicidal behaviour was decriminalised in Hong Kong in the 1960s following the law change in Britain. However, discrimination against individuals with mental illnesses or suicidal behaviour is still not uncommon in the work place and in our community.
At a government or administrative level, stigma can have an impact on resource allocation. In high-income and low- and middle-income countries, stigmatised conditions such as mental illnesses and suicidal behaviour receive a much smaller proportion of health and welfare budgets than is appropriate, given their huge impact on the overall health of the community. Furthermore, fund-raising efforts to support public health initiatives in this area are particularly difficult because of a lack of interest - again, because of the stigma attached.
Massive public education programmes have been of limited use in reducing the stigma associated with mental illness and suicide. New, innovative methods that target specific groups or that creatively use social media need to be developed and tested. Despite the difficulty and complexity of fighting the stigma, we don't have a choice if we want to improve the quality of life of individuals with mental illness and suicidal tendencies while also reducing the huge burden suicide places on both families and communities. Unless the stigma is confronted, it will continue to be a major barrier to the treatment of mental illnesses and the prevention of suicide.
Every year, World Suicide Prevention Day provides an opportunity to refocus our collective energies on addressing this fundamental problem. Changing cultural attitudes requires an awareness of the many forces that influence community norms, and the concerted effort of a wide range of community stakeholders over a prolonged period.
This is an ideal time to inspire people to develop creative new methods for overcoming this stigma. Comprehensive local or national plans to prevent suicide will not reach their full potential until this problem is effectively addressed.
Collectively, we can make a difference and transform the world into a better place for everyone.
Paul Yip is a vice-president of the International Association for Suicide Prevention and convener of World Suicide Prevention Day, 2013. He is director of the Centre for Suicide Research and Prevention at the University of Hong Kong