Suicide: Scotland's silent killer

When Clare Haughey, Minister for Mental Health, in announcing the Scottish Government’s target to reduce the country’s suicide rate by 20 per cent by 2022, said that Scotland was striving to become a place “where suicide is preventable”, there was one glaringly obvious question: how?

How could suicide, the most unpredictable, unique and silent of killers, be prevented?

How could anyone be expected to prevent a death executed with such determination by the one and only person who knew it was coming?

Rory O’Connor, Professor of Health Psychology and director of the Suicidal Behaviour Research Laboratory at the University of Glasgow, has been working on providing the answers to these questions since the 1990s.

“A great question you’ve just asked is how do we identify or prevent suicide,” he tells me, as we sit in his office within the grounds of Gartnavel Royal Hospital in the west end of Glasgow.

Do we understand the transition from thoughts of suicide to attempting suicide?

“We do lots of different sorts of research. We do stuff which is large-scale epidemiological surveys trying to understand who’s at risk, who’s suicidal, how often do people become suicidal? Do we understand the transition from thoughts of suicide to attempting suicide?

“And we do a lot of work with people in a clinical context, if you’ve attempted suicide. We’ve a lot of work from hospitals immediately following a suicide attempt, in terms of understanding and then we also do some intervention-based work, brief intervention work to try and hopefully help the most vulnerable.”

What has guided a lot of the work carried out by the suicide research lab is a model of suicide developed by O’Connor, called the ‘integrated motivational volitional model’.

“It’s a bit of a mouthful,” laughs O’Connor. “But it’s basically a model which has helped us understand the emergence of suicidal thinking, so we can better identify who’s at risk. And also, to understand that, thankfully, most people who think about suicide never make this transition to attempting suicide or dying by suicide.

“Across the world, we think about a third of people who think seriously about suicide do make that transition. And so, my model is trying to help us understand, first of all, what leads people to become suicidal, and then to cross this precipice from thoughts to attempts.”

The key driver to somebody becoming suicidal is they feel trapped by unbearable emotional pain

O’Connor’s model is being used by the National Suicide Prevention Leadership Group – a group for which he is one of the academic advisers – which was set up by the Scottish Government as part of its Suicide Prevention Action Plan.

“What my model is, in a very simple way, is if you’re trying to understand why people become suicidal, there’s key things to think about. First of all, as you point out, every suicide is unique,” explains O’Connor. “What my model tries to do is identify common features. And I would argue that the key driver to somebody becoming suicidal is they feel trapped by unbearable emotional pain, which usually results from feeling defeated, humiliated, a sense of shame or loss, or rejection.

“And that’s what’s driving the sort of pain. The feelings of defeat and shame and loss can arise from a whole range of factors, so it’s important when we think about suicide, we take a lifespan approach. So, we know, for example, that people who experienced early life trauma are vulnerable to suicide. And we’ve done some experimental-based work, which shows that not only are they at increased risk of suicide, but that trauma actually affects your stress response, how the body responds on a physiological basis.

“My argument is, if you experience early trauma, or you’ve been made unemployed, or you’re from a really disadvantaged background, or you’ve been treated so badly when you come in contact with clinical services, you feel a sense of shame, or whatever it may be. For example, if you attempt suicide or self-harm and come into A&E, a lot of patients report that they’ve been treated in a less than compassionate way, which contributes to their sense of ‘God, I’m not worth anything, I’m a burden’.

“All these sorts of factors lead you to become defeated, or humiliated or shamed. And then that sense of entrapment, that’s a key driver for you becoming suicidal in the first place.”

O’Connor says that the “single best predictor” of whether a person will die by suicide is whether they have attempted suicide or self-harmed in the past.

Suicide in Scotland is at a five-year high, with men far more likely than women to take their own lives

He adds: “We’re moving towards a better understanding of what differentiates people who just think about suicide and people who attempt suicide. It’s really important to highlight, though, that given the complexity of suicide, we’re still no better than chance, the flipping of a coin, at predicting who will die by suicide. But what my model and others do is give us an insight, even though some people might show no signs, but most people, you will see some signs and the entrapment or the defeat, or humiliation are all part of the puzzle, and this complex puzzle leads to suicide.”

Suicide in Scotland is at a five-year high, with men far more likely than women to take their own lives. In 2018, three times more men than women killed themselves.

There were 784 probable suicides registered in Scotland in 2018, compared with 680 the previous year and the overall figures for males and females last year were 581 and 203 respectively.

As the leading cause of death in young and middle-aged men in most countries – including the UK – suicide has become a major public health challenge.

As a result, the Scottish Government launched its suicide prevention action plan in 2018, pledging to reduce the number of suicides by 20 per cent by 2022.

But while the figures are stark, O’Connor is quick to point out that even though there has been a recent rise in suicide rates here, a lot of progress has been made over the last 10 to 20 years, coinciding with Scotland’s decision to tackle suicide as a public health issue.

“If we look across the world, we have about 800,000 people dying by suicide each year; in the UK, it’s between 5,000 and 6,000 and in Scotland, about 800 die by suicide each year,” he says. “If you look over the last 10 or 20 years, Scotland has really led the way internationally in terms of the work we do with regards to suicide prevention at a national level and a local level.

“Indeed, the good news story has been that up until last year, the suicide rate had been decreasing, so the Scottish suicide rate decreased by about 20 per cent over the last ten years, and although it’s difficult to pinpoint why we think that is the case, part of it is because it’s been treated as a public health priority and it’s looking beyond mental health responses and that’s something which we in Scotland have done really well.

Every suicide is a tragedy, but when we’re seeing this increase in young people, it’s a really important time so we can better understand why there’s this increase, and how we can respond as effectively as possible

“The reason it’s such a priority now is that last year, our suicide rates increased, but Scotland is no different to England and suicide rates in England went up as well, also amongst young people and that’s really a concern. Every suicide is a tragedy, but when we’re seeing this increase in young people, it’s a really important time so we can better understand why there’s this increase, and how we can respond as effectively as possible.”

O’Connor’s work, therefore, has never been more important, and as we sit drinking coffee while discussing the most complex nature of human torment, it’s hard not to wonder how he can deal with all this weight sitting firmly on his shoulders.

A cursory glance around his office reveals rows of thank-you cards, the walls of the room within the rather bleak-looking hospital block are brightened up by children’s paintings, while cheesy pop music plays quietly in the background.

It feels almost like a visual metaphor for how he deals with the grimmest realities of life.

“It’s tough,” he admits. “But one thing I’ve got better at over the years is my own self-care.

“There’s a group of people here who all do research on suicide and self-harming, so no day passes by without me doing something on suicide. I meet people who’ve lost a loved one to suicide, so self-care is really important for me.

“There’s someone I speak to on a regular basis to help me manage my own wellbeing, I run and play tennis, do other things. And I also have mentors who can provide an outlet.

“But I also feel incredibly privileged to work in the area I do, and incredibly humbled when I speak to family members who’ve lost a loved one to suicide. Even though I can never help them understand why, specifically, their loved one died by suicide, for example, often we can help them understand what might have been going through their head and the fact that people share their life with me, both in that context, but also in the research, people who take part in our study, people that attempted suicide, share their experiences with us, it’s really humbling but hopefully, can help others, or help us to help others not die by suicide.”

The next obvious question is how O’Connor, who was just a young psychology student when he began to specialise in suicide, came to enter that field of research in the first place.

“My involvement in some ways was serendipitous. I was a psychology undergraduate student at Queen’s University in Belfast and I’d done an undergraduate project on depression and hopelessness, which is related to suicide. And then as it would happen, I was going to do a PhD, not on suicide, but then the man who turned out to be my PhD supervisor, he said to me, there’s a possibility of funding a PhD on suicide, would you be interested? And so, I jumped at the chance and it was serendipitous at that stage.

“But then the really sad thing is that some years later, he took his own life. Without him, I would never have embarked on a field of suicide research. And I often wonder how it happened that he came to me and said that.

“What it highlights to me, I’ve always been incredibly passionate about suicide research and prevention, but I’ve lost two people really close to me to suicide – my supervisor being one of them – it just highlights the scale of the challenge. Nobody’s immune.”

And it’s this sense that it can happen to anyone, at any time, that is driving the research in a bid to work towards the Scottish Government’s suicide reduction target.

O’Connor and his colleagues have developed an intervention known as ‘safety planning’, which helps a vulnerable person to identify triggers which could lead to them having suicidal thoughts.

It works by helping a potentially suicidal person to keep themselves safe in moments of crisis, by distracting themselves, by contacting a friend, relative or service who could help them, and by keeping their environment safe and free from methods of suicide.

Suicide is usually not about wanting to die. It’s about wanting the pain to end

“They can formulate a plan to keep themselves safe, but part of it is also to agree there’s someone you can speak to in a moment of crisis. And that’s really, really important to have somebody there that you can speak to. Actually, over the weekend, a friend of mine contacted me, he’s acutely suicidal but that he knows that there’s somebody he can speak to, and having that person, having somebody there, is important.

“That’s only one part of how we respond to suicide prevention, because what we need to make sure is that there is more in-depth access to psychological treatments or other psychosocial interventions to keep them safe.

“Access to mental health services is always challenging, and I think that we need to make sure that we’ve got the services tailored to the most vulnerable.

“One of the biggest challenges we have is there’s not enough investment in suicide research. And that’s not just Scotland, that’s nationally and internationally. If you think about the fact that suicide is the leading cause of death amongst middle-aged men, the amount of investment is just minuscule in suicide research compared to cancer research or heart disease for the number of people affected.  And then also making sure the research gets into practice.”

O’Connor ends with some sobering words, which, somehow, make each one of Scotland’s 784 recorded suicide deaths in 2018 even more of a tragedy.

“Suicide is usually not about wanting to die,” he says. “It’s about wanting the pain to end. That’s what drives the emergence of suicidal thoughts.”