Sharon is a talented Sliema hairdresser who works on High Street. David, a garrulous newsagent, works next door. Both watch out for Ian. Ian self-harms. He lives nearby and has no support. His family have abandoned him.
Sharon cooks an extra meal at home for him and David helps with odd jobs at Ian’s place. Ian smiles when he has a chat with his two guardian angels.
There are many Ians in Malta. In fact, there are some 1,200 locals who are isolated, in crisis and who self-harm. These Ians are 100 times more likely to commit suicide than the general population. Of these, some 50 people will die annually. If they are not fortunate enough to have Sharons and Davids, they risk dying a lonely, miserable death.
Sharon and David are our sentinels. They call the crisis line whenever Ian or others in the neighbourhood are unwell. They too are members of the crisis team as they ‘create hope through action’.
Adopted as this year’s slogan for World Suicide Prevention Week by the International Association for Suicide Prevention and the World Health Organisation (WHO), hope and action are the essence of a national suicide prevention strategy.
The strategy, already in its draft form, outlines two principal objectives: to reduce suicide and self-harm behaviour among the general population and provide better support for those who survived or are bereaved or affected by suicide. Media messages this week exhorting ‘Intemmu s-suwiċidju (Stop Suicide)’ highlight this need.
As detailed in WHO’s seminal 2018 document, the strategy is crucial because it not only outlines the scope and magnitude of the problem but, more importantly, it recognises that suicidal behaviour is a major public health problem.
Suicide is the second biggest killer in the 18 to 35 age group after trauma globally and yet the service provision is comparatively small. The strategy signals the commitment of a government to addressing the issue, recommending a structural framework and incorporating various aspects of suicide prevention. By providing authoritative guidance on key evidence-based suicide prevention activities, it identifies what works and what does not work.
The strategy recognises key stakeholders and allocates specific responsibilities to them rather than having disjointed committees whose output, while being potentially useful, is limited and not concerted. The strategy will help identify key gaps in existing legislation, service provision and data collection, indicating the human and financial resources required for interventions.
One European study found “that if an area-wide suicide prevention intervention were to achieve only a modest one per cent reduction rate in the number of suicides, in most scenarios this remains highly cost-effective”.
The strategy furthermore shapes advocacy, awareness-raising and media communications while suggesting a solid framework of monitoring and evaluation, thereby instilling a sense of accountability among those in charge of interventions.
Suicide is the second biggest killer in the 18 to 35 age group after trauma globally and yet the service provision is comparatively small
The strategy encourages Suicide Prevention Acts, especially for high-risk groups such as ethnic minorities, substance users, jailed people and transgender/gay persons.
Established in several US and Asian states, such acts mandate having crisis-trained professionals based in government and private organisations to spot the early warning signs of suicide in terms of prevention, intervention, resolution and postvention. These acts have decreased the suicide rate significantly.
Finally, the strategy provides a context for a research agenda on suicidal behaviours.
Suicide is a behaviour which can be a response to any combination of difficult circumstances, including relationship breakdown, loss of employment and money worries. There may be no obvious underlying reasons. Many people who take their own lives are thought to have identified or unidentified depression or another mental illness, and a wide range of factors can contribute to the development of mental health problems.
The internet can be an invaluable resource for individuals experiencing self-harm and suicidal feelings. It provides opportunities to access information, find options for support and provides a platform to speak openly about difficult feelings that can be hard to discuss face to face. However, it can also carry potential risks by presenting opportunities to access graphic content, details around methods of harm and content that glorifies or promotes self-harm and suicide.
Access to such content can be distressing, triggering and may act to encourage, maintain or exacerbate self-harm and suicidal behaviours. It is, therefore, vital that sites and platforms hosting user-generated content take action to reduce the accessibility of potentially harmful content and put mechanisms in place to maximise support opportunities for vulnerable users.
Through crisis work, the local suicide rate has dipped slightly in the past decade (six per 100,000 population approximately). Nevertheless, anecdotal observations from crisis frontliners reveals that self-harm is on the increase, and COVID anxiety is a perpetuating factor. Suicide prevention thus has to become a national priority.
People who take their lives are often trying to stop emotional pain inside them which is as real as physical pain. Often they don’t necessarily want to die, but to end unbearable feelings. Given this, it’s important not to judge the person who has died. Sadly, people bereaved by suicide can feel pressurised to ‘move on’, which forces them to hide their feelings. The pain may never go away but life finds a place around it.
This is why we have to instil hope through action. Every loss is a preventable tragedy which transcends generations and leaves a huge void in loved ones who anguish throughout their lives, seeking answers they may never find.
Malta urgently needs a suicide prevention strategy. There can be no health without mental health. Given the signs of the times, there can be no mental health without a national suicide prevention strategy. WHO recommends that this complements a mental health strategy which despite being an excellent start, barely mentions addressing the tip of the arrowhead in mental health, namely crisis presentations.
We need a state-of-the-art accident and emergency for mental health just like there is a formidable A&E for physical illness. This is readily achieved by setting up a national crisis resolution and home treatment team.
Based at a Mater Dei crisis centre, close to all acute multidisciplinary amenities should they be required, the team would coordinate all self-harm presentations along evidence-based guidance.
With adequate resources and financing at par with those available for physical illness, we can reach out to the community and provide on-site treatment. This initiative mirrors physical health strategies wherein illness is increasingly tackled out of hospital where possible, with obvious advantages for the person and state.
We owe this not only to the many Ians out there. We owe this also to those who lost loved ones to suicide, as well as to the many Sharons and Davids who quietly instil hope through their heroic action to help prevent suicides.
If you have been affected by this article or are struggling, get in touch on the free 24/7 crisis line (+356 9933 9966) or download the free Kriżi app for help.
Mark Xuereb is a crisis psychiatrist and assistant university lecturer.