EARLY INTERVENTION IN YOUTH SUICIDE PREVENTION AND COMMUNITY ENGAGEMENT
Suicide has a devastating and far-reaching impact on families, friends and communities. The stigma, poor surveillance and the fact it’s considered a criminal offence in some countries means that many people are not able to get help. These facts and the lack of timely interventions make suicide a serious public health issue globally (WHO, 2014).
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On 7th October 2013, World Health Organization (WHO), launched the ‘Mental Health Action Plan 2013-2020’, focusing on mental health, an issue that has been neglected for a long time. A collective decision was taken by member countries to work towards the global target of reducing the suicide rate by 10% by 2020 all over the world.
Worldwide, suicide accounts for the second highest cause of death in 15-29 year-olds (WHO 2014). The mental health of youth and the alarming increase in their suicidal behaviour is a matter of great concern. With suicide rates among teens nearly doubling in the last eight years fears have increased that we are raising a “suicidal generation” ( Shipman, 2019).This sharp increase in suicide in the late teens can be attributed to several factors. While self-harm, mental illness, alcohol, drug misuse and, social isolation are some of the risk factors common to all age groups, others like family adversity, bullying, internet, social media, educational stress and relationship break- up are youth-specific (Rodway et al., 2016).
Traditionally mental healthcare has been focused on adults and community-based early interventions for youth have always been neglected. The associated stigma, decreased mental health knowledge, poor accessbility to suitable services and inadequate health system has led to reluctance among people aged between 12 and 25 years in accessing mental health services when compared to people belonging to other age groups. (McGorry & Mei, 2018).
On 10th October 2018 World Mental Health Day, British Prime Minister appointed Jackie Doyle- Price as minister for suicide prevention, a step to improve mental health particularly suicide. Research conducted in 2018, by the Brent Centre for Young People revealed that teenage suicide due to hopelessness in London was four times the national average, with a marked increase of 76 % among post-teens (19-24)groups ( The Independent, 2018). The appointed minister would be working to improve these figures.
The WHO target can be achieved only with active participation from communities to prevent suicide especially in youth (WHO, 2014). Several countries have taken initiatives that has seen tremendous progress in early intervention services for youth mental health. Some of the successful initiatives are discussed below.
Australia was one of earlier countries to initiate suicide prevention strategies. In Australia, a government funded, innovative and integrated youth mental health care model called Headspace was created to provide youth-friendly, stigma-free, non-judgmental early intervention services to 15-25 year old presenting with high levels of psychological distress. People belonging to marginalized group and those at risk of mental health issues also found the model to be beneficial (McGorry & Mei 2018). Since the inception of Headspace there has been significant reduction in suicide ideation and self- harm among youth, a decrease in absenteeism from school and work place was also noted (McGorry & Mei 2018).
The success of Headspace has prompted other countries like UK, Ireland, Canada, USA, Europe and Asia to adopt culturally suitable models. Headstrong and the Jigsaw in Ireland and Youthspace, in Birmingham, UK are examples of two such models developed to cater to youth mental health in these countries. These offer easy accessibility for effective community-based mental health care for individuals aged 12–25 years (McGorry & Mei 2018).
Preventing Suicide in England: A cross-government outcomes strategy to save lives developed in consultation with members of the National Suicide Prevention Strategy Advisory Group (NSPSAG) is a strategy developed by Government to address suicide prevention in United Kingdom. The key objectives of this strategy: “a reduction in the suicide rate in the general population in England; and better support of those bereaved or affected by suicide” (Mackley et al., 2018).
In January 2017 the Third Progress Report, entitled ‘Preventing suicide in England’ was published. The aim of the report was to refocus on patients who are identified to be at higher risk of suicide, such as young and middle-aged men, and bring new focus on support for bereaved families also educating young people about mental health (Mackley et al., 2018).
#308conversations is an initiative launched by the Mental Health Commission of Canada for suicide prevention. In this programme each of Canada’s 308 Members of Parliament and community leaders have discussions within their community about suicide prevention. The success of this initiative prompted the World Health Organization to collaborate with the Mental Health Commission of Canada to adapt this approach for global use (WHO 2014).
In any healthcare system early intervention plays an important role. For suicide prevention, early intervention techniques can be grouped into three main criteria namely individual or ‘indicated’, group or ‘selective’ and ‘universal’ interventions ((Catalogue.nla.gov.au, 2019).
Individual or ‘indicated” intervention which is the most commonly understood methods, treats individuals displaying suicide-related behaviors. It involves the concerned individual as well as the people around them like family, friends, colleagues, teachers etc. ((Catalogue.nla.gov.au, 2019)
Group or ‘selective’ intervention focuses on specific groups and communities at higher risk of suicide in the society, like LGBT, youth bereaved by suicide, or those with history of mental illness or previous attempt at suicide and those who have self-harmed and it operates at national and local levels ((Catalogue.nla.gov.au, 2019).
A ‘universal’ intervention targets the entire population or a particular segment of it, on the assumption that some individuals within the population may be at risk of suicide, but these risk factors will not be exhibited. It increases the general awareness of suicide risks and it is commonly used to screen mental health issues in schools (Catalogue.nla.gov.au, 2019)
The aim of most intervention strategies conducted across clinical, educational, workplace, community, digital, and face-to-face settings is to reduce the risk factors and promote protective factors (Catalogue.nla.gov.au, 2019).
Robinson et al., (2018) in their meta-analysis have analyzed the complete spectrum of interventions across multiple settings like clinical, educational/workplace and community and their impact on suicide-related outcomes. They had reported that frequency of self-harm and suicidal ideation was reduced with brief contact interventions in clinical settings, and psycho-education combined with screening in school setting.
The drawback of the study was that it neither included low-middle income countries nor demographic populations which are at increased risk of suicide and also very few studies were conducted in workplace, universities and primary care. Furthermore, with suicide being relatively rare, it was difficult to obtain a statistically significant sample size which could demonstrate the impact of intervention on suicide related outcome (Robinson et al., 2018).
Significant difference has been observed in the patterns of suicide rates based on age, gender and time across countries (Roh et al., 2018). A phenomenon known as ‘gender paradox’ was observed in the suicidal behavior of adolescents. The absolute number of completed suicide was found to be higher among male adolescents as compared to females, but suicidal ideation and attempts were more frequent among female adolescents (Roh et al., 2018). In certain countries like China and India, higher suicide rates were seen in female youth as compared to male, and in the west suicide rates for females aged 14 or younger were found to be higher.
In several European countries there was a remarkable decrease in suicide rates among the males,however, the rates were either stable or increased in the females (Roh et al., 2018). Firearm restrictions and improvement in global health were cited to be the reason for this decrease. In contrast, increasing suicide rates for both genders were noticed in Korea and Japan, economic recession, inequality, and rapid changes in family structure were believed to be the reason (Roh et al., 2018).
Although intervention programs are important in treatment of mental health issues in youth, community involvement is also required to achieve the WHO target. Discussed below are some of the ways in which community engagement contributes to suicide prevention in youth.
Suicide prevention is something that cannot be achieved by single person, an organization or an institution on their own, it needs the whole community’s support. Communities’ gives individuals a sense of belonging, vulnerable individuals are provided with social support and follow-up care, they raise awareness and help fight stigma surrounding suicide and support individuals bereaved by suicide. Sometimes community members become “gatekeepers” to identify people who are high risk of suicidal behaviour or to identify emerging suicide clusters in their community (WHO, 2014).
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In recent years community engagement techniques have been recognized as an innovative tool in tackling mental health issues especially in low income and minorities’ population, but very often these strategies don’t have clear guidelines for their successful implementation (Mendel et al., 2011). It becomes difficult to know where or how to initiate action especially when dealing with a sensitive issue such as suicide prevention. Often, communities find they are not prepared adequately or are too overwhelmed to successfully establish suicide prevention strategies. Against this background the WHO toolkit provides suggestions which are practical and which communities all over the world can use regardless of their available resources or their current progress status with reference to suicide prevention efforts (WHO 2014).
Suicide prevention efforts are effective when community engagements use well planned strategies that help to understand various aspects of suicide. Clear goals need to be set and activities that are proven to be effective should be prioritized (Sprc.org, 2019). It’s important that community members voice their concerns and opinions about suicide prevention in their particular community. This process helps in identifying gaps, gather information about the available resources and ongoing activities in that community.(WHO, 2014).
Before starting it is important to know the extent of the community engagement, the population or region that is involved, available data and data limitations (WHO, 2014). It will be useful to have prior information regarding suicide incidence and suicide prevention prevalent in the particular community. Information regarding numbers , means and access to means, the associated stigma, cultural or religious beliefs in that particular community, ongoing suicide prevention programmes and particularly the manner in which the suicide issue is addressed by the community will help in formulating effective suicide prevention strategies(WHO, 2014).
Involving people from the community in planning and carrying out engagements paves the way for successful suicide prevention strategy. A good way to start community engagement is to create a steering committee of around 10 like-minded people from different background equipped with diverse skills and ideas but whose concerns are similar and who are motivated to engage in suicide prevention (Mental Health Commission of Canada, 2015; Suicide Prevention Australia, 2014).
The formal and informal leaders in a community like police, politicians, religious leaders and other members like nurses, teachers, firefighters etc., who have the ability to act as gatekeepers have an important role to play in trying to achieve a common goal (WHO, 2014). Gatekeeper training is an essential activity in suicide prevention. It is important that these people called ‘Community Facilitators’ are educated about various aspects of suicide prevention and play an active role in identifying vulnerable persons who are at risk of suicide within the community (Coppens al, 2014,). Uniting the community and bringing people together can help achieve this common goal of suicide prevention, as demonstrated by Inuit population in Canada (Kral et al., 2009).
Teamwork, open dialogue, and compromise are hallmarks of successful community engagement and it is essential to establish these at the beginning itself. Community engagement plays an important role in restricting access to means of suicide. Awareness programmes and community education are important especially in context where suicides are impulsive (WHO, 2016b). For instance, in rural agricultural communities especially in low- and middle-income countries pesticide poisoning is very common means of committing suicide,because pesticides are easily accessible in such communities. Hence, in such communities , potential suicide prevention activities should target farmers and their families (WHO, 2014).
Suicide is shrouded in stigma and increasing dialogue about it will help reduce the stigma associated with it and is a practice frequently used in suicide prevention. This can be achieved through educational programmes conducted by a health care professional or support group member/ volunteer or a bereaved survivor or an individual who has experienced self-harm (WHO, 2014). In some instances creativity like art participation can be used to address to raise awareness, reduce stigma to help individual and communities heal following suicide by suicide survivors sharing their experience in public (Mohatt et al.,2013).
Suicide is a public health problem and the media has a major role to play in influencing opinion and attitudes of the public to a large extent. It is important that the media act responsibly while reporting cases in order to avoid imitation of suicidal acts by vulnerable persons. Inappropriate reporting on suicide in the media may lead to a contagious effect or “Werther effect””, on the other hand responsible media reporting of suicide will have a protective effect and leads to what is known as the “Papageno effect”. Responsible media coverage of suicide can correct misperceptions and myths that surround suicide. Communities can productively use media outlets for conveying public health messages about suicide, suicide prevention, it can be used to encourage vulnerable people and those at increased risk for suicide to seek help, and provide information regarding support groups and services where help can be found when required (WHO, 2014).
School-based mental health awareness, interventions and training skills required to tackle some of adverse life situations such as stress, suicide attempts and other mental health issues have been shown to be effective in reducing incidence of suicide among adolescents (Wasserman et al., 2015). Including youth into suicide prevention programmers will be useful, as they will be able to identify the inherent risk factors that are youth centric in their community and this can provide invaluable help in the planning community engagement (WHO, 2014). The Australian funded organization Headspace is an example of hugely successful programme in which youth participation and engagement formed the pillar of the model (McGorry & Mei 2018).
It is common knowledge that crisis precipitates suicidal behavior. It is important that crisis support is available and easily accessible. Communities have an big role to play in such instances, as they can help by giving information about various helplines, support groups and other crisis intervention services that can be accessed. Another important area where communities can be involved is in lobbying for increasing the availability of support services/ helplines for suicide prevention. They can help to motivate and encourage persons in crisis to get help from support services available. Crisis support services and help-seeking are important activities in suicide prevention (WHO 2014).
To conclude suicide in teenagers remains a major public health concern globally. Although suicide prevention is feasible, preventing suicide is not an easy task. Several factors like biological, psychological, social, environmental and cultural are thought to responsible for precipitating suicide. Recent studies have shown that suicide prevention involves a wide range of activities, from accurate and timely assessment of mental disorders and effective intervention techniques to environment control of risk factors like restricting the means.
National suicide prevention strategy is multi-sectoral and specific to each country as the cultural and social identity of each country is different. The success of any national suicide prevention strategy depends to a large extent on the contribution from community. Communities influence and shape policy and services by initiating activities that are comprehensive and combine multiple strategies that focus on key areas that are appropriate to their local context. Vulnerable people need to feel a sense of belonging and require help in coping with emotional and physical difficulties and this is provided by the community support system.
The use of specific and focused strategies that reflect the local needs , effective healthcare and social support service by community groups – as discussed at length above – will make it possible to achieve the WHO global target of reducing the suicide rate by 10% by 2020 worldwide.
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