Jason Bantjes and Ashraf Kagee write that many factors that lead to suicide are not psychiatric or medical, and require a holistic approach.
Cape Town - Imagine a mother coming home to find her daughter lying in a pool of blood after having cut her own wrists. The horror of such an experience is unimaginable, but for some it is a harsh reality.
For the family and friends of the person, suicide is often incomprehensible, confusing and tragic.
For the person who attempts or completes suicide, the world is often an overwhelming place to be, and ending one’s life appears to be the only option.
The World Health Organisation estimates that 1 million people a year die by suicide worldwide, with the number predicted to rise to 1.53 million by 2020.
Suicide has been declared a global public health crisis. Official statistics suggest the suicide rate in South Africa is about 13.25 per 100 000. Suicide accounts for just under 10 percent of all unnatural deaths, but these figures are probably conservative.
Collecting accurate suicide statistics in South Africa is difficult due to under- and misreporting causes of death.
Official statistics indicate about 80 percent of suicide completers in South Africa are men – a trend also found in most other countries around the world.
In poor rural communities suicide rates may be as much as 2.4 times higher than in cities. It is estimated that for every completed suicide, there are 20 suicide attempts.
As for the racial distribution of suicide, nationally registered suicides between 1984 and 1986 indicated that they were highest among whites, followed by Asians, coloureds and black people. However, these studies were conducted during the apartheid era leading to poor record-keeping and inaccurate statistics.
Many people who engage in suicidal behaviour have a psychiatric illness, usually a mood disturbance or personality disorder. Data from various countries indicate that between a quarter and one-third of those who completed suicide had been in contact with mental health services in the 12 months before ending their lives.
Health professionals and traditional healers thus have an important role to play in suicide prevention. Yet many South Africans do not have access to mental health-care services.
Even though mental illness appears to play a role in suicidal behaviour, most individuals with psychiatric conditions do not engage in suicidal behaviour.
It would thus seem that the relationship between death by suicide and mental disorder is mediated by other factors.
Various studies show 40 percent of people who take their own lives do not have depression, and up to 10 percent have no diagnosable mental disorder. For some, suicidal behaviour may be a “rational choice”.
In our research among university students who have had suicidal intentions, we found that suicidal behaviours – thoughts, feelings, intentions and attempts – had a strong relational component. Participants indicated that for them suicidal intentions were a means to communicate distress, provoke action or elicit sympathy.
Suicidal behaviour thus often occurs within an interpersonal context and can have a communicative function.
The men spoke about the pressure to conform to rigid, narrow and restrictive gender norms and traditional ideals about men needing to be strong, heterosexual, financial providers and protectors of women. For many of these men, seeking help or showing vulnerability was a sign of weakness. A perceived failure to live up to the “dominant masculine ideal” – being macho, unemotional, independent and rational – resulted in feelings of shame and fear of being ostracised by others.
Feelings of shame, anger and social isolation are often the core emotions leading up to deliberate self-harm and suicide. Suicidal behaviour for some represents a way out, an escape from unbearable emotions.
Some participants reflected on the socio-political context of present-day South Africa. Their perception is that the changes the past few of decades have left some young men feeling disempowered, marginalised and hopeless.
They said women had experienced some measure of liberation, but men were still often restricted by conventional gender norms and societal expectations.
They also expressed disillusionment at the lack of political and economic transformation and unfulfilled promises of education, employment, health care and housing. Some black participants described a sense of discontinuity between the traditional customs associated with their parents and the Western ideas they saw embedded in the “new” South Africa.
Our research on attempted suicide in Cape Town suggests situational and contextual factors (interpersonal conflict, financial concerns, exposure to traumatic events, personal loss and homelessness) and personal factors (feelings of powerlessness and experiences of marginalisation) may also play an important role in precipitating suicidal behaviour. It appears substance abuse is also an important factor.
The causes of suicidal behaviour are varied and multiple. There is no single factor or group of factors that can be pinpointed as the exact cause of all suicides.
Some suicides occur without warning, but typical signs include a depressed mood, feelings of hopeless- and helplessness, social isolation and a sense of disconnectedness.
There is a widely held perception that suicidal behaviour is simply a symptom of mental illness – mental health care workers should thus be responsible for preventing suicides and hospitals are the place for suicidal individuals to be “cured”. But this medicalisation of suicide obscures the fact that many factors that contribute to suicide are not psychiatric or medical. Many mental healthcare workers believe it is inappropriate to expect them to prevent all suicides because many factors that precipitate suicide are beyond their control.
Currently, South Africa has no national suicide-prevention strategy. Given the complexity of suicide, such a strategy requires research and planning. However, any effort to reduce suicide should focus on increasing access to psychological services, and providing help to individuals who have interpersonal difficulties. It should also address poverty, homelessness, gender dynamics and substance abuse. Creating schools and communities where individuals feel safe and connected is also important. Fostering social cohesion and feelings of connectedness and belonging would need to be central to any effective policy.
With the combined efforts of politicians, policymakers, researchers, clinicians, parents, teachers and young people, suicidal behaviour can be reduced.
If you have suicidal urges, contact your doctor, see a mental health care professional, phone Lifeline (0861 322 322), or visit The National Depression and Anxiety Group website (www.sadag.org).
* Dr Bantjes and Professor Kagee are in the psychology department at Stellenbosch University and part of the African-Norwegian Mental Health Research Group.
** The views expressed here are not necessarily those of Independent Newspapers
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