Suicide and Mental Health

I- Introduction:

According to a recent WHO report, about 450 million people are affected by mental, neurological and behavioural problems in their lives and among these 873,000 people die of suicide every year with mental illnesses common to all countries and people with mental disorders usually suffer from social isolation, poor quality of life and increased mortality (WHO report, 2005). Mental illnesses have been found to be precipitated with chronic conditions of cancer, heart and cardiovascular diseases and diabetes and AIDS. Although cost effective treatment methods for mental disorders do exist, according to the WHO , the obstacles to effective treatment of mental illness include a lack of recognition of the seriousness of mental illness and a lack of understanding of the benefits of the mental health services and according to WHO figures most poorly developed economies devote less than 1% of their health expenditure on mental health needs of people.

The unit of WHO responsible for overseeing mental health needs of people, the Department of Mental Health and Substance Abuse provides guidance for the achievement of two broad objectives:, namely

(a) closing the gap between what is needed and what is currently available to reduce the burden of mental disorders worldwide, and

(b) promoting mental health. (WHO, 2005)

WHO has recently launched mental health Global action Programme (mhGAP) which focuses on partnerships to help countries combat stigma of mental illness and reduce the burden of mental disorders and promote mental health. There are 100 collaborating centres around the world for implementing this objective and involves the coordinated action of policies and interventions of departments of education, social welfare, justice, rural development and women's affairs.

Mental health is a major public health concern and in 2001 WHO published its report focusing on mental health as the primary issue in its agenda, emphasizing the need for new understanding and a new hope. The World Health report 2001 which focused on mental health helped in shedding new light on mental disorders and offers hope for those suffering from mental disorders and to their families. The report examines the social and psychological burden associated with mental health problems and identifies the principal contributing factors and the scopes and obstacles in treatment. It also provides a critical review of the health services and provisions available with panning an recommendations that can be incorporated in healthcare systems. The mental health Global action Program was a follow up of the World Health report and attempted to close the gap between what is needed and what is available to mentally ill patients and their families. The significance of WHO's efforts are evident in the countries serious concerns about improving mental health problems around the world.

Through the efforts and actions of the mental health Global Action Programme (mhGAP), there is an opportunity to advance the momentum generated to intensive action s that people with mental illness can access the much needed services and achieve a highest level of recovery and again get entry in mainstream community.

In this essay, we would first take a detailed look at the overwhelming mental health problems and increasing suicide rates worldwide laying the foundations for a more detailed study on the links between mental health problems and psychological illnesses with suicide rates and drug abuse. We provide extensive statistical data on mental health problems and their relation to suicides and drug use worldwide especially focusing on the distribution of suicide rate and the mental health situation in the UK. Our claim that suicide rates worldwide are related to mental health issues have been substantiated by studies of the Government of UK department of Health and the National statistics provided. Studies reveal that most mental disorders are associated with suicide and drug use and vice versa.

Providing a statistical foundation to our claims, we would take our arguments further with research evidence on care and health services on mental disorders and substance abuse which can have suicidal consequences. We would discuss suicide cases and how these are related to mental illness and substance abuse using studies and evidence within clinical settings.

Part II to be inserted here -

III - Suicide Mental Health and Substance Abuse Risk factors and Relationship

The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".

Thus, in order to attain proper health, improvement of the mental health of individuals is also essential. This focus and special emphasis on mental health is essential as it brings with it a high degree of burden and to reduce this excess burden and adverse impact of mental disorders on individual and society, effective preventive and promotional measures have to be taken. The WHO Department of Mental heath and Substance Dependence emphasizes on the goal of reducing the burden associated with neurological and mental disorders and aims to promote mental health worldwide. The Department has identified prevention of mental disorders and promotion of mental health as one of its priority projects under the mental health Global Action Programme (mhGAP).This project helps in identifying the most effective strategies in this field across different cultures and also helps countries to implement and evaluate them (Prevention and Promotion in Mental Health, WHO, 2002).

According to Baxter and Appleby (1999), there have been very few studies on long-term suicide risks due to mental disorders in the UK and their paper attempted to establish this relation between mental disorders in psychiatric patients and long term suicide risks using a sample of 7921 individuals identified from the Salford Psychiatric Case Register. Using the NHS central register, mortality by suicide or undetermined external causes of suicide were determined during a follow up period of up to 18 years and suicide rates were estimated as rate ratios. The results indicated that suicide rate has gone up in the last 18 years and the ratio for males was 11.4 compared with females which was at 13.7. The risk of suicide seems to be highest in young patients although high risk continued into late life. The highest risks of suicide were associated with mental disorders of schizophrenia, affective disorders, and personality disorders and in males' substance dependence. Risks of suicide were also associated with the number of admissions in a hospital but not with any co morbidity. The authors conclude from their study that the suicide risks estimated in their study are generally higher than previously reported as in schizophrenia and personality disorder and reported in previous in-patients. Patients within high risk of suicide are diagnosed with an illness in the previous 1-3 years and usually for suicide prevention strategies, more than one previous admission cases should be regarded as priority groups who should be put under special care by mental health services.

In another similar 1999 study, Walsh et al estimated the prevalence of risk factors associated with para-suicide in a large community based sample of patients suffering from chronic psychosis. For their study they selected 704 subjects with chronic psychosis and interviewed using a battery of testing instruments. The 2 year para-suicide prevalence was estimated and a comparison was made between attempters and non-attempters on a range of socio-demographic and clinical variables. The study results indicated that 2 year prevalence of para-suicide was 18.8%. the authors suggest that suicide attempters are likely to be younger, of white ethnic origin and with a diagnosis of an affective disorder and are in most cases currently depressed having experienced more auditory hallucinations and having received treatment with antipsychotic drugs for a long period. Walsh et al concluded that para-suicide was found to present a considerable clinical problem within these particular groups of people within psychotic disorders and continual risk assessment seems to be essential to reduce a high rate of suicides and suicide attempts.

Neale (2000) studied the relations of drug overdose and suicide attempts and aimed to explore suicidal intent among drug users who were experiencing a fatal drug overdose. For the design, Neale used semi-structured interviews and 77 drug users experiencing non-fatal overdose and attending six hospital accident and emergency departments in two Scottish cities during 1997-1998 were interviewed. The study aimed at examining the extent of suicidal intent and motivations for intentional overdosing and according to the findings the incidence of suicidal intent was high with 38 or 49% of the respondents reported to have had suicidal thought or feelings before the overdose. The author emphasized that suicidal actions were significantly associated with self reported history of life time mental health problems and with not using drugs prior to the overdosing but not related to other demographic or drug history data. The study however also indicates that qualitative data obtained show that intentional drug overdosing was not always driven by a clear and unambiguous desire to die and suicidal actions were motivated by many psychosocial factors such as predisposing personal circumstances, immediate precipitating events, and poor individual coping strategies and mechanisms to tackle the adverse event in life. Neale concluded from his study that the issue of suicidal intent needs to be addressed routinely in hospital wards and also in accident and emergency departments so that a need for healthcare and support could be assessed and properly implemented (Neale, 2000).

Deliberate self harm (DSH) in patients who leave the accident and emergency departments of hospitals without proper psychiatric assessment was studied by Hickey et al (2001) and the authors claim that deliberate self harm patients, despite their risks of suicide are often released from the accident and Emergency departments without undergoing psychiatric treatment and assessment. This may be due to procedural and administrative policies of hospital management systems and the aim of Hickey et al's study was find the characteristics and outcomes of these high risk patients. The authors investigated the characteristics of the DSH patients who were discharged from an A &E department over a 2 year period and two groups were compared with those who have had psychiatric treatment and assessment and those who did into have any. In their matched control design of the experiment, the outcomes and characteristics of those who did not receive any psychiatric assessment was compared with a group of patients who had psychiatric assessments. The results indicated that of the DSH patients who were discharged directly from A&E departments, 58.9% did not have any psychiatric assessment. Non assessed patients were more likely to have a past history of DSH and in the age group 20-34 years also to have shown difficult behaviour in the AS &E department. Within a year DSH is seen in 37.5% of non-assessed patients compared with 18.2% of assessed patients who are also more likely to undergo psychiatric intervention and treatment. The authors concluded that quite a number of DSH patients were discharged directly from A&E department of hospitals without receiving psychiatric treatment and non-assessed patients are in greater risks of DSH and suicides or suicide attempts than patients who are assessed. The authors suggest that hospital management should include programs of psychiatric assessment in hospital A&E department to prevent risks of self harm and future suicides following discharge.

Haw et al (2002) studied deliberate self harm (DSH) in patients with depressive disorders and pointed out that depression is the most common psychiatric disorder and especially true in cases of deliberate self harm and in patients who commit suicide. Their study aimed to examine the treatment received by DSH patients having depression and tracked their progress following the DSH episode. For their purposes, a representative sample of 106 patients with ICD-10 depressive episode presented at a general hospital following an episode of DSH was investigated. This was done in terms of their treatment before an after the DSH episode and their outcome at follow up. The results indicated that prior to the DSH index episode, 39 patients (36.8%) were receiving treatment from psychiatric services and further 35 (33%) were receiving treatment for mental health related problems from the GP. 49.1% of the patients were receiving antidepressants. After the DSH episode, 88.7% of the patients were offered treatment at psychiatric services as a new referral treatment method or a continuation of previous treatment. From The patients who followed up, 36.3% remained in contact with psychiatric services and 52.3% showing poor compliance with recommended treatment and 60.2% no longer showed the diagnostic criteria of depression however one-third of the patients studied reported a further DSH episode during the follow up period. The authors suggest from their reports that the nature and quality of the services offered have not been investigated and conclude that all patients following DSH need to be screened for depressive illnesses and randomised controlled studies need to be done to see which treatment for DSH patients are most effective.

Gunnell et al (2002) reported on gender differences in minor mental disorder and its relation to suicide. The study highlights that suicide rates in men are three times higher than females and this is in accordance wit the study and reports given by the National statistics department in the UK. Yet as the authors report women have a higher prevalence of community diagnosed depression. To find out the reasons for differences, the authors investigated the paradox examining subjects with a general health questionnaire with measures of minor mental disorder and suicide risks in the sample population. The study was based on 8466 men and women who completed a 30 item questionnaire and were followed through to 1995 for suicide mortality according to the results the long term suicide risks associated with a minor mental disorder has been found as higher in men and the authors concluded that either males have higher risks of suicide when suffering from mental disorder or possibly there are sex differences in the validity of responses to mental health screening questionnaires.

Sex differences apart there have been specific studies on South Asian women who have shown instances of self harm following psychological distress within their homes. Chew-Graham et al (2002) reports an investigation into self reported needs of South Asian women who suffer from distress ad mental health problems that may lead to self harm and suicide the study design used a qualitative study with focused group discussions. In this study, four focus groups of South Asian women were used and each focus group was facilitated by one of the authors of the study and discussions were multilingual in Urdu, English or Punjabi. An interview guide was used and notes were taken for the discussions. The data obtained was analysed according to principles of framework analysis. Certain issues that were considered for the study included social, political and economic pressures; domestic violence; poverty; language problems; family and children's issues; and health. Racism and stereotyping of Asian women and concept of honour in social life seems to be an important aspect of family life for the women resulting in mental distress for which the women saw self harm and suicide as usable coping strategies to deal with their distress. Services taken by these women were at extreme levels and not at the beginning of the problem and the authors' outline the local cases although emphasising the need to generalise and use mental health services approaches accordingly.

Emphasizing the role of employment as means of social inclusion, Mitchell et al (2002) suggest that employment, mental health and substance abuse are intricately related as employment is helpful in making an individual fully active in society. The needs for being gainfully employed is given higher priority by social and healthcare agencies and the numerous difficulties that prevent young people from acquiring employment can be detrimental to psychological health and bring with it associated problems of substance abuse and mental illness following social exclusion. Mitchell et al write 'Unemployment may lead to social alienation, criminal or other antisocial activity and a higher incidence of suicide. Consequently, there is a danger of young unemployed people slipping into a spiral of self-defeating, antisocial and risky behaviour' (Mitchell et al, 2002, p.191). The authors argue that there is very little evidence that mental health agencies working collaboratively with social care and social work voluntary agencies to prevent mental health problems in young people associated with unemployment and substance abuse and this issue is a challenge to mental health professionals.

For our final study we give a very interesting analysis of nurses and doctors perceptions of suicidal cases and suicidal behaviour in young people as studied by Anderson et al (2003). Anderson et al point out that over the past 25 years, suicidal behaviour in young people has continued to remain a major concern for health services around the world as self harm in individuals of age 13-18 is quite common representing a major reason for admission to A &E, accident and emergency department of the hospitals, to paediatric medical services and child and adolescent mental health services. Following an episode of self harm or suicidal attempts, nurses and doctors become the first persons who confront these young people and considering this Anderson et al studied the nurses and doctors perceptions of episodes of self harm and suicidal behaviour in adolescents and young adults. The data was subjected to qualitative and quantitative analysis and their findings revealed two main categories and aassoiuxted subcategories of perceptions namely, Experiences of frustration in practice (with subcategories of non-therapeutic situations, insubstantiality of interventions and value of life), and strategies for relating to young people (with sub-categories including specialist skills in care and reflections on own experience).

According to the study the categories highlight the obstacles in the nurses and doctors who deal with young people engaging in suicidal behaviour. The authors emphasise the need to recognise these barriers that exist within the medical profession in order to improve services and practice.

Summary and Conclusion:

In this essay we discussed several aspects of mental health and its relations to suicide and substance abuse. We began with a WHO reports on mental health and suicide rates worldwide and WHO links on substance abuse and suicide. The fact that mental health and suicide rates are related, are revealed from several studies which we discussed in the later part of our essay. In this context we provided statistical data from countries all over the world given by WHO with special emphasis to substance abuse, mental disorders and suicides and suicide attempts and risks in young adolescents within UK. Use of drugs and emotional and depressive disorders have been found to be high among men than among women in the UK although some studies have indicated that women tend to report more depression than men. Our statistical data spanned from issues on mental health services offered to suicide rates and instances of emotional disorders as compared with other depressive disorders and how these factors related to substance use. However in our later part of the discussion on evidence and research on mental health, depressive disorder, drug misuse and suicide rates we highlighted several other factors and instances suggesting factors such as employment and precipitating events are as important. We emphasised on several issues – long term suicide risks on drug taking and mentally ill patients are higher than in normal population of adults, apparently there have bee some studies on depressive ales being more prone to suicide than depressive females although females are more likely to report depression. Chronic psychosis and schizophrenic illnesses can be a social burden along with any other mental illness and is a major cause of suicide. Some studies on deliberate self harm that has been considered as intentional which may or may not have motivations of suicide suggest that young adults may engage in suicidal activities to harm themselves due to emotional problems, inadequacies, social exclusion and alienation or other family and social problems. Self harm can be a reaction to a situation and is usually done with self poisoning or drug overdose or with other suicidal attempts such as burning or drowning. We finally touched on gender and ethnic issues in suicide and mental health emphasizing on the need for further studies in these areas.

We defined health in terms of both mental and physical health as noted by the WHO and this suggests that mental health is an important part of healthcare and services plan. Considering this the need for analysis and assessment of mental health problems in hospital inpatients and in adults engaged in drug abuse is very important and can go a long way in preventing death rates due to suicide all over the world.

Bottom of Form

Bibliography

Middleton N, Whitley E, Frankel S, Dorling D, Sterne J, Gunnell D.

Suicide risk in small areas in England and Wales, 1991-1993. Soc Psychiatry Psychiatr Epidemiol. 2004 Jan;39(1):45-52.

McAllister-Williams RH, Watson S.

Bipolar disorder ignored by the Mental Health National Service framework but not forgotten by the British Association for Psychopharmacology. J Psychopharmacol. 2003 Dec;17(4 Suppl):7-10. Review.

Owens C, Lloyd KR, Campbell J.

Access to health care prior to suicide: findings from a psychological autopsy study. Br J Gen Pract. 2004 Apr;54(501):279-81.

Foster T.

Suicide note themes and suicide prevention. Int J Psychiatry Med. 2003;33(4):323-31.

Barr W, Leitner M, Thomas J.

Short shrift for the sane? The hospital management of self-harm patients with and without mental illness. J Psychiatr Ment Health Nurs. 2004 Aug;11(4):401-6.

Chiesa M, Fonagy P, Holmes J, Drahorad C.

Residential versus community treatment of personality disorders: a comparative study of three treatment programs. Am J Psychiatry. 2004 Aug;161(8):1463-70.

Lynch F, Mills C, Daly I, Fitzpatrick C.

Challenging times: a study to detect Irish adolescents at risk of psychiatric disorders and suicidal ideation. J Adolesc. 2004 Aug;27(4):441-51.

McCrone P, Bhui K, Craig T, Mohamud S, Warfa N, Stansfeld SA, Thornicroft G, Curtis S.

Mental health needs, service use and costs among Somali refugees in the UK. Acta Psychiatr Scand. 2005 May;111(5):351-7.

Fujino Y, Mizoue T, Tokui N, Yoshimura T.

Prospective Cohort Study of Stress, Life Satisfaction, Self-Rated Health, Insomnia, and Suicide Death in Japan. Suicide Life Threat Behav. 2005 Apr;35(2):227-237.

Chiesa M, Fonagy P.

Psychosocial treatment for severe personality disorder. 36-month follow-up. Br J Psychiatry. 2003 Oct;183:356-62.

Owens C, Booth N, Briscoe M, Lawrence C, Lloyd K.

Suicide outside the care of mental health services: a case-controlled psychological autopsy study. Crisis. 2003;24(3):113-21.

McMillan JR.

Dangerousness, mental disorder, and responsibility. J Med Ethics. 2003 Aug;29(4):232-5; discussion 237.

Middleton N, Gunnell D, Frankel S, Whitley E, Dorling D.

Urban-rural differences in suicide trends in young adults: England and Wales, 1981-1998. Soc Sci Med. 2003 Oct;57(7):1183-94.

Anderson M, Standen P, Noon J.

Nurses' and doctors' perceptions of young people who engage in suicidal behaviour: a contemporary grounded theory analysis. Int J Nurs Stud. 2003 Aug;40(6):587-97.

Henderson C, Dazzan P, Dernovsek M, Tavcar R, Brecelj M.

Evidence-based prevention strategies of suicide behavior in the world: implications for Slovenia. Crisis. 2002;23(3):121-6. Review.

Chew-Graham C, Bashir C, Chantler K, Burman E, Batsleer J.

South Asian women, psychological distress and self-harm: lessons for primary care trusts. Health Soc Care Community. 2002 Sep;10(5):339-47.

Neale J.

Suicidal intent in non-fatal illicit drug overdose. Addiction. 2000 Jan;95(1):85-93.

Burr J.

Cultural stereotypes of women from South Asian communities: mental health care professionals' explanations for patterns of suicide and depression. Soc Sci Med. 2002 Sep;55(5):835-45.

Haw C, Houston K, Townsend E, Hawton K.

Deliberate self harm patients with depressive disorders: treatment and outcome. J Affect Disord. 2002 Jun;70(1):57-65.

Kittelsen SS, Barber JA, Harrington R.

Factors that influence the Cost of Deliberate Self-poisoning in Children and Adolescents. J Ment Health Policy Econ. 2001 Sep 1;4(3):113-121.

Mitchell DP, Betts A, Epling M.

Youth employment, mental health and substance misuse: a challenge to mental health services. J Psychiatr Ment Health Nurs. 2002 Apr;9(2):191-8.

Hickey L, Hawton K, Fagg J, Weitzel H.

Deliberate self-harm patients who leave the accident and emergency department without a psychiatric assessment: a neglected population at risk of suicide. J Psychosom Res. 2001 Feb;50(2):87-93.

Alexander DA, Klein S, Gray NM, Dewar IG, Eagles JM.

Suicide by patients: questionnaire study of its effect on consultant psychiatrists. BMJ. 2000 Jun 10;320(7249):1571-4.

Baxter D, Appleby L.

Case register study of suicide risk in mental disorders. Br J Psychiatry. 1999 Oct;175:322-6.

Hawton K, Houston K, Shepperd R.

Suicide in young people. Study of 174 cases, aged under 25 years, based on coroners' and medical records. Br J Psychiatry. 1999 Sep;175:271-6.

Walsh E, Harvey K, White I, Manley C, Fraser J, Stanbridge S, Murray RM.

Prevalence and predictors of parasuicide in chronic psychosis. UK700 group. Acta Psychiatr Scand. 1999 Nov;100(5):375-82.

Gunnell D, Rasul F, Stansfeld SA, Hart CL, Davey Smith G.

Gender differences in self-reported minor mental disorder and its association with suicide. A 20-year follow-up of the Renfrew and Paisley cohort. Soc Psychiatry Psychiatr Epidemiol. 2002 Oct;37(10):457-9.

Prevention and Promotion of Mental Health and other Reports: see

http://www.who.int/en/

also for statistics see

http://www.statistics.gov.uk/