Suicide prevention in Australia is often represented as, first and foremost, about recognising and getting help and treatment for depression. Everywhere, we are given the message that depression leads to suicide. A search of suicide prevention websites, media reporting, and popular debate turns up repeated calls for awareness about depression.
There’s no doubt that mental illness, especially depression, is a risk factor for suicide. Researchers estimate between 30% to 90% of people who die by suicide have some form of mental illness.
But those estimates also tell us that many people who take their own lives are not mentally ill. Life history and personal circumstances – such as relationship breakdowns, business failure, or unemployment – can play a strong role in the development of suicidal behaviour, irrespective of whether or not that behaviour is accompanied by mental illness.
Suicide is the culmination of complex interactions between biological, social, economic, cultural and psychological factors operating at individual, community and societal levels.
Simply treating mental illness, without addressing the context in which illness has occurred, does not necessarily prevent suicide. Or, as one experienced mental health nurse put it in a conversation with me:
A patient of mine rang and said “that’s it, the antidepressants aren’t working anymore, I can’t go on” … I’d known him for a while and I said, “what else is going on?”
Turns out that what had really got to him was his business was finally picking up, but he couldn’t afford to hire the workers he needed to get the jobs done … his suicidal thoughts didn’t come from depression, they were because some practical things needed to happen, and he couldn’t make them happen.
Connections between mental illness and suicide vary across different demographic groups. Among younger people, for instance, suicide is often linked with school, family, or relationship problems, rather than psychiatric illness.
There are also cultural differences at play: while mental disorders are often associated with suicides in European and North American people, this is not the case in Asia. Varied cultural understandings of mental illness may contribute to part of this difference - but they cannot explain all of it.
Why such a heavy focus on mental illness?
Millions of research dollars have gone towards exploring connections between mental illness and suicide. So when we address mental illness, we are trying to take evidence-based action that can reduce one important risk factor for suicide.
Unfortunately, the relentless focus on depression means we have less research evidence around other contributors to suicide than we do for mental illness. We have created a cycle where we focus on mental illness because we know it relates to suicide, and we know it relates to suicide because we have focused on it.
As a result, suicide prevention programs are typically administered through mental health branches of health departments. Suicide prevention policies are often “tacked on” to mental health policies. Other risk factors and contributors to suicide get a mention, but they are generally relegated to the sidelines.
This in turn makes it difficult to develop rigorous preventive strategies that step outside an “interventionist” medical model, in which suicide is seen as the result of illness.
Framing suicide within a medical model oversimplifies an incredibly complex human behaviour. Focusing on mental illness helps us feel that we are doing something about the “wicked problem” of suicide, but in practical terms it can mean people at risk of suicide may not get the “right” information or the “right” types of help.
There is also the risk of misdirecting scarce resources. For instance, although awareness campaigns are often held up as a suicide prevention measure, we have no direct evidence that years of government-funded depression awareness campaigns have impacted on Australian suicide rates.
Differentiating suicide from mental illness is not just a theoretical debate. It has tangible implications for suicide prevention strategies. When communities at high risk of suicide are identified, for example, the default response is usually to “send in more mental health services”.
But what if the real problem is financial insecurity and stress, brought on by a failing industry on which a whole community relies? Or entrenched social disadvantage? Or loss and bereavement?
Responding adequately to these suicide risk factors calls for a whole-of-life approach that crosses different sectors, agencies, and actors. Ultimately, achieving real change in this area requires more than lip-service and platitudes. It requires a new paradigm in suicide prevention that places suicide – not depression – at its centre.