Category: News

Co-leads Drs Becky Mars and Duleeka Knipe have recorded short spotlight talks for the International Association for Suicide Research which provide an overview of the problem of suicide globally. Watch the short videos here:

 

In this blog post from the Association for Child and Adolescent Mental Health (ACAMH), Dr Abigail Russell talks about research into adverse childhood experiences or ‘ACEs’ and what we know about the relationship between ACES, mental health and self-harm. Abby also discusses her ongoing research at the University of Bristol (PI Dr Becky Mars), which is investigating potential biological mechanisms linking ACEs and self-harm. These include inflammation, pubertal timing and DNA methylation.

In this blog, Lucy Barrass talks about her plans for her PhD which is using data from the Philippines to improve our knowledge of what contributes to poor mental health in this country, focusing on socioeconomic position. Lucy also reflects on her experiences as a new PhD student at Bristol University.

Mental health research is severely lacking in low and middle income countries (LMICs). The burden of disease is high, but the evidence surrounding it is low. Evidence in high income countries (HIC) may not be  generalizable to LMICs due to differences in cultural and societal exposures. Studies from LMICs are mainly performed at one time point or they collect data retrospectively, making it difficult to determine if the exposure came before the outcome; very little evidence is from birth cohort data that can be used to explore causality and early life exposures. A life course approach allows early life exposures to be analysed in synergy with later life exposures.

I’m Lucy Barrass and I am a first year PhD student at Bristol. I previously studied and worked at Newcastle University before I moved to Bristol to pursue this PhD, motivated by an opportunity to improve public health, and develop skills in global health and epidemiology.  As part of a GW4 PhD I plan to use data from a unique dataset in the Philippines to improve our knowledge of what contributes to poor mental health in this country.  I will use data from the Cebu Longitudinal Health and Nutrition Survey (CLHNS), a birth cohort situated in a metropolitan area in the Philippines. The CLHNS was first conducted in 1983, collecting data about pregnant women and their new-born children. The study has collected data between the ages of 0 to 35,  allowing for a comprehensive longitudinal analysis exploring early and later life exposures.  This PhD will use the CLHNS to provide support of the associations between socioeconomic position and mental health in a LMIC. The study aims to identify socioeconomic risk factors for depression and suicidal thoughts, that are contextually relevant and can be used as measures to design interventions. Despite the existence of the CLHNS, there is very little evidence on mental health in the Philippines, particularly on risk factors across the life course and exploring socioeconomic position.

The below image shows some variables which will be used in my analysis, that are present in, or can be constructed from, the CHLNS.

I am still considering comparing the results from the Filipino data to other birth cohorts that measure depression/suicidal thoughts in other LMICs, such as the Birth to Twenty in South Africa. It may provide an added dimension to the results and potentially highlight differences that occur between different populations.

Having been a PhD student for a few months now, I am starting to settle into PhD life and can begin to think about goals and things I hope to achieve whilst I complete it. So far, I am really enjoying it, and I’m looking forward to progressing as a researcher in the coming months and years! I am particularly excited to learn new statistical methods to explore the longitudinal data as I haven’t previously used this type of data and I think this will be really beneficial for my career. Equally, hopefully being able to present my work at international conferences will be something I would love to work towards. I am also excited to be given the opportunity to visit the Philippines to further understand the dataset, both methodologically and culturally and ensure my findings are utilised. If you are interested in hearing more about my PhD, please do get in contact with me!

“People get tremendous anxiety and depression and you have suicide over things like this, when you have a terrible economy, you have death…definitely in far greater numbers than we’re talking about with regard to the virus.”

White House press conference, 23^rd March 2020, US President Donald Trump

In recent days, US President Donald Trump has repeatedly argued that the economic consequences of public health measures to limit the spread of Covid-19 could result in more deaths, due to suicide, than the virus itself. Existing scientific evidence does not, however, support this claim.

It is important to consider the impact that both the Covid-19 outbreak and related public health interventions will have on mental health, mental healthcare, and suicide rates. However, if no public health measures are implemented, the predicted number of Covid-19 deaths in the US over four months is nearly 500 times greater than the number of suicide deaths occurring between 2007-2010 attributable to the 2008 economic recession. The 2008 economic recession would have to last over 1,300 years, for the number of resultant suicide deaths to surpass the number of lives saved by stringent public health measures. Furthermore, evidence indicates the number of suicide deaths can be reduced with employment support measures and historically, in the US, the total number of deaths in the population falls during periods of recession.

Estimated number of suicide deaths in relation to economic recession

In the US between 2007-2010, there were on average 35,850 suicide deaths annually. An estimated 4,750 of these suicide deaths were attributed to the economic recession. Unemployment is a key mechanism through which economic recessions can contribute to increased suicide rates; the increase in unemployment from 5.8% to 9.6% post-recession (2007-2010) was associated with approximately 1,330 of the suicide deaths.

Estimated number of Covid-19 deaths without public health interventions

A key study, which modelled the impact of non-pharmaceutical measures, and led to a change in UK strategy, indicated that without any public health interventions or changes in individual behaviour there would be approximately 2.2 million deaths in the US due to Covid-19. The figures are based on age-stratified infection fatality ratio, ranging from 0.002% among 0- to 9-year olds and 9.3% for those aged ≥80. Most of the deaths are predicted to occur over approximately a four-month period, and around half would be due to healthcare services exceeding their capacity to treat everyone with the infection. In addition, indirect deaths may also occur as a result of over-stretched services. For example, previously treatable heart attacks may now result in death if cardiac care facilities are unavailable. As such, the number of Covid-19-related deaths would be far higher.

Estimated number of Covid-19 deaths with public health interventions

In the UK, case isolation, home quarantine, and social distancing are predicted to reduce the number of deaths that would have occurred with no measures in place (510,000) to approximately 90,000 (an 82% reduction), while adding school and university closure could reduce the number of deaths to around 24,000 (a 95% reduction). These calculations are based on a reproduction number of 2.4 and the triggering of social distancing and closure of educational settings when more than 200 new Covid-19 cases are diagnosed in intensive care units weekly. A similar percentage reduction in the US would equate to around 396,000 or 110,000 deaths respectively.

The wider context

Despite the implementation of a lockdown in Italy, over a six-week period the number of deaths from Covid-19 has far exceeded the 290 excess suicide attempts and deaths that occurred post-recession (2007-2010) as well as the 4,886 total suicide deaths recorded in 2016, the most recent year for which data are available.

A US economic recession may occur irrespective of whether strict public health measures are implemented, although the extent of the recession will likely vary dependent on approach taken. Economic recessions may be associated with a higher prevalence of mental health conditions and cuts to mental health services. In addition to a recession, there may be other mechanisms such as social isolation, by which strict public health measures contribute to increased mortality. Yet, to surpass the number of lives saved from reduced spread of Covid-19, these additional mechanisms would need to contribute to an extra 1.8 million suicide deaths on top of the number of suicides attributed to the 2008 economic recession. This is 40 times more deaths than the annual number of suicide deaths in the US.

Importantly, in contrast to rises in suicide rates, all-cause mortality decreased in the US during both the 2008 economic recession and the Great Depression (1930-33), for example due to shifts in trends in cardiovascular deaths and road traffic accidents. There is also evidence that the effect of unemployment on suicides can be reduced with more generous employment support measures (1,2,3).

There is no doubt that the impact on mental health and risk of suicide for populations, healthcare workers, individuals and their families as a consequence of the Covid-19 outbreak will be profound. It is a situation that could be worsened by a lack of appropriate, albeit extreme, mitigation measures. However, scientific evidence demonstrates that public health interventions to reduce the spread of Covid-19 should not be withheld on the basis that a resultant economic recession would cause more deaths by suicide.

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Prianka Padmanathan is a MRC MARC PhD clinical fellow at the department of Population Health Sciences @_prianka_

Dee Knipe is a Vice Chancellor’s Postdoctoral Research Fellow in the Department of Population Health Science, University of Bristol @dee_knipe 

David Gunnell is Professor of Epidemiology in the Department of Population Health Science, University of Bristol. His research expertise include the effect of the 2008 economic recession on suicide rates (1, 2, 3).

Jacks Bennett is a Bristol doctoral researcher at looking at student mental health and wellbeing @JacksBennett

Group Twitter: @SASHBristol 

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If you or anyone you know is affected by the issues covered in this blog, you can contact the Samaritans for free from any telephone on 116 123 in the UK. Alternatively you can email jo@samaritans.org for details of your nearest branch, where you can talk to one of their trained volunteers face to face. The International Association for Suicide Prevention (IASP) has details of support organisations in other countries.

By Helen Fay 

Jeffrey Epstein – a publicly disgraced financier – died by suicide while awaiting trial for charges of sex trafficking. Unsurprisingly, due to the high-profile nature of his case, reports of his suicide have since proliferated across the globe.

Widespread coverage of suicide is usually met with concerns from mental health professionals. These concerns are not unfounded – there is substantial evidence demonstrating that media reports of suicide can initiate an increase in suicide rates, a phenomenon known as the Werther effect. This effect is more pronounced following coverage of the suicide of a public figure. Accordingly, the World Health Organisation advise that:

“Vulnerable individuals may be influenced to engage in imitative behaviours by reports of suicide, particularly if the coverage is extensive, prominent, sensationalist and/or explicitly describes the method of suicide.”

Yet, it would be incorrect to conclude that all media coverage of suicide is harmful. Despite compelling evidence, research in the field is characterised by inconsistent findings, with a proportion of research showing no effect. Publication bias may overestimate the occurrence of the Werther effect. Due to legitimate challenges in designing ethically acceptable studies, most research investigating media influences on suicide rates employ an ecological aggregate design, which assesses change in suicide rates following a specific media exposure. These studies are typically undertaken post-hoc in response to known ‘epidemics’ or high-profile harmful depictions (e.g., celebrity suicide, high-lethality methods).

The variability of media content may also contribute to these inconsistent findings. There are three well-known mechanisms which encourage the Werther effect: i) the introduction of a novel method to a “vulnerable” population; ii) personal identification with the story of the deceased; and iii) the generation of acceptable impressions of suicide by the media (particularly following celebrity suicides). Focusing on the latter mechanism, the media typically frames suicide in a positive manner (e.g., by glorifying the deceased). However, the journalistic ‘norm’ of framing suicide positively could theoretically explain the consistency by which the media is associated with heightened suicide rates, rather than a direct link.

The media’s framing of Epstein’s suicide was atypical. Due to Epstein’s disgraced position, his suicide was characterised as a “cowardly” and an immoral act. Prior research indicates that negative characterisations of suicide are less likely to have deleterious effects. To illustrate, following the suicide of Robin Williams, the press celebrated him as a successful and inspirational entertainer who could not overcome depression – suicide rates following his death increased by 10% (an additional 1841 suicide deaths in the US). In contrast, suicide rates were unaffected following the death of Kurt Cobain whose suicide received widespread condemnation by the press. Quantifying this notion, Stack’s review found that stories with negative descriptions of suicide were 99% less likely to prompt suicide ‘contagion’.

As early as Durkheim’s (1897) Le Suicide, it has been recognised that cultural influences shape attitudes towards suicide. Cultural differences in attitudes correspond with variations in suicide rates, with more permissive attitudes linked to increased suicide rates. The morality attached to suicide is intrinsically linked to the media and its ability to influence public opinion en masse. Some coverage can normalise suicide as a legitimate response to distress. However, Epstein’s alleged crimes – paedophilia and sex trafficking – are almost universally met with societal contempt. Consequently, Epstein, and the act of suicide were typified as immoral, and are unlikely to prompt suicide suggestion. Indeed, media coverage of the suicides of those in disrepute, such as criminals, are rarely accompanied by an increase in suicide rates.

Rather than viewing all coverage of suicide as detrimental, it is important to consider the specific characteristics of news coverage which could encourage suicidal behaviour. In reference to the coverage of Epstein’s death, the negative framing of his suicide, together with an immoral character appraisal could negate the potential harms associated with widespread news attention. Despite this, it would be extremely contentious to suggest that newspapers should frame suicide as an immoral act. The coverage of Epstein’s death was devoid of compassion towards the bereaved, who are known to be particularly vulnerable following a suicide. Instead, journalists should strike a balance between displaying compassion towards the bereaved and avoiding romanticised depictions of suicide, including those which sanctify the deceased.

A Note on Conspiracy Theories:
Numerous conspiracy theories contend that Epstein’s death cannot be explained by suicide. Despite this, news reports on the topic still present a wide-reaching narrative which frames suicide as unacceptable. Conspiracy stories do not necessarily counteract the influence of reporting on suicide. Suicide rates increased following Marilyn Monroe’s (12% in the US, 9% in the UK) and Robin Williams’ (9.8% in the US) suicide deaths, despite a body of conspiracy theories circulating which disputing suicide as their cause of death.

Key things to remember when reporting on suicide:
1. Think about the impact of the coverage on your audience, particularly vulnerable individuals.
2. Exercise caution when referring to the methods and context of a suicide.
– Avoid giving details of the suicide method, particularly novel methods.
– Remember that there is a risk of imitational behaviour due to ‘over-identification’.
– Never say a method is quick, easy, painless or certain to result in death.
3. Avoid over-simplification of the causes of suicide.
4. Steer away from melodramatic depictions of suicide or its aftermath
-Don’t over emphasise community expressions of grief. Doing so may suggest that people are honouring the suicidal behaviour rather than mourning a death.
5. Aim for non-sensationalising, sensitive coverage
– Don’t refer to ‘hotspots’ or ‘epidemics’
– Don’t promote the idea that suicide resolves problems or achieves results.
– Don’t report on contents of a suicide note.
5. Aim for sensitive, non-sensationalising coverage

Abridged from Samaritan’s (2013) Media Reporting guidelines

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Helen Fay is a PhD Researcher in Population Health Science, Bristol Medical School. Her PhD investigates media influences on decision-making pertaining to suicide methods.

You can follow @HelenAmyFay and @SASHBristol on Twitter.

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If you or anyone you know is affected by the issues covered in this blog, you can contact the Samaritans for free from any telephone on 116 123 in the UK. Alternatively you can email jo@samaritans.org for details of your nearest branch, where you can talk to one of their trained volunteers face to face. The International Association for Suicide Prevention (IASP) has details of support organisations in other countries.

In a recent open letter, campaigners have urged the media to lead the way in using sensitive language when it comes to talking about suicidal behaviour. A similar request has been put forward to researchers and health professionals. There have been several phrases that have been suggested to be unhelpful (primarily from anecdotal accounts from people with lived experience), but the phrase that has gained the most disapproval is “commit suicide”.

You might be asking yourself, “what is the big deal?”. I certainly did when I first started writing about suicide and was consistently corrected. After all commit is a verb indicating that a person was determined to carry out a certain course of action. Yet I soon realised the most common use of the verb commit is in relation to someone committing a crime or an immoral act. People don’t “commit suicide” (i.e. a crime). Suicide has been decriminalised in the majority of countries worldwide. But this phrase has unhelpful undertones, which might further stigmatise this behaviour. With this understanding I’ve been in support of any drive to encourage more appropriate language use, and with the help of my colleagues have been actively encouraging academic journals and conference organisers to dissuade professionals using this language.

As professionals we don’t want to further stigmatise suicide, and as language matters we should be trying to help reduce the associated stigma. Stigma, we know, is a barrier for accessing health care, so in my opinion any effort to reduce stigma should be pursued. Some argue, however, that our push to move away from the term “commit suicide” is over simplistic, and that changing language does not change reality. The evidence being quoted here is weak, and in my view the question remains, does changing our language help? Does it reduce stigma? We simply don’t know. But a small change may help. Getting people to question their language brings into their consciousness the importance of the words they use, and the impact their words might have on others.

An argument has however been made for not moving away from the term “commit suicide”. Perhaps the alternative phrases (i.e. “die by suicide”) remove a person’s agency. I can see this argument, and I know that some use the term “commit suicide” without any understanding of implications of criminality. Take me for example, I certainly didn’t know about the link. But once I did, there was no going back. A friend of mine died by suicide in 2016, and for me reading about him “committing suicide” in the media felt wrong.

For professionals there are two things to consider. The language used to talk to an individual regarding an experience (in this case related to suicide) should be guided by the language that the person feels comfortable using. This should be assessed on a case by case basis. However, when talking to the public about suicide, professionals should use the language that is most acceptable to the greatest number of people. But here is where we stumble. At present we don’t know what phrase the majority of people with a lived experience of suicide find the most sensitive and appropriate. There simply is no empirical evidence to guide us. So perhaps, this is the time to push the pause button on the current drive for us to drop the term “commit suicide”.

As a researcher, evidence-based decision-making is important to me. With the help of fellow colleagues at the University of Bristol, University of Nottingham and the Samaritans, we launched an anonymous online survey for those who have experience of suicide. We hope that this evidence will help inform the debate and plan to release the results of this survey as soon as possible. A copy of the report will be hosted on this website, so stay tuned!

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Dee Knipe is a Vice Chancellor’s Postdoctoral Research Fellow in the Department of Population Health Science, University of Bristol. She is an an epidemiologist with a special interest in suicide and self-harm in low and middle income countries.

You can follow @dee_knipe (group account @SASHBristol ) on Twitter.

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If you or anyone you know is affected by the issues covered in this blog, you can contact the Samaritans for free from any telephone on 116 123 in the UK. Alternatively you can email jo@samaritans.org for details of your nearest branch, where you can talk to one of their trained volunteers face to face. The International Association for Suicide Prevention (IASP) has details of support organisations in other countries.