Suicide is a difficult topic to discuss—it’s painful for those who've seen suicide affect their loved ones. And yet, it affects us all on a global scale.
*Note: The following piece talks about suicide. Please read at your own discretion.
While we’ve come a long way in education and awareness efforts surrounding suicide and mental health, we have a long way to go. Countries like the US and South Korea are still facing above-average percentages of suicide-related deaths. The global COVID-19 pandemic is responsible for an increase in anxiety and stress, which we know are exacerbating factors for suicide.
In light of Suicide Prevention Awareness Month, we spoke with psychiatrist Fred Lewis, VP, Scientific Affairs at PRA about suicide, its global presence, and ways we can help prevent it.
How do suicide rates vary across the globe? Where is it more prevalent and in which groups? Why?
There is a considerable differential in terms of suicide prevalence, when looking at it from a global perspective. In order to understand this differential, you must consider the etiologies and antecedents of suicide in the study of suicide or suicidology. Even within a small country, you'll see differences in various cultural groups. Some of it is due to not only cultural, but also religious reasons. We don't have a single etiology for suicide—there are so many factors that contribute to its risk. There are likely antecedents that have to do with mental illness that increase your risk for it, but that alone is not enough.
There are many other things that can contribute, like extreme stress, poverty, loss of jobs, and the impact of things like COVID-19. There are spiking numbers of suicides in various populations, particularly younger people. Certain factors increase that risk—substance use, for example, adds an additional risk for suicide.
When you take a look at the global picture, you're looking at about 800,000 deaths a year worldwide, which is twice the homicide rate. It certainly underscores how serious this problem is. When you look at that 800,000 deaths by suicide, that's about 1.4% of all deaths that occur globally.
Countries like Greece, Peru, and Iceland have rates less than 1%, which is best in the global average. Then you have the US, which is about 1.5% to 1.7%, which is slightly above the global average. Then you have countries where it’s considerably higher, such as South Korea, where we see a rate currently of about 5%, almost three times the global average. Japan is also quite high at about 3%, although this rate has been falling and is beginning to approach 2%.
Countries with falling prevalence rates support the notion that more action is being taken to stem the tide and reduce the number of suicides. These actions include better outreach, more support, and possibly more access to mental healthcare, which then becomes a discussion and political debate about national access to healthcare professionals. When you look at the specialty of psychiatry, you’ll see it's the most underserved specialty. There's a tremendous shortage of psychiatrists in the United States—certain areas have four or less psychiatrists within an entire state.
With COVID-19 forcing many practices to shut down face-to-face care, telehealth has emerged as a savior to the psychiatric profession, but more importantly to our patients. Psychiatrists are now able to continue to safely care for their patients and communicate face-to-face in a virtual environment.
When you take a look at the global picture, you're looking at about 800,000 deaths a year worldwide, which is twice the homicide rate. It certainly underscores how serious this problem is.
Fred Lewis, VP, Scientific Affairs
While external factors play a large role in affecting a person’s mental health, what internal factors also contribute?
Certain psychiatric disorders put patients at increased risk for suicide, and it's not just the self-evident disorder of depression. When you look at major depression as a diagnosis, contrary to popular belief, it doesn't have the highest suicide rate. Bipolar depression, the depressive phase of bipolar disorder, is much more serious in terms of the number of attempts and completed suicides. I’m always concerned about patients who suffer from any of the depressive disorders as being at elevated risk. Another example of an at-risk population for suicide is schizophrenia. During the first two years of their diagnosis, there’s quite an increased risk for self-harm.
There is growing evidence of the impact of genetics on risk of suicide. When you consider an illness like bipolar disorder, we're talking about a condition with a very strong genetic risk. It is an autosomal dominant disorder with incomplete penetrance, resulting in a very high concordance rate of bipolar diagnosis in monozygotic twins, approximately 80%. In unipolar depression, we find a much lower concordance of diagnosis. Surprisingly, even schizophrenia has a concordance rate of less than 60%.
Suicide is often a result of not receiving treatment for a mental health condition. Why is there such a high prevalence of suicide despite the multitude of treatments?
Access to mental health care is still a problem in the United States. In many of these illnesses, patients are in denial themselves or have limited self-awareness of their illness. In fact, limited insight is a characteristic of some mental illnesses such as schizophrenia, where the individual doesn't believe they’re sick. Unfortunately, we see high rates of noncompliance and noncooperation in these populations.
In America the legal system is strongly in favor of patients’ rights to accept or refuse treatment. As long as the patient is not clearly a danger to himself or others, then treatment shouldn’t be forced. This explains why you see so many mentally ill people on the streets of our cities. Fifty percent of the homeless are suffering from an untreated major mental illness.
Still, there are some breakthroughs and awareness is spreading. For example, with the seminal introduction of much safer antidepressants such as Selective Serotonin Reuptake Inhibitors (SSRIs) in 1989, we now see 52% of all mental illness being treated in settings other than psychiatry. Essentially, patients are being treated predominately in primary care settings, family physicians and internists. Other specialists are engaging as well, such as pediatricians and gynecologists. This development has greatly expanded access to quality mental health care.
What are ways the public can help spread awareness and education about suicide? How can we work to end the stigma that people with mental health issues face?
I believe that most people have likely experienced a suicide, either in their family or extended friend circle. In my own family there's been two losses—both painful experiences.
It shouldn’t be this way, but people are reluctant to talk about suicide. Nobody wants to come out and say that someone died of their own hand—that in itself just further adds to the stigma. The family feels embarrassment. Unfortunately, they're afraid of the judgment and the pejorative way in which victims are characterized.
So, it’s incredibly important to address prevention. It’s about being able to share suicidal thoughts with a professional so that a definitive intervention can be initiated. There’s a new treatment that was recently approved by the FDA that specifically reduces suicidal ideation and it does it extremely quickly, within 24 to 72 hours. This is a major breakthrough—if we can get people to admit their thoughts of self-harm, then we can admit them to the hospital and potentially treat them with this seminal product.
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