To be or not to be

A debate older than dirt.
(Pic : BBC)

The final individual AMs debate of the term was held yesterday and wasn't a particularly upbeat one as it addressed the sombre issue of suicide.

AMs called for :

• The National Assembly to "regret" the 300-350 people who take their own lives in Wales each year, and recognise suicide's the leading cause of death for 20-34 year olds; particularly amongst those who have an underlying mental illness.
• More to be done to encourage people to talk about suicidal thoughts and feelings.
• The Welsh Government to - amongst other things - improve data collection on those at risk, ensure follow-up support to those admitted to A&E following suicide attempts and ensure people are pointed towards appropriate counselling and support services.

There's a detailed look at the facts and figures behind suicide in Wales from the Assembly's Members Research Service on their In Brief blog.

In opening, Eluned Parrott AM (Lib Dem, South Wales Central) said discussions about suicide were often abstract and focused on statistics (clip). She then presented a short video - included in the clip - featuring the mother of Christopher Wood, who committed suicide despite being treated for mental illness for four and a half years.

There are around 300 suicides in Wales each year, which is three times the car accident death rate. 90% of those had an underlying mental illness. Ignoring the issue – described as the "final taboo" - is part of the problem because it marginalises suffers, while stigma and discrimination may prevent people seeking help.

The Welsh Government should ensure their Together for Mental Health strategy delivers on the ground. Eluned raised concerns that statistics gathering is inadequate due to complications caused by coroner's inquests. Mind say 48% of  patients have to actively seek out treatment and therapies, while families are left to cope on their own both before a suicide and in the aftermath.

Jenny Rathbone AM (Lab, Cardiff Central) said suicide is mainly a men's issue, and men often find it harder to seek help (clip). She outlined a case where a man was prescribed Prozac before being offered counselling, when what people need is someone to listen and empathise. The increased use of anti-depressants should be of concern as it suppresses underlying problems and the drugs can become addictive.

Young people have paid a particularly high price recently – cuts to wages, unequal incomes and high property prices – and this causes mental strain and reduced confidence. Community mental health services are important, but are treated as a secondary pathway for treatment, so people still have difficulties accessing things like talk therapy.

Mark Isherwood AM (Con, North Wales) said suicide was a tragic, devastating event, with the legacy being "a wound that never heals" (clip). He was hopeful though, saying the Applied Suicide Intervention and Skills Training scheme ensured 90% of participants had increased confidence. Also, substance abuse is a suicide risk, while young men are reluctant to discuss mental health.

There's been a rise in hospital admissions for self-harm - particularly amongst young girls. However, 81% of suicides are men, while the LGBT community also have issues with higher rates of self harm and suicide. Research states an early response to a mental health emergency reduces the risk of a patient going on to develop a substance abuse problem, self-harm or attempting suicide later in life. Local authorities and health boards need to work with the voluntary sector and listen to service users, while suicide prevention plans should be applied consistently across Wales.

Bethan Jenkins AM (Plaid, South Wales West), through her own experiences, said it's often hard for others to understand what goes through the mind of someone in that position and why their behaviour changes (clip). Even outwardly happy people might not be very happy inside, citing Robin Williams and Gary Speed. Whenever there's a suicide everyone's shocked, but there's a need to "peel away that shock" and ask why people, particularly young men, are feeling desperate and why they don't feel they can speak to anyone.

Bethan detailed the CALMzone scheme in Liverpool, which focuses on men's mental health and offers services in a contemporary and appealing manner, emphasising there's no shame in seeking help. There were complaints from the service's Welsh users that Welsh strategies were "too NHS-style and stuffy". Bethan also brought up research from South Korea involving women with both physical problems and suicidal thoughts who made progress with exercise. Meanwhile, an app had been developed in Liverpool to help identify trigger points amongst those who are identified as being a suicide risk via their social media posts.

In reply, Health Minister Mark Drakeford (Lab, Cardiff West) accepted it was a "difficult and emotive topic", and we should regret each and every suicide, which leaves a lasting impact on family, friends and social circles (clip). In a bit of good news, there were 146 fewer suicides in Wales in 2014 compared to 2013 and Wales had the lowest suicide rate of the UK's nations in 2014.

Mark Isherwood raised concerns that narrative verdicts from coroner's courts were excluded from the figures and the Minister accepted there were difficulties with the data.

Moving on, the causes of suicide were complex to understand but were an interaction between the personal and the social, but were also shaped by gender and age; although suicide is a leading cause of death amongst the young, there are a greater number of suicides amongst older men in particular. There are also economic factors, where poor prospects for young men lead to a "chain of attainability being broken".

As well as focusing training on people who might come into first contact with suicidal people – like GPs and the police – there's a need for a fundamental shift in culture. We can't pretend it's easy as it's profoundly disturbing for all involved; the Minister described how a woman visited his constituency surgery and showed him neck wounds from where she'd tried to take her own life because she was overburdened by debt.

The Talk to me 2 scheme is improving learning and monitoring systems, and Swansea University has one of the most comprehensive suicide databases, which helps determine where efforts are most needed - like A&E psychiatric services, but no single thing works for everyone and there needs to be a broad range of semi-tailored services.

In concluding, Angela Burns AM (Con, Carms. W & S. Pembs.) said it was brave to talk about suicide in an open way (clip). AMs needed reminding that any of of us can have "dark times", and she praised the Minster's courteous response, appreciated that lot of activities were being undertaken.

Angela accepts there's no "magic bullet" that will stop people committing suicide – which she described as a "hard word that doesn't explain the acres of anguish behind it". However, there's a need to look at how they're recorded as families sometimes resent deaths being recorded as suicides rather than depression. She also called for better access to talking therapies and support for schemes like "Men's Sheds" for older men.

The motion was approved unanimously.

Preventing the Unpreventable?

If domestic violence is often portrayed as being a women's issue then, in the same vein, suicide is a men's issue. Neither's 100% accurate, but everyone who spoke deserves credit for saying it as men's health issues are often sidelined. Mark Isherwood also deserves a hat tip for pointing out LGBTs have a pronounced problem with suicide and self-harm as a group too.

One gender generalisation that's probably true is that men and women approach problems in different ways. When faced with a situation, men try to engineer ways to solve it by ourselves. That "by ourselves" bit is important. I don't think it's because men have been raised like that, we're hard-wired that way.

We also have a much stronger "fight or flight" reflex, lack strong social support networks (unlike most women) and, to be perfectly honest, men are expendable by design and by culture. In many warrior cultures, including Japan, the Roman Empire and the old Celtic societies suicide was, and in some cases still is, considered an honourable act for men (and prominent historical noblewomen too).

If, as a man, you come to the conclusion that ending your life is the only option on the table - having exhausted all others - you opt for it and are more likely to use a method that works. That might explain why suicide attempt figures are similar for both sexes, but more men die. Men also often have to be tricked into talking about feelings and emotions and that's why schemes like the aforementioned CALMzone are important.

There's a difference between preventing someone who has suicidal thoughts from considering it, and preventing someone actually going through with it. Only the former is preventable, and it requires people to seek help or have someone trained in suicide prevention in the right place at the right time.

Nobody seriously considering suicide would seek help, and men (as a group) are even less likely to do so. While services are useful for those who are near suicidal, to really prevent suicide you have to address factors driving people towards it and sometimes mental illness is co-morbid with a non-medical problem - what Mark Drakeford described as a mix of the personal and the social.

When someone commits suicide, it's probably because we voted for it, read it, wrote it, ignored it, said it or thought it. For example, it's estimated up to 600 extra suicides in England have occured in areas where UK Government's disability assessments were more proactive, which were in turn a response to media and public outbursts about "benefit scroungers".

That's why suicide's a taboo. Society drives people to suicide both directly and indirectly, and we don't like being confronted with that because it makes us feel bad, while the deceased might have found some peace at last.

If chronic unemployment and nobody giving you a chance are the reasons behind it, improved mental health services won't find you a decent paying job. If it's chronic loneliness, again, the NHS and charities can't provide you with friends; you're just another person in a queue.

Improved mental health services and counselling can't pay off crippling debts, bring back your dead friends or relatives, find you a partner so you won't feel like you'll die alone, make you feel less of a burden on society, cure a terminal disease, wipe traumatic experiences from your memory or prevent you being abused as a child. They can't forgive your past or make everyone else see that you're perfectly "normal" so the bullying and daily abuse will stop.

It can certainly help you through it and provides an emotional crutch, but it doesn't solve the problem and you're still left to deal with it and come to terms with it alone. There's no shame in being unable to cope with that, and being able to cope with it doesn't necessarily make you a strong person, just lucky.

So the worst thing is, while you can curb numbers of suicides, there's not a single thing a new framework, strategy or even utopia on Earth can do to stop it happening. It's one person and one choice at one moment in time.