“A Strategy to Prevent Suicide in New Zealand. 2017. A Draft for Consultation”
A Submission to the Ministry of Health by Staff of The Nathaniel Centre
We note and endorse the ambition of the Strategy that ‘everyone is able to have a healthy future and see their life as worth living’. Promoting the concept that every life is worth living is critical, we believe, in addressing the high suicide rates in New Zealand. Exploration of this concept, which raises important philosophical and ethical questions concerning societal views about what a ‘successful life’ looks like, may generate important insights as to why suicide rates for certain groups, such as youth, Māori, elders, and disabled people, are higher than for other groups.
A cornerstone of Catholic teaching is the belief that every human life has “intrinsic value” and is to be protected and nurtured at every stage of its development. Those who do not conform to the increasingly dominant ableist idea of what a successful life looks like (e.g. those who suffer deprivation, disability, mental illness, or the limitations of ageing), are particularly vulnerable to the suggestion that their lives are not worth living. These are the people who are most in need of protection and support. We see that there is an urgent need to focus on reducing the stigma associated with ‘difference’ and to foster the view that every human life has unconditional dignity and worth. Among other things, this will require our society to counter the increasingly accepted and relationally impoverished societal narrative which equates the value of a person’s life with their subjective perceptions about the quality of their life, all too often based on factors that reflect an ableist or functionalist worldview.
1. The Strategy provides little specific or material direction for how suicide rates might be reduced:
- No organisations, agencies or individual roles are identified as taking a lead in developing the activities listed (except the very general – ‘employers’, ‘communities’, ‘whanau’).
- The ‘Activities’ are very general. Statements like ‘communities working together to establish age-friendly communities’ express admirable aspirations, but are not helpful in providing direction to ‘communities’ or to an agency that might take a lead. There are many such statements in the Strategy.
2. The Strategy does not appear to build on suicide prevention work that is already taking place or on earlier work in this area. It does not explicitly refer to the Action Plan 2013-2016, nor draw on other strategies, for example, the Youth Suicide Prevention Strategy In Our Hands and Kia Piki te Ora o te Taitamariki, and the two evaluations of that Strategy.
3. For these reasons, we have found it difficult to provide specific feedback on much of the Strategy as the pathways and actions are so general they can be interpreted to cover almost all possible interventions.
4. We are concerned at the way that ‘Maori’, ‘Pacific’, ‘Maori communities’ and ‘whanau, hapu and iwi’ are tasked with many Activities while there is no suggestion that any agency has been tasked with funding or providing resources to these groups and individuals. While it is essential that Maori and Pasifika are involved in the development of suicide prevention initiatives for their own communities, it appears from the Strategy that they are expected to already know what is needed to prevent suicide while being left to take full responsibility to undertake the various Activities suggested.
Suicides Amongst our Elders
5. We note that the Strategy focuses largely on young people aged 15 – 24 years, something that is understandable given their markedly higher rates of suicidal behaviour. However, we consider that there needs to be a complementary focus on older age groups as well, particularly for those over 75 years of age.
6. While the rate of suicide tends to decrease over the older age groups, there is an increase in numbers committing suicide in the age groups over 70, and for males over 85 years the suicide rate of 40.9 per 100,000 is the highest for any age group (males 45-49 is 32.6 and males 20-24 is 28.8 per 100,000). The 85+ age group is a particularly vulnerable group, and evidence of increasing loneliness amongst elders and of increasing elder abuse in New Zealand suggests that rates could worsen. See graph below for 2013 figures:
Figure 1: Age-specific suicide rates, by five-year age group and sex, 2013
Rates are expressed per 100,000 population. Error bars represent 95% confidence intervals. If two confidence intervals do not overlap, there is considered to be a statistically significant difference between the two groups being compared. Source: New Zealand Mortality Collection.1
7. In a presentation to the Suicide Prevention Conference 2013, Prof Yeates Conwell2 made several points concerning older adults:
- Older adults are the most rapidly growing segment of the population
- 'Baby boomers' have tended to have higher suicide rates than earlier or later cohorts at all points in the life course. The fact that 'baby boomers' are now coming into the older age groups, a time of increased risk and increased lethality, means that we are therefore likely to see more suicides amongst this cohort.
- There is one completed suicide for every 30 attempts in the general population, but for older adults there is one completed suicide for every 4 attempts. This is because older people are more frail (more likely to die), are more isolated (less likely to be rescued), and older people use more immediately lethal means and use them in ways more likely to result in death.
8. It well accepted that even mild depression – the kind that would not render a person legally incompetent – can have a marked effect on one's predisposition to life, including a person's willingness to consider ending their life prematurely. The Mental Health Foundation of New Zealand identifies depression in the elderly as often linked to health problems. It also notes that "The risk of suicide in people with depression is significant."3
9. Dysthymia, a chronic form of depression that is typically described as a "mild depression" (also referred to as "subthreshold depression") has been shown, because of its ongoing nature, to have a devastating impact on people's lives. Persons with this type of "minor depression" are at increased risk of developing a major depression4 and exhibit very similar statistics relating to suicide mortality and number of repeated suicide attempts as persons with major depressive disorders.5
10. While the New Zealand Mental Health Survey indicates that those over 65 years have proportionately lower rates of depression than other age groups, there is evidence that some groups of the elderly suffer high rates of depression. In the New Zealand LiLACS longitudinal study, which recruited 421 Maori aged 80-90 years and 516 non-Maori aged 85 years living in the Bay of Plenty and Rotorua districts, the prevalence of depression (measured by the Geriatric Depression Scale) was reported as ranging from 22 percent for Maori men and 23 percent for non-Maori men to 26 percent for non-Maori women and 30 percent for Maori women.6 In addition, physical health generally declines with age which has consequences for social functioning and emotional role functioning.7
11. Detection and treatment of depression has been found to be an effective strategy to prevent late-life suicide.8
12. Conwell reported that 'indicated' (e.g. screen, detect and treat depression at primary care level) and 'selective' (e.g. a depression care manager in primary care) interventions are successful, particularly for older women.
13. The 2015 Office for Senior Citizens (Ministry of Social Development) report on Elder Abuse notes a number of studies which have demonstrated links between elder abuse and depression.9 The recent Australian Report on Elder Abuse notes that risk factors for the person experiencing abuse include depression, as well as social isolation and physical disability.10
14. The Office for Senior Citizens report also notes that "around one in ten older people ... report some form of abuse (closely linked to vulnerability and coercion)". While there are no population-based studies of elder abuse in New Zealand, most research estimates that between 2 to 5 percent of the older population may be victims of elder abuse.11 The proportion increases dramatically when the person is dependent on carers, where studies estimate almost a quarter of older people who are dependent on careers have reported suffering "significant psychological abuse".12 Similarly, Age Concern in New Zealand reports that it receives more than 1,500 confirmed referrals each year of older people facing abuse or neglect.13
15. Reports from the 2001 Census show that there were 450,426 people aged 65 and over living in New Zealand, which means there could be between 9008 (2 percent) and 22,520 (5 percent) older New Zealanders suffering some form of abuse and neglect. It is estimated that only 16 percent of the actual number of abuse incidents reach service agencies.14
16. Any strategy to prevent suicides amongst our elders must be closely linked to the prevention of abuse experienced by this group.
17. Research has established that those making serious suicide attempts are likely to be characterised by high rates of social isolation, feelings of loneliness, poor social support and lack of a close, confiding relationship.15 Several studies have established that loneliness is a significant problem for elders in New Zealand: an Auckland Council commissioned study found that 9 percent of Auckland residents aged over 50 were severely lonely, and 44.5 percent moderately lonely;16 a study investigating the rate, degree and impact of loneliness in a sample of 332 older community-dwelling New Zealanders found more than half of the sample (52 percent) was found to be lonely to some extent with 44 percent being moderately lonely and 8 percent severely lonely;17 the New Zealand Longitudinal Study of Aging described a minority of participants as 'not lonely' (48.8 percent); the rest were considered 'moderately lonely' (41.2 percent); 'severely lonely' (7 percent); and 'very severely lonely' (3 percent).18
18. While there are many precipitating factors involved in elder suicide, we believe that much more attention needs to be given to critiquing the ageist and ableist societal narrative that is increasingly inclined to equate value of life and personal dignity with health and independence ('not being a burden').
19. A focus on the suicide of elders, while 'targeting' a particular group and raising awareness of the 'value' and dignity of this group, may also work at a universal level by challenging societal attitudes about 'useful' or 'successful' lives that will assist in suicide prevention for all age groups.
Suicides within Corrections Facilities
20. We note also that there is no mention of prisoners in the Strategy and yet the suicide rate for prisoners is higher than that of the general population. In addition, the rate of suicide amongst Māori men is higher than that for all men (25.6 Māori men compared with 18.8 men per 100,000 in 2012), which the Department of Corrections reports as significant for them, since around 90% of offenders in prison are male and just over half identify as Māori.19
21. The Department of Corrections also reports an increase in 'self-harm threat to life incidents' from six for the year 2011/2012 to 26 for the year 2015/2016. ('Unnatural deaths', with suicide being the most common cause of these, increased from five to 11 over the same period).20
22. Given these figures, and given the high rates of mental health or substance use disorder amongst prisoners,21 we would like to see more emphasis in the Strategy on suicide prevention for the prison population.
Disabled People and Suicide
23. While New Zealand data concerning disabled people and suicide are not readily available, there are a number of reasons why this group should be considered vulnerable to higher suicide rates.
24. It has been found that disability status is a strong predictor of suicide ideation risk.[i] Disabled people are among the most disadvantaged in terms of employment, interpersonal acceptance, economic stability, freedom of mobility and community access, all variables thought to have a significant bearing on suicide potential.23
25. The New Zealand Disability Survey reports that for 12 percent of adults and 21 percent of children, psychological or psychiatric difficulties were the main impairments.24 It suggests that an estimated 242,000 people (adults and children) were living with long-term limitations in their daily activities as a result of the effects of psychological and/or psychiatric impairments.
26. It is disappointing and concerning that disabled people are not mentioned at all in the Strategy.
27. It is also the case that deprivation and suicide are correlated. The Ministry of Health Report on suicide for 2013 found that rates of suicide increased consistently with the level of deprivation. The highest rate was among those residing in quintile 5 areas (the most deprived areas), with a rate of 15.4 per 100,000 population, followed by quintile 4 (12.1 per 100,000). The lowest suicide rate was seen among those who resided in the least deprived areas, quintile 1 (7.3 per 100,000). For both males and females, the suicide rate was twice as high amongst those residing in the most deprived areas compared with those living in the least deprived areas.25
28. The association between deprivation level and suicide is most apparent in the youth population (15–24 years) where there were at least four times the number of suicides for this population in deprivation quintiles 3–5 compared with quintiles 1 and 2. For those aged 25–44 years, there were 2.5 times the number of suicides in deprivation quintiles 3–5 compared with quintiles 1 and 2.26
29. Other studies have found an association between deprivation and suicide rates for young and middle-aged males in England27 and young adults in Scotland.28
30. The association of deprivation with suicide is not addressed in the Strategy but we suggest this is a potentially a risk factor for suicide, particularly amongst young people, and as such definitely needs consideration.
State of Mental Health Services in New Zealand:
31. In New Zealand currently, there are clearly pressures on mental health provision, and funding over recent years has not been able to meet increased need. In view of this, we consider that the Strategy should also advocate for increased provision of mental health support at both primary and secondary health care levels as part of its approach in addressing suicide rates amongst all age groups.
32. The Ministry of Health's Director of Mental Health reported29 that specialist mental health and addiction services are experiencing increasing pressure. The number of people engaging with specialist services increased from 143,060 people in 2011 to 162,222 people in 2015. It noted that despite increases in funding, the sector faces 'new and shifting challenges' and that 'services are experiencing increasing pressure'.
33. In a report on discharge planning for mental health patients from hospital, the Auditor-General has recently found that 'the timeliness, quality, and effectiveness of discharge planning (and the associated follow-up work) are impaired by pressures on inpatient and community services and other factors' and that some inpatient units have high occupancy rates – sometimes beyond their capacity – and in some places there is limited availability of community services to discharge people to.30
34. We note also that those who suffer from mental illness would be particularly susceptible to a premature death under the proposed End of Life Choices Bill being sponsored by David Seymour in which a person is eligible for assisted dying if they suffer from 'a grievous and irremediable medical condition', which can include mental illness.
Links between suicide in the general population and legalised euthanasia and assisted suicide:
35. There is also the potential additional risk of an increase in suicide rates in response to moves to legalise/decriminalise assisted suicide/euthanasia, which needs to be considered and addressed. The strategy document does not address the issue of physician-assisted suicide or euthanasia. While the issues may appear at first glance to be separate, there is sufficient evidence to suggest that they may well be directly linked to the wider issue of suicide in society.
36. Legalising assisted suicide is a particular risk for our elders in a context in which older people are experiencing greater rates of social isolation and depression as noted above. Were euthanasia or assisted suicide to be legalised, many such 'legal' requests could potentially hide what would otherwise have been regarded as tragic suicides linked to a reactive depression that is directly related to abuse or neglect or to the limitations of ageing – a depression that can and should be treated.31
37. The contagion effects of suicide are well known, both the links between media coverage of suicide and youth suicide,32 as well as that between parental and offspring suicidal ideation and suicide attempts.33 It has been found that the relative risk of suicide following exposure to another's suicide is two to four times higher among 15-19 year olds than among other age groups.34
38. Exposure to the suicidal behaviour of family members has been well-established as a risk factor for youth suicidal behaviour.35
39. While it is still premature to make definitive comparisons of suicide rates in jurisdictions that have or have not legalised euthanasia, it is worth noting that in the Netherlands the number of completed suicides (excluding premature death by euthanasia) has risen from 1,500 in 2003 to 1,871 in 2015, that is from 9.6 to 11.1 per 100,000 population (euthanasia was legalised there in 2002).36
40. If assisted suicide/euthanasia were to be legalised, young people and others at risk of suicide would be faced with two competing paradigms - 'acceptable suicide' and 'unacceptable suicide'. The concept of 'rational' suicide, for those who find their lives intolerable and not worthwhile, will be in direct conflict with the fundamental goal and message of suicide prevention programmes.
41. In view of recent attempts to change the law regarding assisted suicide/euthanasia, the Strategy needs to address and challenge this potential development, which would impact significantly on the approach and messages of suicide prevention initiatives.
While the "Strategy to Prevent Suicide in New Zealand" is wonderfully aspirational, we believe it needs to be more specific in terms of articulating specific interventions and in identifying, and advocating for, the resources and support required to ensure that the expressed aspirations lead to effective action.
While we understand and agree with the need to focus on the groups identified - Māori, mental health service users, Pacific peoples, and young people – we believe that the Strategy has failed to identify other demographic groups at risk of suicide, that is, our elders, persons being detained in correctional facilities and disabled people, as well as those living in the most highly deprived areas. We consider these groups should also be included for targeted activities.
We suggest that those who do not conform to the increasingly dominant ableist and ageist idea of what a successful life looks like, for example, those who suffer deprivation, disability, mental illness, or the limitations of ageing, are particularly vulnerable to the suggestion that their lives are not worth living. We suggest that a strategy to prevent suicide might need to address this underlying social narrative.
Finally, we have highlighted the need to be aware of the competing paradigms that would be created were New Zealand to legalise euthanasia or assisted suicide. Such a move that would effectively amount to acknowledging the notion of 'rational suicide', something which we believe would impact negatively on suicide prevention in the general population.
- (Ministry of Health, 2016b, p. 8)
- (Professor Yeates Conwell, 2013)
- See https://www.mentalhealth.org.nz/get-help/a-z/resource/13/depression
- (Cuijpers, 2004).
- (Holmstrand, Engstrom, & Traskman-Bendz, 2008)
- (Teh et al., 2014)
- (Budge, Claire, Stephens, Christine, & Stichbury, Christopher, 2014)
- (Turvey et al., 2002)
- (Office for Senior Citizens, 2015)
- (The Australian Law Reform Commission, 2017)
- (Glasgow, K & Fanslow, J.L., 2006)
- (Cooper, Selwood, & Livingston, 2008) (2008) 37 Age and Ageing 151 at 158
- See https://www.ageconcern.org.nz/ACNZPublic/Services/EANP/ACNZ_Public/Elder_Abuse_and_Neglect.aspx#howmuch
- (Beautrais, A.L., Collings, S.C.D., Ehrhardt, P., & et al., 2005)
- (Waldegrave, Charles, King, Peter, & Rowe, Elizabeth, 2012)
- (La Grow, Neville, Alpass, & Rodgers, 2012)
- (Noone, Jack & Stephens, Christine, 2014)
- (Department of Corrections, n.d., p. 63)
- (ibid n.d., p. 63)
- A 2015 study found ‘62% of prisoners had experienced a mental health or substance use disorder, while 20% had experienced both in the 12 months before the study’ (ibid n.d., p. 62)
- (Russell, Turner, & Joiner, 2009)
- (Gill, 1992)
- (Statistics New Zealand, 2013)
- (Ministry of Health, 2016b, p. 19)
- (Ministry of Health, 2016b, p. 20)
- (Rezaeian, Dunn, St Leger, & Appleby, 2005)
- (Exeter & Boyle, 2007)
- (Ministry of Health, 2016a)
- (Office of the Auditor-General, 2017, pp. 3–4)
- (O’Connell, Chin, Cunningham, & Lawlor, 2004)
- (Crepeau-Hobson & Leech, 2014). (Sisask & Varnik, 2012)
- (Goodwin, Beautrais, & Fergusson, 2004)
- (Haw, Hawton, Niedzwiedz, & Platt, 2013)
- (Crepeau-Hobson & Leech, 2014, p. 59)