The ‘Black Dog’ Just Might Go Away: Exploring Mental Health & Suicide
John Madden, B.A. (Hons) & Niall MacGiolla Bhuí, PhD.
Dissertation Doctor’s Clinic/TheDocCheck.Com
We’ve a couple of questions for you. Have you ever felt really depressed? Really down? If so, you’re just the same as millions of men and women, teens and even kids around the world. It is part of the complex human condition to wonder about the meaning of life. This is all the more pronounced when life doesn’t quite go as we have planned, imagined and hoped it might. Some of us are better than others at positive reflection – in the sense that we are able to process and filter negative events and non events. Some of us get ‘really down’ and find it immensely difficult to function in a way that society expects or demands of us. That’s ok. You are you and have your own lens on life. But, all of us can benefit from a kind word from a concerned family member, friend, neighbour, colleague, GP or mental health specialist. There is absolutely no shame in reaching out. You will still be as ‘manly’ as ‘masculine’, ‘one of the lads’ should you do so. Let’s create a culture where it is the norm to for men to talk about our mental health. Let’s do all we can to stop even one more suicide in Ireland.
This is the first in a series of three papers on mental health and suicide in contemporary Ireland that we’re going to pen over the coming months. In these papers, we set out to provide a mix of scholarly, professional and personal commentary on these two hugely important issues written in a style that is accessable to a general readership with the simple aim of informing our readers of two crucially important topics. We will, firstly, present some statistics just to place our discussion in context and we will then extrapolate out from these into a brief look at Ireland and Greece and comment on the role of the prevailing economy in terms of mental health and suicide – with a particular focus on men. We want our readers to be more aware of mental health and better informed with regard to strategies they can avail of when experiencing difficult periods or events in their lives.
Globally, suicide has become a really significant public health problem across the world. The World Health Organisation (WHO) reports over one million people die by suicide every year, a rate that translates to one death every forty seconds (O’Donnell and Wilkinson, 2011). In 1998, suicide represented 1.8% of global death but is now predicted to increase to 2.4% by 2020 (Bertolate and Fleischmann, 2009). Just as a note, we use the terms ‘suicide’ and ‘suicided’ as distinct from ‘committed suicide’ as we have always fround the latter to be distasteful and judgemental.
A Change in the Social and Legal Order
The last century in Ireland, and indeed abroad, has witnessed significant change in attitude and knowledge in relation to mental health, suicide, and suicidal ideation (Schijvers, 2011). This is most notable in the growing literature written by key authors such as Joiner (2005); Richardson, Clarke and Fowler, (2013) and Bertolote and Fleischmann, (2009) on understanding the causes and nature of suicide.
Within Ireland, the eventual decriminalisation of suicide just over two decades ago (1994) has, thankfully, led to significant changes in policy, service provision and the growth of educational programmes. Perhaps, most importantly, it has led to a cultural shift in terms of being able to discuss mental health and suicide in this country. We see this, in particular, with a number of high profile persons (such as Niall Breslin) who have brought such discussion into the public realm and have made several TV documentaries on the theme of mental health. Many actors, sportstars and musicians are now talking about their own mental health and the kinds of pressures they face every day. Mental health is the topic of thousands of blogs and daily tweets and status updates across various social platforms.
Looking Back to Understand the Present
Over a century ago, the Sociologist, Emile Durkheim (1897) proposed, in his theory of anomic suicide, social change provides differing levels of uncertainty for the individual, some easier to deal with than others. He further suggested other sociological theories to account for suicide – namely the lack of assimilation of the individual into society. He believed the more dependent the person had to be on his own resources rather than having external outlets for support, the larger the suicide rate in the society. Of course, his theories have been widely critiqued and developed, but they are certainly worth referencing.
More recent research points to suicide also being associated with a range of social factors such as critical illness, recent hospital discharge, living in isolation and a person having a history of substance abuse and experience of self-harm. Nonetheless, suicide can never be simplified with a single identifiable cause; instead, it is normally the culmination of a complex interplay of events or factors in a persons’ life (Appleby, Amos and Parsons et al, 1999; Joiner, 2005).
Statistics indicate that males die by suicide more frequently than do females; however, reported suicide attempts and suicidal ideation are more common among females (Crosby et al, 2011). Further to this, Schrijvers (2011) informs us that the difference in suicide rates for males and females is partially a result of the methods employed by each gender. Females are far more likely to attempt suicide; however, they are more likely to use methods that are less violent or immediately lethal. Females tend to rely on drug overdosing which can take more time. Males frequently complete suicide through more violent and high mortality actions such as firearms, carbon-monoxide poisoning, and hanging.
Mental Disorders & Suicide
A recent meta-review of meta-analyses of suicidal risk in mental disorders, showed particularly high rates of suicide were found in borderline personality disorder. Risk of suicide was estimated at forty five times that of the general population, depression twenty times greater risk, bipolar disorder seventeen times greater risk, schizophrenia thirteen times greater risk, anorexia nervosa thirty one times greater risk and alcohol misuse or dependence sixteen times greater risk (Chesney et al, 2014). It is, therefore, clear there is a strong association between psychological factors and suicide.
Kalmar (2013) found in his meta-analysis of the protective and risk factors for suicide in adolescents, there are numerous reasons why a person might take one’s own life. This includes life history; demographic systems e.g. gender, age and ethnicity; philosophical and theological e.g. the values associated with their culture and; psychodynamic e.g. a person’s feelings or emotions. Further to this, Kalmar argues despite the already recognised background factors, it is often unlikely professionals or family members will ever truly know the precise reasons behind suicide due to its multi-causal nature. Kalmar affirms, while the aforementioned variables have a major role in suicidal ideation; suicide is also determined by biological factors. In other words, Kalmar appears to be proposing a bio-psychosocial model to explain suicide.
The Economy & Suicide Rates: Greece and Ireland
This sharp increase in suicide rates has led researchers to explore causal explanations for the striking rise, especially in young men. Nordt (2015); Webb (2015) and Warnke (2015) affirm the worlds’ economic circumstances are a key factor in the notable increases in suicide rates. A prominent example of spiralling suicide rates can be seen across Europe, notably Greece in recent times. As a result of the crippling economic recession, strategies of austerity were imposed on the nation which resulted in mass unemployment and a general sense of dispondency. Fountoulakis et al (2014) composed a study to calculate the instances of parasuicide and completed suicide per annum in Northern Greece from the years 2000-2012 and to compare the correlations with unemployment. Their results illustrate a significant rise in the suicide rates in 2007 from 328 to 477 in 2011, which marks a 45% increase in suicide rates attributable to worsening economic conditions (Fountoulakis et al, 2014). Remember, behind every statistic is a devastated family member, wife, husband, child, friend or work colleague.
In Ireland, Richardson, Clarke and Fowler (2013) carried out [the] ‘Report on the All-Ireland Young Men and Suicide Project’, this initiative was implemented “to investigate and identify effective mental health promotion and suicide prevention work and recommend and pilot appropriate policy initiatives for the island of Ireland.” Within the report the authors recognize that ‘the recent spike in suicide rates among young males in both Northern Ireland and the Republic coincides with the economic turndown and increasing levels of unemployment. It is clear that there is an understanding of the socio-economic background to the rate of suicide among young men. ‘Income inequality’ characterises one of the risk factors for suicide in young men in addition to the ‘socio-economic impact of the recession and ‘living and working conditions, unemployment and socio-economic status.’ Further to this Putnam, Frederick and Snellman (2012) state that people from a lower socio-economic status report a significantly lower social connectedness, which bolsters the studies carries out by Ryan (2003) where he found that growing suicide rates have also been linked to a lack of connectedness to the social fabric of life.
The Suicide of our Tradesmen in Ireland
Helliwell (2004) states that the decrease in social capital and reductions in income that are associated with economic recession lead to higher rates of suicide. In and Irish context, Corcoran and Arensman (2010) found that between 1996 and 2006 those who were unemployed were at a much greater risk of dying by suicide than their employed counterparts. They proposed that the stability in suicide rates in the past ten years was extremely likely to change due to increasing unemployment and this is particularly the case for tradesmen where the suicide rates are nothing less than shocking.
Further to this, Arensman et al (2013) found that individuals that were employed or had been employed within the construction or production sector accounted for 40% of suicide between September 2008 and June 2012. Farmers and agricultural workers accounted for 13.2% and those that worked in sales or business 8.9%.
In this introductory paper, we hope we have shown it is clear the reasons for suicide are often varied and can be a cluster or culmination of triggers rather than just the one felt to be obvious to observers. The broad array of research gives us insights into the range of factors but suicide and the reasons for the act itself are individualised from person to person. What may result on one person suiciding, may not result in another person choosing the same path with much depending on how resilient an individual is and how futurist he/she is in thinking.
It is only through increased awareness, investigation and probing of the subject that we will ever gain a fuller understanding of the topic. Perhaps a quote from a somewhat unlikely source can give us food for thought – Man goes to doctor. Says he’s depressed. Life seems harsh, and cruel. Says he feels all alone in threatening world. Doctor says: “Treatment is simple. The great clown – Pagliacci – is in town. Go see him. That should pick you up.” Man bursts into tears. “But doctor…” he says “I am Pagliacci.
Reference list & Suggested Reading
Appleby L., Shaw J., Amos T., McDonnell R., Harris C., McCann K., Kiernan K., Davies S., Bickley H and Parsons R. (1999). Suicide Within 12 Months of Contact with Mental Health Services: National Clinical Survey. BMJ: 318; 1235-1239.
Arensman E., Wall A., McAuliffe C., Corcoran P., Williamson E., McCarthy J., Duggan A. and Perry IJ. (2013). Second Report of the Suicide Support and Information System. National Suicide Research Foundation. Cork: University College Cork.
Bertolote, JM. and Fleischmann, A. (2009). Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective. Oxford: Oxford University Press.
Chesney E., Goodwin GM. and Fazel S. (2014). Risks of All-Cause and Suicide Mortality in Mental Disorders: A Meta-Review. World Psychiatry, 13 (153-160)
Corcoran, P. and Arensman, E (2010). Suicide and Employment Status during Ireland’s Celtic Tiger Economy. European Journal of Public Health.
Crosby A., Han B., Ortega L., Parks S. and Gfoeer J. (2011). Suicidal Thoughts And Behaviours Among Adults Aged > 18 Years in the United States, 2008-2009. MMWR Surveillance Summaries 2011: 60 (no. SS -13)
Durkheim, E. (1897). Le Suicide. London: Penguin Press.
Fountoulakis, K., Savopoulos, C., Apostolopoulou, M., Dampali, R., Zaggelidou, E., Karlafti, E., Fountoukidis, I., Kountis, P., Limenopoulos, V., Plomaritis, E., Theodorakis, P. And Hatzitolios, A. (2014). Rate of Suicide and Suicide Attempts and Their Relationship to Unemployment in Thessaloniki Greece (2000-2012). Journal of Affective Disorders. March 2015. 174 (131-136).
Gliatto, MF and Rai, AK (1999). Evaluation and treatment of patients with suicidal ideation. American family physician 59 (6): 1500–6.
Helliwell, J. (2004). Well-Being and Social Capital: Does Suicide Pose a Puzzle?. National Bureau of Economic Research Working Paper No. 10896
Kalmar, S. (2013). The Possibilities of Suicide Prevention in Adolescents. A Holistic Approach to Protective and Risk Factors. Neuropsychopharmacologia Hungarica 2013. XV. EVF. I. SZAM.
Nordt, C., Warnke, I., Seifritz, E. And Kawohl, W. (2015). Modelling suicide and unemployment: a longitudinal analysis covering 63 countries, 2000 – 11. The Lancet Psychiatry Volume 2, No. 3, p239–245.
O’Donnell, H. and Wilkinson, E. (2011). Prevention of Suicide in Northern Ireland. Mental Health Practice, Vol. 15 (8).
Putnam, D., Snellman, K. and Frederick, C. “Reply to Gao et al: Racial Composition Does Not Explain Increasing Class Gaps in Obesity.” Proceedings of the National Academy of Sciences of the United States of America 111.22 (June 2014): 2238-2238.
Richardson, N., Clarke, N. and Fowler, C. (2013). A Report on the All-Ireland Young Men and Suicide Project. Men’s Health Forum in Ireland: Ireland.
Santrock, J. W. (2007). A Topical Approach to Human Life-span Development (3rd ed.). St. Louis, MO: McGraw-Hill.
Schijvers, D (2011). The Gender Paradox in Suicidal Behaviour and its Impact on the Suicidal Process. Journal of Affective Disorders 138 (2): 19-26.
 “Suicidal thoughts, also known as suicidal ideation are thoughts about how to kill oneself, which can range from a detailed plan to a fleeting consideration and does not include the final act of killing oneself.” Gliatto,
MF; Rai, AK (1999).
 The biopsychosocial model is a general model or approach stating that biological, psychological (which entails thoughts, emotions, and behaviours), and social (socio-economic, socio-environmental and cultural) factors, all play a significant role in human functioning in the context of disease or illness. It posits that, health is best understood in terms of a combination of biological, psychological, and social factors rather than purely in biological terms (Santrock, 2007).
 Taken from the feature length Movie “Watchmen” (Warner Bros., 2009).