We know a lot about suicide. We know the numbers. We know there are signs of risk. And we know the devastation it causes.
Sadly, we also know that we don’t know nearly enough. As a country, we haven’t been able to prevent the rising numbers of people taking their own lives every day.
This month, the Office of National Statistics released a new set of figures on suicide in the UK. It showed that rates had risen by 11.8%, reversing falls seen in the previous four years.
The ONS report showed there are more males taking their own lives: men aged between 45 and 49 years had the highest age-specific suicide rate.
There are also more people under 25s doing so. Particularly females aged between 10 and 24, where the rate has increased significantly since 2012.
Unsurprisingly, we ask ourselves why. According to Nick Stripe, Head of Health Analysis and Life Events at the ONS, “While the exact reasons for this [rise in suicide rates] are unknown, the latest data show that this was largely driven by an increase among men who have continued to be most at risk of dying by suicide.”
In a submission to Women and Equalities Committee inquiry earlier this year into the mental health of men and boys, we gave evidence around the most pressing issues affecting men and boys’ mental health.
While there is relatively little evidence, we cited research which found that men don’t typically talk about having suicidal feelings and are more likely to bury their heads in the sand, where they are hidden from support services and remain undiagnosed.
While this is a complex area, identifying the cause of suicidal feelings is also abstruse. There are many societal drivers, including drugs and alcohol, economic adversity, unemployment, workplace problems, housing instability, social isolation and difficulty accessing help.
Difficulty getting support is sometimes down to lasting stigma surrounding mental health. While great strides have been made in encouraging people, particularly men, to talk about their emotional wellbeing, clearly this change won’t happen overnight. Many men typically model traditionally masculine ‘strong and silent’ behaviours to their sons, who are likely, in turn, to do the same. It will take time and effort to break the cycle.
At the same time, culturally it remains tough for males to express or share their inner worlds with those closest to them, or with professionals. Indeed, society’s gendered treatment of boys continues to prevent or make it difficult for males to discuss emotions without judgement.
For younger women, a group which has also seen an increase in suicides, there is an understandable focus on social media and self-harm as possible causes or indicators of risk.
While social media has opened up a whole new world of opportunities and has incredible potential to do good, it can bring about an increased sense of vulnerability and pressure. Young people have reported pressure to conform and present themselves in an unsustainable idealistic way with raised expectations about what constitutes ‘good’, ‘happy’, ‘successful’ and so on.
Much is known about adolescent development and the need for healthy social relationships during this time. It is not difficult to imagine how an over-reliance on texting, Instagramming and gaming in order to make such connections may be developmentally and emotionally detrimental.
The impact of social media on sleep should not be underestimated either. There are also links between bullying and social media and bullying and suicide. In addition, there are also ties between social media and the development or maintenance of eating disorders. In fact, eating disorders have the highest mortality rate of all childhood mental health disorders, including through suicide.
The rise of the self-harm epidemic in female teens in particular and higher teen suicide rates generally is alarming. We know that instances of self-harm are rising rapidly: the proportion of females aged 16-24 who have self-harmed increased from 6.5% in 2000 to 19.7% in 2014.
According to Professor Louis Appleby of Manchester University who leads the National Suicide Prevention Strategy for England, and who is one of the authors of a recent study published in the Lancet Psychiatry Journal, “Non-suicidal self-harm may be associated with later suicide. As young people get older, reaching age groups that already have higher suicide rates, the self-harm they have learned may become more serious and more likely to have a fatal outcome.”
We know that the majority of people who self-harm are not suicidal, while also knowing that many people who die by suicide have self-harmed. There is, therefore, no doubt that individuals who self-harm are at an increased risk of attempting or completing suicide. This needs to be taken seriously as a risk factor.
Being alert to escalating self-harm, either in relation to frequency or severity is important, as this in particular signifies an increasing risk. Individual factors are also highly pertinent when trying to disentangle self-harm as a ‘coping’ behaviour as opposed a ‘suicidal’ one; motivation and intent as well as expectation of outcome following self-harm all contribute to a more sophisticated understanding of risk.
It’s my belief that the very real risks associated with self-harm are often too easily dismissed or accepted as the norm within certain mental health populations. People feel the need to harm themselves for a reason. Whether they are choosing to die at that time may be unclear, however the evidence that those who self-harm are more likely to die by suicide than those who don’t is undeniably worrying.
Repeated self-harm certainly presents a challenge for mental health professionals, many of whom work with clients who have been self-harming for a number of years. Indeed recent data from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness shows that amongst self-harmers who took their own life, imminent suicide risk was judged to be low or not present in around three quarters of patients.
It is easy to become oblivious to those who self-harm. Whilst professionals cannot wrap patients up in cotton wool, it is imperative that we are constantly assessing the risk and this involves looking for subtle changes.
And although, sadly, some suicides come ‘out of the blue’ with very few warning signs, self-harm, alongside other known risk factors, should always ring an alarm bell with any mental health professional. Because if self-harm indicates risk, it also provides an opportunity to intervene, through early help and prevention.
But to intervene early and effectively means services have got to fit. They have to be available, accessible and they need to suit the individual.
The fact that most men who take their own lives are unknown to services may tell us something about stigma, societal pressure or an inability to express emotions, but it could also tell us something else: that services may lack appeal. More research is needed to better understand the barriers to existing services and the type of support which would appeal.
Ultimately, for boys and men, a cultural shift is needed, where they are given the same freedoms as females in their ability to express emotions. Shorter-term, however, a continuation of the work we see through organisations such as Heads Together in encouraging conversation is positive – if only half the story. There must be a determined focus on the availability, type and mode of intervention on offer to males. This is an area which should be open to innovative approaches that can be tested and trialled.
There are, of course, some people who take their own lives who are known to services but who are not seen as high risk. This could be due to a number of factors. They may, for example, present as ‘positive’, having made the decision to end their life. They could feel genuinely relieved and therefore choose not to share their plans which they may believe could disappoint their therapist or result in him/her trying to prevent them from completing suicide. Again, it is difficult but essential that practitioners stay tuned to behaviours and statements which could demonstrate risk.
Hard as that is, they must also take into account the wider issues at play. This is an area highlighted by Professor Appleby following the publication of the ONS suicide rates. One of his Twitter comments made the link between mental health and poverty:
“Suicide rates are strongly influenced by deprivation & the econ adversity many have faced in last 10yrs – not only job loss but zero hours, benefits & where to live – are bound to have had an impact, though less clear how these factors explain today’s abrupt rise. Many young people are anxious about jobs, the cost of housing, escalating debt, how they look. They also see environmental crisis, narrowing of their horizons, social injustice. And power lying with people who have different values & aren’t listening.”
So while we can and should continue to research the groups most at risk from suicide, the indicators of risk, the drivers and the services available, we should also have a wider perspective on what is happening in society, politically and economically to prevent the devastation of suicide.
Commenting on the ONS report, Andy Bell at the Centre for Mental Health wrote: “Some 6,507 lost lives, all with friends, relatives, colleagues and others who feel the pain of loss for the rest of their lives. We owe it to all of them to do all we can to prevent suicide in every community nationwide.”
I can’t say it better than Professor Appleby in one of his closing tweets:
“We need to give young people a positive message about their place in the world, the chance to shape their future, economically & politically, with right values. To replace anxiety with optimism & confidence. Not just about their own lives but where society as a whole is heading.”
Dr Lynne Green, clinical psychologist