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
In April 2017, the Ministry of Health issued a draft “Strategy to Prevent Suicide in New Zealand” for public consultation setting out a framework for “how we can work together to reduce suicidal behaviour”. The following article is a summary of the submission made by staff of The Nathaniel Centre. The full submission is available on our website: http://nathaniel.org.nz/submissions/429-a-strategy-to-prevent-suicide-in-new-zealand-2017-a-draft-for-consultation
General Discussion
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.
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. There is an urgent need 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.
Our Response
1. We note that the Strategy provides little specific or material direction for how suicide rates might be reduced, that organisations or agencies are not identified as taking a lead, and that the ‘Activities’ are very general. The pathways and actions laid out in the Strategy can be interpreted to cover almost all possible interventions.
2. We are concerned at the way that ‘Maori’, ‘Pacific’, ‘Maori communities’ and ‘whanau, hapu and iwi’ are tasked with many Activities while no agencies have 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
3. We understand the focus on young people given their higher rates of suicidal behaviour but we suggest that there needs to be a complementary focus on older age groups as well, particularly for those over 75 years of age. For males over 85 years the suicide rate is the highest for any age group. Evidence of increasing loneliness amongst elders and of increasing elder abuse in New Zealand suggests that rates could worsen.
4. The Mental Health Foundation of New Zealand notes that “The risk of suicide in people with depression is significant”1 and there is evidence that some groups of the elderly suffer high rates of depression. One study found depression was reported for 22 percent of Maori men (age 80-90 years) and 23 percent of non-M?ori men (age 85 years), and 30 percent of M?ori women (age 80-90 years) and 26 percent of non-Maori women (age 85 years).2
5. The 2015 Office for Senior Citizens (Ministry of Social Development) report on Elder Abuse reports that “around one in ten older people … report some form of abuse (closely linked to vulnerability and coercion)”. Most research estimates that between 2 to 5 percent of the older population may be victims of elder abuse.3 Age Concern in New Zealand reports that it receives more than 1,500 confirmed referrals each year of older people facing abuse or neglect.4 It is estimated that only 16 percent of the actual number of abuse incidents reach service agencies.5 Any strategy to prevent suicides amongst our elders must be closely linked to the prevention of abuse experienced by this group.
6. 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.6 Loneliness is a significant problem for elders in New Zealand: in one study 9 percent of Auckland residents aged over 50 were severely lonely, and 44.5 percent moderately lonely;7 another study of older people found more than half of the sample was lonely to some extent, with 44 percent being moderately lonely and 8 percent severely lonely;8 the New Zealand Longitudinal Study of Aging described less than half of participants as ‘not lonely’, 41.2 percent as ‘moderately lonely’, 7 percent as ‘severely lonely’ and 3 percent as ‘very severely lonely’.9
7. 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’).
8. 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
9. There is no mention of prisoners in the Strategy, yet the suicide rate for prisoners is higher than that of the general population. In addition, the much higher suicide rate amongst M?ori men is significant since around 90% of offenders in prison are male and just over half identify as Maori.10
10. The Department of Corrections reports an increase in ‘self-harm threat to life incidents’, from six in 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).11
11. Given these figures, and given the high rates of mental health or substance use disorder amongst prisoners,a we would like to see more emphasis in the Strategy on suicide prevention for the prison population.
Disabled People and Suicide
12. It has been found that disability status is a strong predictor of suicide ideation risk.12 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.13
13. It is disappointing and concerning that disabled people are not mentioned at all in the Strategy.
Deprivation
14. 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), and the lowest suicide rate was seen among those who resided in the least deprived areas. 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.14
15. The association between deprivation level and suicide is most apparent in the youth population where there were at least four times the number of suicides for this population in deprivation quintiles 3–5 compared with quintiles 1 and 2.15
16. 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.
State of Mental Health Services in New Zealand
17. Growing pressures on mental health services over recent years in New Zealand mean we have not been able to meet increased need. We consider that the Strategy should advocate for increased provision of mental health support at both primary and secondary health care levels.
18. The Ministry of Health’s Director of Mental Health reported16 specialist mental health and addiction services are experiencing increasing pressure, and that the numbers engaging with specialist services have significantly increased over recent years. The Auditor-General has recently found that discharge planning is ‘impaired by pressures on inpatient and community services and other factors’.17
19. We note 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
20. There is a potential additional risk of an increase in suicide rates in response to moves to legalise assisted suicide/euthanasia, which needs to be considered and addressed. There is sufficient evidence to suggest that these issues may well be directly linked to the wider issue of suicide in society.
21. Legalising assisted suicide is a risk for our elders in a context in which older people are experiencing greater rates of social isolation and depression, as noted above. 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.18
22. 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.19 Exposure to the suicidal behaviour of family members has been well-established as a risk factor for youth suicidal behaviour.20
23. 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).21
24. 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 ‘acceptable’ 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.
25. 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.
Conclusion
While the “Strategy to Prevent Suicide in New Zealand” is wonderfully aspirational, we believe it needs to be more specific in articulating interventions and in identifying, and advocating for, the resources and support required to ensure that the expressed aspirations lead to effective action.
We agree with the need to focus on the groups identified - Maori, mental health service users, Pacific peoples, and young people – but believe that the Strategy has failed to identify other demographic groups at risk of suicide, that is, 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 address this underlying social narrative.
Finally, we suggest competing paradigms would be created were New Zealand to legalise euthanasia or assisted suicide, which would effectively acknowledge the notion of ‘rational suicide’. Such a move would impact negatively on suicide prevention in the general population.
Endnotes
[a] 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’. Department of Corrections. Department of Corrections 2015/2016 Annual Report. Wellington
[1] See https://www.mentalhealth.org.nz/get-help/a-z/resource/13/depression
[2] Teh, Ruth, et al. (2014)."Self-rated health, health-related behaviours and medical conditions of Maori and non-Maori in advanced age: LiLACS NZ." The New Zealand Medical Journal (Online) 127.1397.
[3] Glasgow, K., and Janet Fanslow. (2007). "Family violence intervention guidelines: Elder abuse and neglect." Wellington: Ministry of Health.
[4] http://www.ageconcern.org.nz/ACNZPublic/Services/EANP/ACNZ_Public/Elder_Abuse_and_Neglect.aspx
[5] https://www.ageconcern.org.nz/ACNZPublic/Services/EANP/ACNZ_Public/Elder_Abuse_and_Neglect.aspx#howmuch
[6] Beautrais, A. L., et al. (2005). "Suicide Prevention: A review of evidence of risk and protective factors, and points of effective intervention." Wellington: Ministry of Health.
[7] Waldegrave, Charles, King, Peter, & Rowe, Elizabeth. “Aucklanders 50 and over: a health, social and demographic summary analysis of the life experiences of older Aucklanders.” (Report prepared for the Auckland Council, Research, Investigations and Monitoring Unit). Wellington: Family Centre Social Policy Research Unit and Elizabeth Rowe of Elizabeth Rowe Consulting.
[8] La Grow, Steven, et al. (2012) "Loneliness and self?reported health among older persons in New Zealand." Australasian journal on ageing 31.2, pp. 121-123.
[9] Noone, Jack, & Stephens, Christine. (2014). “The New Zealand Longitudinal Study of Ageing: Summary Report - social integration, health and quality of life”. (The New Zealand Longitudinal Study of Ageing (NZLSA)). Palmerston North: Massey University.
[10] Department of Corrections. Department of Corrections 2015/2016 Annual Report. Wellington.
[11] ibid n.d., p. 63.
[12] Russell, D., Turner, R. J., & Joiner, T. E. (2009). Physical Disability and Suicidal Ideation: A Community?Based Study of Risk/Protective Factors for Suicidal Thoughts. Suicide and Life-Threatening Behavior, 39(4), 440–451.
[13] Gill, C. J. (1992). Suicide intervention for people with disabilities: a lesson in inequality. Issues L. & Med., 8, 37
[14] Ministry of Health. (2016b). Suicide Facts: Deaths and intentional self-harm hospitalisations: 2013. Wellington: Ministry of Health. P.19.
[15] Ministry of Health. (2016b). Suicide Facts: Deaths and intentional self-harm hospitalisations: 2013. Wellington: Ministry of Health. P.20.
[16] Ministry of Health. (2016a). Office of the Director of Mental Health Annual Report 2015. Wellington: Ministry of Health.
[17] Office of the Auditor-General. (2017). Mental Health: Effectiveness of the planning to discharge people from hospital. Report by the Office of the Auditor-General. Retrieved from http://www.oag.govt.nz/2017/mental-health/docs/mental-health.pdf. pp. 3–4.
[18] O’Connell, H., Chin, A.-V., Cunningham, C., & Lawlor, B. A. (2004). Recent developments: suicide in older people. BMJ: British Medical Journal, 329(7471), 895.
[19] Haw, C., Hawton, K., Niedzwiedz, C., & Platt, S. (2013). Suicide Clusters: A Review of Risk Factors and Mechanisms. Suicide and Life-Threatening Behavior, 43(1), 97–108. https://doi.org/10.1111/j.1943-278X.2012.00130.x
[20] Crepeau-Hobson, M. F., & Leech, N. L. (2014). The Impact of Exposure to Peer Suicidal Self-Directed Violence on Youth Suicidal Behavior: A Critical Review of the Literature. Suicide and Life-Threatening Behavior, 44(1), 58–77. https://doi.org/10.1111/sltb.12055
[21] https://www.cbs.nl/en-gb/news/2016/26/more-suicides