By asking somebody if they have considered suicide, you risk putting the idea into their head
Absolutely not, and, by raising the subject, you may give them a very welcome and helpful opportunity to reveal thoughts that are difficult to talk about.
Prof Paul Fearon, medical director at St Patrick's Mental Health Services, says they routinely ask patients about suicide but, broadly, through three graded approaches depending on the circumstances.
The first is to ask: “Do you think life is worth living or would you rather be dead?” That is to ascertain if there is what’s called “a passive death wish” where “somebody might be ambivalent but they have no intention of doing anything about it, they just wish they weren’t here”.
If somebody says they have sometimes wondered about suicide, then: “Have you ever thought you might do it?” is asked to establish if they have suicide ideation. In other words, if they are at the stage where they are thinking about it but haven’t made a decision and may well end up not doing it.
“Then at the severe end is when they say they have thought about it, then the question is: “Are you thinking about actively doing it or have you tried it?” A yes to that would be suicidal intent, which is, of course, very serious.
“If you are worried about a friend or relative, you can ask that first question and see where that leads,” he says. Often the fact that somebody is caring enough to ask that can open – something that they might not have considered seeking help for before.
A reluctance to mention the "s" word in conversation is perhaps about the concerned relative or friend's own struggle with not being able to manage if the answer is "yes", suggests Leigh Kenny, regional manager of greater Dublin at the suicide prevention charity Pieta. "But that's okay because we are not born equipped to deal with everything and this is a really difficult place to be."
However, you are not going to put that seed into their head, she stresses. “It’s going to be there or it’s not going to be there. You are asking out of a best intention place; I believe that is heard.”
People who are struggling with depression may be relieved at the opportunity to share their thoughts, as the weight of it can be hard to live with. However, a person hearing that somebody has suicidal thoughts needs to know they are not there to fix it for them.
“The best thing they can do is not be silent around it,” she says. If somebody agrees they have contemplated suicide, “then it is important that plan is discussed safely and a plan to disarm their plan and remove their method is also encouraged and discussed safely”.
Suicide can come out of the blue
Not to the person who takes their own life, it doesn't. However, that does not mean somebody else could have picked it up, says Fearon.
“It may not come out of the blue in terms of the person’s internal world but it may well come out of the blue in terms of the family around them.”
People who have made the decision to do it “may purposefully not leave any clues and carry on as if nothing is there because they don’t want anybody to know, for very understandable reasons. The tragedy is that family, friends, spouses, spend the rest of their lives feeling guilty about something they probably didn’t have any control over.
“Do not blame yourself,” he says to all who have lost a loved one through suicide. Ultimately, the person who takes their own life do it themselves “and as tragic as that is, that does not mean you are responsible for picking up on it and maybe changing it. That is not to say it isn’t changeable.”
Kenny knows people who have lost loved ones to suicide who would say there were no signs. That may be true, she acknowledges, but she also believes if everybody was better equipped on what to listen for, that would be a positive development. Pieta is currently running a, Know Suicide: Know the Signs, campaign.
Indications of someone’s suicidal intentions could be very subtle and it could be through a joke, she adds. “I find adolescents tend to say it through a jokey way, such as ‘wouldn’t I be better off dead’ but actually there is a bit of weight in that comment.”
People who say they want to die will always find a way
"Suicidal risk is incredibly dynamic," says Fearon. People can move forwards and backwards between having a passive death wish to serious intent over weeks, days or even hours sometimes. That is why they ask patients about it "and then ask again".
“If you are suicidal you do not remain suicidal,” he says.
Thinking it is only a matter for time before somebody takes their own life is a hopelessness that is not helpful, says Kenny. "We are born to live, born to survive" and there is ambiguity right up to the very end. She refers to Kevin Hines (39), one of only a handful of people to survive jumping off San Francisco's Golden Gate Bridge, in a suicide attempt in 2000. Now a suicide prevention campaigner, he says he felt instant regret the moment he let go of the railing and knew then he didn't want to die.
“We will never know how many people who did take their own lives might have changed their minds too late in the process,” says Kenny. We need to believe that people don’t really want to take their lives, it is rather that, in that moment, they perceive they are left with no alternative.
It can’t be said that a person’s suicide is inevitable, agrees MacHale. However, “there are situations where a person is engaged in active treatment and everybody has worked really hard and done their best, including the patient,” she says. Yet, due to a range of circumstances, it still happens.
Suicide rates in Ireland are increasing
Despite a common perception that suicide is becoming more frequent in Ireland, that is not the evidence we have, says Prof Siobhán MacHale, honorary clinical associate professor at the Department of Psychiatry, RCSI. The numbers are definitely lower than they were, although they have plateaued in recent years
In 2012, for instance, 581 suicides were recorded in the Republic and that had dropped to 447 by 2017, according to mortality data compiled by the Central Statistics Office (CSO). “The challenge with suicide is that the actual, factual data is a number of years behind. We’re talking about at least a three-year gap,” she says.
This is due to issues such as waiting lists for coroner’s courts. In the vacuum, people speculate about rising figures on the basis of hearing of incidents locally or through social media and the data is not yet available to confirm or contradict these impressions.
In relation to the CSO figures, the HSE’s National Office for Suicide Prevention (NOSP) explained in a briefing document last January that the data is provided in different stages – firstly based on year of registration and called “provisional”; they are revised later by year of occurrence and deemed “official”; finally, they are revised again, to include “late registrations”.
Figures for all three stages are complete only up to 2017, while the “official” number of suicides for 2018 is 437 and the “provisional” total for 2019 is 421.
Somebody, somewhere must be to blame for not preventing a person from taking their own life
If an individual takes their own life, there tends to an erroneous belief that somebody missed the signs, be it within the health system, or among family and friends, says MacHale. But "it is not always somebody's fault. In the same way as somebody dying of cancer or heart attack is not always somebody's fault."
Adopting zero tolerance of suicide as a preventative approach in clinical healthcare is not, she explains, the same as having the expectation that it will never happen. Just as the health system will do its best for people with physical illness, inevitably some patients will die.
Similarly, with serious mental disorder, despite the best efforts in addressing patients’ needs and intervening, there is no requirement that a professional should be able to predict and prevent somebody’s suicide, she says.
“What we do know is if we intervene and address the needs and the risks, that has a significant impact on reducing rates of self-harm, which in itself would predict [suicide] but there is no direct co-relation.”
Self-harming is a preliminary suicide attempt
Self-injury through, say, deliberately cutting or burning yourself, is not typically meant as a suicide attempt. In fact, for many people, it is a coping tool, a way of staying alive, says Kenny. "However, some people who do self-harm may feel suicidal and they may attempt to take their own life. That is why self-harm must be taken seriously."
It indicates they are struggling to deal with emotional suffering and overload; they go into panic mode and then do an act of self-harm, through which there may be temporary relief from not being able to regulate emotions. “It doesn’t mean there is anything wrong with them,” Kenny says. “They just need to learn some coping tools other than self-harm.”
Rather than taking self-harm away and leaving them with nothing, therapists give individuals another strategy to turn to when they go into panic mode during emotional overload. “It may be to ring a friend, go for a walk or jump into the shower . . . they build on their own strategies.”
Although there is no straight line from self-harm to suicide, there is a relationship between the two, says MacHale. “Self-harm is the largest predictor of completed suicide. If somebody carries out an act of self-harm, they are 40 times more likely to kill themselves than somebody who has never taken that step. However, if you were to follow up 100 people who have self-harmed over a year, one of them will have killed themselves by the end of the year.
“Therefore, to intervene with the other 99 by taking them into hospital is both unproductive and unavailable to us.”
Self-harm is just attention seeking
People who self-harm are "attention needing" for sure, says Kenny, and that has to be taken seriously. However, that is quite different to "attention seeking".
Many people who practise self-harm don’t talk to people about what they are going through, and there is “shame and guilt around it”, she says. Pieta is there to hear them.
Being suicidal is a marker of mental illness
There is some mental illness for which the risk of suicide goes up, but it is a complete untruth to say everybody who takes their own life has or had a mental illness, says Fearon. Some 800,000 people worldwide die by suicide every year and the majority of those will never have had a mental illness.
There are a lot of non-psychiatric factors that increase your risks, he says, including older age; being a male; being widowed is a greater risk than being single, which in turn is a greater risk than being married; having a chronic physical illness and being in pain.
Suicide is a selfish act
On the contrary, often suicidal people believe they are a burden to loved ones and are doing them a favour by removing themselves from their lives. "Suicide is at the end of a long probable chain of thoughts and it is rarely, if ever, done for selfish reasons," says Fearon. "It is ultimate despair."
If you have a friend who you feel isn’t doing well, do reach out, he urges. “It doesn’t have to be a straight out, ‘are you going to kill yourself?’ because that is a conversation stopper.” Rather, start with a “how are you doing?” and, eventually, maybe ask the question “do you ever think life is not worth living?”
Increasing resources for voluntary agencies and mid-level mental health services will be sufficient to prevent suicide
The State is doing some of the right things in investing in mental health support but this is not going to safeguard the smaller group of patients who have severe mental illness, are at greater risk and who require specialised psychiatric care, argues MacHale, who works in Beaumont Hospital in Dublin. Sufficient tertiary-level treatment is not accessible through the six per cent funding that mental health services currently get from the overall health budget.
“Slaintecare says is should be at least 10 to 12 per cent, that is the average in EU. It used to be that in Ireland, in 2007, and it has dropped and dropped and dropped.”
It is good that public awareness is being raised around mental health and suicide, she adds, “but there has been no associated increase in the professional services available to patients who are actively suicidal, including the availability of beds”.
– Pieta House, 1800 247 247, text HELP to 51444.
– Samaritans, 116 123, email@example.com.
– Suicide Or Survive, 1890 577 577, firstname.lastname@example.org.
– Aware, 1800 80 48 48, email@example.com.
– Childline, 1800 666 666, text 5101.
– HSE Drugs and Alcohol helpline, 1800 459 459, firstname.lastname@example.org.
– Traveller Counselling Service, (01) 868 5761, 086 308 1476, email@example.com.
– HSE Crisis Text Service, Text 50808.
– St Patrick's Mental Health Services, (01) 249 3333, firstname.lastname@example.org.
– Alone, 0818 222 024, email@example.com