World Mental Health Day 10 October 2019

Open Statement by the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health

Removing obstacles to liveable lives: A rights-based approach to suicide prevention

I welcome the opportunity to comment on this year's World Mental Health Day theme of suicide prevention. The prevalence of suicide is an indication that the mental health of individuals and populations must be seriously addressed—this is a human rights imperative.

Each individual suicide is a tragic loss that affects individuals, families, and communities. It represents an admirable life lived under remarkably difficult circumstances, often heroically endured over the long term. The loss of a loved one to suicide can be devastating; often leaving many people wondering what might have been done for someone in such despair who saw suicide as the only way out. Although each suicide is complex, and there are innumerable pathways to each individual act, the high number of suicides represents a global public health issue in need of large-scale attention.

Population-level research has demonstrated that government policies and social institutions, working closely with civil society, including user-led organizations, can significantly lower suicide rates. There is evidence that a rights-based approach, in synergy with modern public health approaches, strengthens mental health promotion and suicide prevention. An overall decrease in suicide rates has corresponded with global advances in the reduction of extreme poverty, greater gender equality, reduction of interpersonal violence, trends toward the abolition of child corporal punishment, and through the creation of civic space and public trust.

Providing holistic support for individuals and populations as a whole, particularly those who are most vulnerable, enables the attainment of the right to health by addressing the structural and psychosocial determinants of distress, such as childhood trauma and abuse, social inequality and discrimination. A focus on locating problems and solutions within individuals obscures the need to address the structural factors that make lives unliveable. Suicide, which is firstly a public health issue, cannot be resolved through increased prescribing of psychotropic medication worldwide.  In the face of staggering suicide rates, scaling up already-existing approaches that target individual brain chemistries risks exacerbating the vicious cycle of stigma and social exclusion that often aggravates loneliness and helplessness. We must pursue new routes to suicide prevention that invest in fortifying healthy, respectful, and trustful relationships and community connectedness.

In many countries around the world, it remains highly stigmatized to speak of suicide, whether this involves discussing suicidal thoughts, attempts, or the loss of a loved one to suicide. This makes it difficult to accurately account for the number of suicides in each country or region. The best estimates suggest that almost a million people die by suicide each year, making suicide the 15^th leading cause of death worldwide and the second leading cause among adolescents.

According to the latest statistics from the WHO, approximately 80% of all reported suicides occur in low and middle-income countries, where deaths due to self-poisoning with pesticides account for a large percentage of suicides. However, the average rate as percentage of the population is higher in high-income countries, where guns are more often used in attempts.

Scaling up screening and individual approaches miss the mark

Research in high-income countries suggests that approximately half of those who die by suicide have a diagnosis of depression. In addition, people who have been diagnosed with other mental disorders, addictions to drugs or alcohol, suffered trauma and loss, and those who are facing acute stress at work or in their relationships, are at increased risk for suicide.

In response, some have pushed for wide-scale and mandatory mental health screenings to increase the identification of people in distress and connect them to treatments. Unfortunately, however, there is insufficient support that screening can identify individuals at risk for suicide and prevent them from acting. A large percentage of suicide attempts are impulsive and unplanned in a moment of acute despair. Regular screening and monitoring of the population are unlikely to prevent such cases.

There is also a risk that a "screen and intervene" approach may have other iatrogenic effects by contributing to policies that prioritize ineffective practices (e.g., involuntary hospitalization and the excessive use of antidepressants) over practices based on modern public health and human rights principles. Efforts to identify, monitor, and predict individuals' propensities for violence (including suicide as self-directed violence) run the risk of further stigmatization and discrimination of those identified. Precaution must be taken to avoid exacerbating harmful myths by portraying people in distress as potential perpetrators of violence. Research demonstrates that people suffering from emotional pain are at an increased risk of being victims of violence, and they are in need of protection against discrimination and exclusion.

In many parts of the world, antidepressant prescriptions are widely used as a way to prevent suicide. Although many who die by suicide have received a diagnosis of depression and anti-depressants have helped many overcome severe forms of depression, excessive medicalization, and an overreliance on biomedical interventions that target the brain, seem to miss the mark. Driven by misconceptions that depression and suicide are a result of chemical imbalances, prioritizing suicide prevention through the treatment of depression is not evidence-based practice, nor is it compliant with the right to health. Research suggests that such focus on identifying depression in individuals and targeting them with biomedical interventions fails to reduce suicide risk. Oft-used individual interventions such as prescribing antidepressants and asking about suicidal thoughts do not reduce the risk of suicide. In fact, there is a growing body of research to suggest that excessive reliance on certain biomedical interventions, including antidepressants and voluntary and involuntary hospitalization, may have a counterproductive effect and lead to increased suicide risk. There is an urgent need to transition from addressing depression and suicide as the products of chemical imbalances toward examining how distress arises within power imbalances.

This has important practical implications as it moves the target of interventions from individuals and their brains to relationships and other determinants of health and well-being.

There is support for a number of population-based approaches, such as restricting access to guns and other lethal means, regulating availability of poisonous pesticides, managing safety risks in public spaces, increasing awareness of bullying and addressing bullying in schools with effective whole school based interventions, and avoiding sensationalizing suicide in media reports. Most importantly, there is an urgent need to recognize that policies protecting all human rights are necessary for the realization of mental health and well-being in populations.

Toward a rights-based approach

Instances of suicide and mental distress are inextricable from local cultures, histories, and environments. For example, studies documenting the elevated suicide rates among Indigenous populations have connected suicide to social discrimination and health disparities resulting from histories of colonization.

What is common across these varied contexts and cultures is the fact that suicide is linked to societal level issues. Issues such as economic deprivation, isolation and a lack of social inclusion, and obstacles to accessing healthcare and social support (including restrictions to sexual and reproductive health services) are associated with increased suicide rates.

There is a substantial relationship between trauma and suicide, with exposure to interpersonal violence and abuse arising within systemic issues affecting families and communities. What the global movement for mental health is describing as the high burden of mental diseases may also be described as the high burden of the effects of trauma and other adversities, including child abuse and neglect and other adverse childhood experiences.

Interventions are needed that avoid medicalizing emotional pain and empower individuals in vulnerable situations. Prevention strategies should prioritize addressing health determinants and improving human living conditions over those that disempower individuals and perpetuate social exclusion and stigma by pathologizing diverse responses to adversity. A reduction in structural and interpersonal violence—particularly gender based violence and child abuse and neglect—and the resulting trauma is essential for addressing the major underlying causes of suicide.

A human-rights approach to suicide goes beyond a focus on mental health concerns and places problems of inequality, homelessness, poverty, and discrimination at the heart of prevention strategies. Investing in strengthening human rights such as equality, children's rights, non-discrimination, labour rights, and environmental rights are inseparable from the attainment of the right to health. In line with such an approach, governments should increase access to low-income housing, child abuse prevention and family support, quality physical and mental healthcare and social services, and attempt to lessen the burden of obstacles to health for all.

The structure of governments and political discourse itself impacts mental health and suicide on a societal level. For example, authoritarian and totalitarian ideologies and policies disrupt the relationships between individuals and communities and the State. The erosion of trust and abuses of power that arise within rigid hierarchical power structures are detrimental to the mental health of a society. This intoxicates the quality of relationships and the emotional environment for societies and thus affects all settings (families, schools, workplaces, communities, societies at large) and contribute to wider prevalence of different forms of violence within population, including suicide. Similar toxic patterns can also be seen in more open and democratic societies where inequalities are increasing.

Despite the importance of addressing environmental factors as a core component of a rights-based approach to suicide, people will still experience distress and suicide will remain a human response to such distress. As such, individualized responses to suicide will remain a vital component of a rights-based response to suicide prevention to ensure people have the care and support they need to not only stay alive, but to build the necessary skills that can help them thrive. This cannot be achieved through the excessive use of medication, nor through coercion and isolation, which remain stalwart features of mental health systems. It requires continuity of care in the community and more robust systems of support that can adequately reach people where they live, work, learn, and play. Many of these innovations do not exist within the health sector, they are in our communities and far too often exist on the fringes including peer support groups, peer crisis respite, neighbours supporting veterans, parenting support, educational support, employment training, and school-based inclusion programs. This requires the immediate scaling up of such community supports, so they can emerge from the shadows and take their rightful place at the center of a rights-based approach to suicide prevention.

Within the health sector, addressing suicide in the individual must shift and begin with the complexity of that human person and not the homogeneity of a diagnosis. We must seek solutions that both prevent the accumulation of trauma and desperation that leads to suicide and respond to those in crisis in a way that addresses the underlying issues that have so deeply affected them. Responses within the health system far too often focus on the immediate crisis and not the complex and long-term build-up of such despair or the long-term recovery that is often required. This is a systemic failure of the imagination that has wasted human and financial resources in the futile pursuit of a panacea, inflicted unnecessary pain and suffering, and costed countless lives. Interventions that are non-coercive, shrewd in the prescription of medication, focused on building coping skills, and which emphasize the unique experience of the individual show much more promise and must be prioritized.

Accountability is a core element of a rights-based approach to suicide. For decades, significant investment has been made into suicide prevention with little impact on the outcomes. How are we holding stakeholders accountable for this failure? Accountability demands that future investment and policy learns from the mistakes of the past and establish transparent and accountable systems to ensure we do better for those who need support the most. Without accountability, business as usual continues. All the while, services and supports in the community remain elusive.

On World Mental Health Day, I recommend that States adopt strategies for preventing suicide through a rights-based approach that avoids excessive medicalization and instead follows modern public health principles which focus on addressing societal determinants, promoting autonomy and resilience through social connection, tolerance, justice, and healthy relationships.  The collective failures of our past must catalyze us to do better moving forward.