The Chairman of Lifeline Australia, John Brogden, shared an important message recently in the Sydney Morning Herald with “The national emergency we can no longer ignore”. As a suicide attempt survivor himself, he grimly noted that 2500 Australians still take their lives every year – seven deaths per day. He has rightly called for it to be seen as warranting a national campaign, and the need to improve how we understand suicide.

That last point may not appear to be particularly significant, particularly as there is something that should be self-evident about suicide. “The unfortunate few people with mental health issues are obviously at risk of suicide, which is due to them becoming too depressed”. What’s interesting about that sentence, is that none of those components are true.

Firstly, with regards to the unfortunate few – we are now more aware that mental illness is extremely common. As much as a quarter of the population will suffer from depression at some point in their lives – not sadness, not bereavement or grief, but a clinical situation where their capacity to process emotions becomes damaged and requires intervention. The commonest mental illness is still anxiety – not a fear of spiders or avoiding black cats, but a pathological inability to control how they respond to the normal world.

Our very reasonable skepticism then intervenes. 25% of the population? Where are all the people falling off office buildings on a daily basis? We should be having fulltime Monty Pythonesque “bring out your dead” carriers operating the streets. Then comes the rather unusual reality that, in the world of mental health, suicide is actually rather rare.

Multiple international studies confirm that there are two spikes in lifetime risks of suicide – the 18-25 age bracket, and the 80 years old and above bracket. I work fulltime as an old age and adult psychiatrist, covering both high-risk areas, and process approximately 800-1000 cases a year. Yet I encounter a completed suicide approximately once every 2 years. Whenever we get a case it is a tragedy for myself and my teams, but whilst I remember every patient we have lost, I often consider it strange that there are not more we have to remember.

The reality is that, most patients with mental health issues merely suffer in silence and continue. Treatment can considerably improve their functioning, and perhaps explains why I can count on one hand the suicides that I am aware of after 12 years of clinical practice. Yet the most interesting – and novel – issue in this is the premise that depression and suicidality are two different things.

Fairweather-Schmidt and colleagues of the University of Melbourne studied 7485 people and applied statistical analysis to query whether suicidal behaviour was a symptom of depression or an independent construct. What was fascinating, was that their research indicated that the data fitted a two-factor model of depression and suicidality better than a single-factor model – meaning that suicidality was distinguishable from depression.

This fits a number of preceding studies looking at the effectiveness and roles of medication. We have known for a long time that there is a temporary increase in suicidality in the first few weeks of starting an antidepressant before the patient starts to improve in mood – which is why they require monitoring during this period. What has also been known is that there are interesting distinctly “antisuicidal” properties of certain medications – such as lithium and clozapine.

What this all means is that if a person is distressed and feeling that life is not worthwhile, there may be a serious issue – and, most importantly, a reversible issue. They do not need to be otherwise depressed. They may have a mental illness – and if they do, it is not an unusual issue, about as common as having an elevated blood pressure. And they deserve help.

Suicidality is never normal. The body’s self-preservation instincts are built into every cell. A person thrown into water will instinctively twist every muscle in their body in order to gasp for air. Something has to go seriously awry before the mind starts to override the body.

The need to preserve life is built into all of us. We should have the same approach to our friends and relatives, regardless of how depressed we think they may – or may not – be.

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