Suicide in Ireland and around the world: The facts, figures, and strategies

In November 2023, the Central Statistics Office published data showing that, in 2020, there were 504 deaths from suicide in Ireland, a decrease from 538 such deaths in 2019.^1,2 While the decrease is welcome, national statistics mean little to anyone who is bereaved by suicide or has experienced a suicidal state of mind. Almost three-quarters of suicide deaths (72.6 per cent) were in males, and almost one-in-10 were in people aged 65 and older. This article examines definitions of suicide and self-harm, global rates of suicide over recent decades, evidence-based intervention strategies, and future directions for research and service developments.

Definitions of suicide and self-harm

Suicide is intentional self-killing, while deliberate self-harm is the intentional infliction of non-fatal harm on oneself. The latter includes a wide variety of methods, such as self-cutting and self-burning.³ Suicide and self-harm are major public health issues which merit attention at all levels: Individual, family, community, and society. In the US, the National Institute of Mental Health (NIMH), in common with similar organisations across other jurisdictions, provides clear information to the public about risk factors for suicide: “People of all genders, ages, and ethnicities can be at risk. Suicidal behaviour is complex, and there is no single cause. The main risk factors for suicide are:

• Depression, other mental disorders, or substance use disorder;

• Chronic pain;

• Personal history of suicide attempts;

• Family history of a mental disorder or substance use;

• Family history of suicide;

• Exposure to family violence, including physical or sexual abuse;

• Presence of guns or other firearms in the home;

• Having recently been released from prison or jail.” ⁴

Looking at the scientific literature more broadly, general risk factors for non-fatal deliberate self-harm include female gender, younger age, poor social support, major life events, poverty, being divorced, being unemployed, mental illness, and a history of previous deliberate self-harm.³ Risk factors for suicide include male gender, poor social support, major life events, family history of suicide, chronic painful illness, mental illness, and a history of previous deliberate self-harm. Availability of means is also significant for both deliberate self-harm and suicide.

In terms of mental illness, suicide is associated with major depressive disorder (long-term risk of suicide 10-to-15 per cent), bipolar affective disorder (10-to-20 per cent), schizophrenia (10 per cent), and alcohol dependence syndrome (15 per cent).⁵ In addition, individuals who engage in deliberate self-harm have a 30-fold increased risk of completed suicide over the following four years.⁶ Other contextual factors also matter, as the NIMH points out:

“For people with suicidal thoughts, exposure, either directly or indirectly, to others’ suicidal behaviour, such as that of family members, peers, or celebrities can also be a risk factor…. Stressful life events (such as the loss of a loved one, legal troubles, or financial difficulties) and interpersonal stressors (such as shame, harassment, bullying, discrimination, or relationship troubles) may contribute to suicide risk, especially when they occur along with suicide risk factors.”⁴

Overall, then, there are risk factors for deliberate self-harm and suicide at the level of the individual, in the context of their family and social circle, and against the backdrop of their socio-economic situation, as well as the events of day-to-day life. As the NIMH points out, “family and friends are often the first to recognise the warning signs of suicide, and they can take the first step toward helping a loved one find mental health treatment.”⁴

Global rates of suicide

Given the diversity of personal, medical, social, and other risk factors associated with self-harm and suicide, it is not surprising that rates change over time. What is interesting, however, is the magnitude of the shift over recent decades (which is substantial), the direction of the change (which is positive), and its distribution around the world (which is uneven). This merits close attention if we are to understand the challenges presented by suicide today and the best ways to address them.

In 2019, Naghavi, on behalf of the Global Burden of Disease Self-Harm Collaborators, used estimates from the Global Burden of Disease Study 2016 to describe patterns of suicide mortality globally, and regionally. It examined 195 countries and territories by age, sex, and socio-demographic index, and also described temporal trends between 1990 and 2016.⁷

This group found that there were an estimated 817,000 deaths from suicide globally in 2016, accounting for approximately 1.49 per cent of total deaths that year. This is an enormous number of deaths, which confirms suicide as a public health problem of the greatest magnitude.

Looking at trends over time, however, data showed that the age standardised mortality rate for suicide decreased by 32.7 per cent (27.2-to-36.6 per cent) worldwide between 1990 and 2016. This is an extraordinarily important statistic, and one which offers real hope for the future. While a one-third decline in the suicide rate is not nearly enough, it shows that positive change is possible. If the rate can decline by one-third, surely it can decline by another third? Or more? Nobody is born wanting to die by suicide, and even one suicide is one too many.

Notwithstanding the positive trend and progress to date, there is clearly still more work to be done. When ranking leading causes by age-standardised mortality rate, this study found that suicide deaths were in the leading 10 causes of death across eastern Europe, central Europe, high-income Asia Pacific, Australasia, and high-income North America.⁷ The authors also note that the decline in the suicide mortality rate is not universal – men still have higher rates of suicide than women at all time-points (except among those aged 15-to-19 years), and the greatest decline in rates is seen in women, rather than men, thus potentially widening the gender gap. In addition, much of the global decline to date is attributable to falls in suicide mortality in China and India, rather than certain other countries.

“Taken as a whole, these patterns reflect a complex interplay of factors, specific to regions and nations, including sociodemographic, sociocultural, and religious factors; levels of economic development, unemployment, and economic events; distribution of risk factors, such as exposure to violence or use of alcohol and drugs; choices of and access to means of suicide; and patterns of mental illness […] as well as culturally specific relations with suicide. Moreover, although the decrease in suicide mortality has been substantial during the period 1990 to 2016, if current trends continue, only 3 per cent of 118 countries will attain the sustainable development goals target to reduce suicide mortality by one-third between 2015 and 2030” (citations omitted).⁷

These international variations highlight regions and issues that need particular attention, but the global decline in the suicide mortality rate is still an enormously positive development. It provides clear evidence of progress rather than deterioration in at least one important indicator of mental health. There is, of course, still substantial work to be done, and global statistics mean little to those who are suicidal or bereaved by suicide, but there are reasons for optimism. In addition, as best as can be established, Covid-19 did not increase rates of suicide.⁸

Evidence-based approaches to suicide prevention

In day-to-day clinical practice, it is not possible to predict who will die by suicide.^3,9 Even so, preventive measures are possible. These can be considered at three levels:

• The political level (eg, re-shaping the landscape of risk for psychological distress, mental illness, and suicide);

• The population level (eg, restricting access to means of deliberate self-harm and suicide for the entire population);

• The individual level (eg, seeking to alleviate distress, treat mental illness, and reduce the likelihood or severity of self-harm). While there are connections across the three levels, it is useful to consider each in turn.
  
  

First, at the broadest, political level, it is necessary to address the root causes of much (but not all) psychological distress, mental illness, deliberate self-harm, and suicide. These root causes include poverty, inequality, injustice, prejudice, and all forms of social exclusion.¹⁰ These problems must be addressed at the political level, locally, nationally, and internationally. Advocating on these themes requires that healthcare professionals move beyond the world of individual patient care, step outside the clinic, and enter the realms of public advocacy, social activism, and political involvement.

Second, restricting access to means of deliberate self-harm and suicide across the entire population can help reduce rates of deliberate self-harm and suicide. Given that it is not possible to predict suicide in individual cases, the strongest evidence to date supports suicide prevention measures that avoid prediction altogether and simply apply to the entire population, regardless of apparent risk. On this basis, restricting access to means of self-harm can prove effective. This might include national bans on the most toxic forms of pesticide in countries where pesticide is commonly used for suicide, or restricting access to firearms, in order to reduce risks associated with impulsivity.⁹

At the level of the individual, it is important to remain aware of the possibility of self-harm and suicide, to provide open, honest assessments, and to deliver care that is responsive, flexible, person-centred, and evidence-based.In terms of specific interventions, it is vital to establish a strong therapeutic relationship that facilitates disclosure, to suggest involving family or friends in care (as appropriate), and to have clear arrangements for follow-up care and emergency access.

Specific therapeutic interventions for self-harm will depend on the individual case and the presence or absence of mental illness. In broad terms, there is evidence to support psychological interventions in certain situations, such as dialectical behaviour therapy (DBT) in some people with personality disorders, or brief interventions, although the evidence-base is limited.⁹

Certain medications for the treatment of particular conditions might also reduce risk in some people, although it is difficult to assemble a complete evidence-base because people at apparently high risk of self-harm or suicide are often excluded from clinical trials. Despite this methodological issue, there is evidence of potential benefit in terms of reduced suicidal behaviour with certain medications, including, most notably, lithium, which appears to be associated with reduced risk of suicide in people with bipolar disorder and depression. This effect seems to be specific to lithium.¹¹ As a result, lithium is, perhaps, the psychiatric medication with the most convincing evidence-base for reducing risk of suicidal behaviour, and this should be considered in prescribing decisions in bipolar disorder. More broadly, individual care should include careful therapeutic risk assessment, formulation, therapeutic risk management, and safety planning, as appropriate to each individual case.¹²

Future directions for research and service development

This article has examined various definitional, clinical, and preventive matters relating to deliberate self-harm and suicide. Throughout all such discussions, it is important to bear in mind the NIMH’s reminder that suicide is not a normal response to stress. “Suicidal thoughts or actions are a sign of extreme distress and should not be ignored. If these warning signs apply to you or someone you know, get help as soon as possible, particularly if the behaviour is new or has increased recently.”⁴

In Ireland, the HSE National Clinical Programme for the Assessment and Management of Patients Presenting to the Emergency Department following Self-Harm Model of Care was established in 2016,¹³ and the HSE National Office for Suicide Prevention supports the implementation of Connecting for Life: Ireland’s National Strategy to Reduce Suicide, 2015-2024.¹⁴ These vital measures help to raise awareness and focus both policy and practice.

In terms of useful directions for future research and service development, it is helpful to start from a broad, societal perspective. Psychiatry is a social endeavour as well as a medical one, so a wide-angle lens is optimal. From this position, there is a clear need for continued study of the political, social, and economic contexts in which thoughts of self-harm and suicide develop, are interpreted, and are managed. Mental illness is often a factor in these situations, but mental illness does not occur in a vacuum, so it is neither accurate nor helpful to view self-harm and suicide as entirely personal matters.¹⁵Research and interventions need to acknowledge this broader perspective, as well as providing supports at the levels of individuals, families, and communities. In terms of population measures, Beattie and Devitt note that restricting access to means (as discussed above) and reducing overall alcohol consumption are both likely to help reduce rates of suicide.¹⁶ In terms of individual-level care, they note the potential of DBT and lithium for certain patients, as well as the possible roles of follow-up contacts and safety planning interventions. Ochuku and colleagues point to similar evidence-based strategies for suicide prevention, such as means restriction, improved mental health literacy and access to psychosocial support, and responsible media coverage of suicides.¹⁷ In addition, the importance of positive therapeutic relationships cannot be overstated, and the provision of support to families.

Author: Prof Brendan Kelly, Professor of Psychiatry at Trinity College Dublin and author of Resilience: Lessons from Sir William Wilde on Life after Covid (Eastwood Books)