The Ethiopian Medical Association commemorated the annual World Suicide Prevention Day (WSPD) of 10th September by noting the day on its website (https://www.ethiopianmedicalass.org/world-suicide-prevention-day/). This is an important recognition and evidence of the commitment of the association to national/global wellbeing and equity. The WSPD is organised by the International Association for Suicide Prevention (IASP), with endorsement of the World Health Organisation, to help “focus attention on suicide prevention”.
Suicide is not a diagnosis. It is a judgment of a completed act made considering the following three criteria:
- Intent: The victim intended to kill him/herself
- Nature: The death was determined to be due to unnatural causes
- Perpetrator: The victim’s own action caused the death
The definition generally has a legal overtone and, in some countries, like the United Kingdom, only authorised persons, such as a coroner, can make the verdict of ‘suicide’. Whoever makes the verdict, all three criteria must be fulfilled to say a suicide death has occurred who ever makes the determination. Thus, suicide is an irreversible final act. In this regard, doctors may not have opportunity to do much other than to support the family of the deceased. But doctors can contribute significantly to the prevention of suicide. Before discussing what doctors can do, let us highlight the epidemiology and causes of suicide.
Every year globally, the lives of at least 700,000 people end tragically through suicide. Over three-quarters of these occur in low- and middle-income countries. Within the east African region, as defined by the UN, the rate of suicide ranges from 5.02 to 15.71 per 100,000 per year [Figure 1].
The annual rate of suicide in Ethiopia’s is in the middle, 9.63 per 100,000 per year. This means 30 people die of suicide every day with at least 150 people facing the prospect of living the rest of their lives under the shadow of the consequences of the suicide of a loved one. This is without considering the extensive impact on the community.
Although the overall rate in the region, including Ethiopia, has shown slight decline (Figure 1], the share of deaths from suicide has increased compared with the global average or European trend [Figure 2].
Probably the best study on suicide (completed suicide) was done by Prof. Abdulreshid Abdullahi Bekry. Through a meticulous analysis of death records of 15 years, he estimated the rate of suicide to be around 7.7 per 100,000 per year in Addis Ababa—higher in men at (12.7) compared with women (2.45). As this study was based on records, it is a clear underestimation of the actual rate. Suicide may be particularly under-reported among the homeless and the rural population given the high prevalence of suicide attempts among these groups. We have speculated elsewhere that “Suicide might indeed be a hidden cause of death in traditional societies because of the high level of stigma and associated religious and cultural condemnation. For example, in a study of 100 key informants, primarily consisting of community and religious leaders from Ethiopia, people who commit suicide were considered “condemned sinners” who do not deserve appropriate funeral rituals but should be buried in isolated unmarked place. Those who attempt suicide were “feared” and considered “cruel” and “untrustworthy””. Such community attitude and the nature of the death has a lasting and pervasive impact on surviving family members.
What causes suicide
|Table 1: Individual and socio-environmental factors associated with Suicide|
• Mental disorder
• Alcohol or drugs or other external agents
• Physical illness/chronic
• Chronic pain
• History of previous attempt
• Lack of social support
• Social isolation
• Family history of suicide
• Stressful life events
• Disruption to social cohesion (anomie)
• Accessibility of means
• Season of year
Suicide results from a complex interaction of personal (e.g., age, life events, mental illness), social (e.g., social isolation), environmental factors (e.g., availability/access to means of suicide) and geopolitical factors (e.g., loss of normal social cohesion or anomie) (Table 1). Even though these risks have been known for a long time, the current state of knowledge does not allow certain prediction of suicide in an individual. Yet, both predicting the level of risk and addressing, or at least reducing, these risk factors is essential for reducing suicide.
What can doctors do?
Given the complex nature of suicide, it is unrealistic to expect doctors alone to prevent suicide. Multi-faceted approaches to address all the potential risk factors is required. Policy interventions, such as controlling the means of suicide and other risk factors, should be top of the list of any preventive approach. For example, controlling access to pesticides in farming communities seems to have some promise. In India, central communal storage of pesticides was found to be effective. Within the limits of the study “none who used the centralized storage attempted or died of suicide”. Another good example is the UK’s legislation limiting the size of packs of analgesics sold over the counter. Suicidal deaths from paracetamol and salicylates were reduced by nearly a quarter following the legislation. The reduction also included admissions to liver units and liver transplants as well as non-fatal overdoses from these drugs.
Equally important is the quality and accessibility of care for people with poisoning. Moreover, it is mostly police who may be called to attend to a suicide scene or to someone who has attempted suicide. It is important to train police in the management of such encounters. Emergency service providers, such as ambulance crew, require basic training in the management of someone who has attempted suicide. All these call for policy interventions: expanding the available care resources and expertise, mandating training, and engaging in key community interventions.
But doctors can play a critical role in preventing suicide or reducing the impact of suicide on families.
First, all doctors should be familiar with suicide risk assessment. Suicide risk assessment is exactly like any other assessment—any doctor with the basic skills of interviewing a patient should be able to conduct suicide risk assessment. Suicidality is a human act that is out of the ordinary. It is against the human instinct and a result of a significant level of irrational thinking. Although often doctors feel annoyed by people who seemingly take the doctors time to deal with “real” needs, it is important to understand that intentionally trying to harm oneself is not a healthy behaviour.
Secondly, take any communication of hopelessness and suicidality seriously. At least as seen in developed countries, many people who commit suicide do access a medical care before the act. In Ethiopia and other developing countries, this could be traditional healers, priests, and family members. But a good proportion may also see doctors. Some doctors may think asking about suicide may increase the risk; however, there is no evidence that it does. On the contrary, patients experience a sense of relief when asked. It is always important to be careful and show empathy when asking.
Thirdly, compassionate approach, good rapport and intent listening may go a long way to persuade the person who is expressing hopelessness that they are worthy as a human being, and that life is worth living. Trying to mobilise support for them is also important. Patients are usually happy for their family members to know about their suicidal preoccupations.
Fourthly, ability to assess or quantify the level of risk of suicide helps to make determination of the sort of help that may be required and the urgency of the need. One of the common tools used in this regard is the SAD-PERSONS scale (Box 2). Those scoring low, unless there are other clear reasons, should be managed as outpatient. Those scoring ‘High’ typically require admission or referral for further evaluation and care. But, in the absence of such facilities, the family should be notified of the risk and closely monitor the situation with appropriate support of the doctor. Those with medium risk may be managed as outpatient depending on the broader need.
Fifth, some form of co-morbid mental disorder is found in around 90% of those who commit suicide. Depression is the commonest. Therefore, ability to diagnose any comorbid mental disorders, particularly depression, bipolar disorder, and substance abuse is critical.
Sixth, all doctors should have the required skills to provide emergency care for someone who has attempted suicide. Doctors should also be able to provide emotional support to survivors. Survivors react to the suicide of a loved one with a mixed emotion of sadness, guilt, shame, anger, confusion, and fear. They may engage in painful search for meaning. The grief process may be complicated. Understanding these emotions, expressing compassion, and providing support are important.
Seventh, such dramatic events can take a toll on the doctor. Doctors should know how to self-care.
Finally, doctors should observe and document carefully the trends and collate data beyond the individual level information. All doctors are clinical scientists and can make significant contributions to policy if they also take their responsibility for conducting applied research seriously. We know very little about suicide in Ethiopia, including common causes, availability of resources, what doctors do, where suicides are more common in the country, what should be done at the national level, etc. Grassroots evidence is required to build the essential evidence base.
Suicide is a tragic event that can be prevented. Doctors can play central role in the prevention process. Having basic expertise in suicide risk assessment, management of suicide attempts and contributing supporting the policy inputs should be within the sphere of responsibility of all doctors. In doing so, doctors should know how to be compassionate to themselves and self-care.
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[Abebaw Fekadu is Professor of Psychiatry and Co-Director of the WHO Collaborating Centre for Mental Health Research and Capacity Building at the Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University. He is also Director of the Medical Discovery Centre at the College of Health Sciences, Addis Ababa University (www.cdt-africa.org)]