SUICIDE PREVENTION STRATEGIES IN KENYA

Suicide is the act of deliberately killing oneself.

Suicide attempt is used to mean any non-fatal suicidal behaviour and refers to intentional self-inflicted poisoning, injury or self-harm which may or may not have a fatal intent or outcome.

It is important to acknowledge the implications and complexities of including self-harm in the definition of “Suicide attempt”. This means that non-fatal self-harm without suicidal intent is included under this term, which is problematic due to the possible variations in related interventions. However, suicide intent can be difficult to assess as it may be surrounded by ambivalence or even concealment.

In addition, cases of deaths as a result of self-harm without suicidal intent, or suicide attempts with initial suicidal intent where a person no longer wishes to die but has become terminal, may be included in data on suicide deaths. Distinguishing between the two is difficult, so it is not possible to ascertain what proportions of cases are attributable to self-harm with or without suicidal intent.

Suicidal behaviour refers to a range of behaviours that include thinking about suicide (or ideation), planning for suicide, attempting suicide and suicide itself. The inclusion of ideation in suicidal behaviour is a complex issue about which there is meaningful ongoing academic dialogue.

The foundation of any effective response in suicide prevention is the identification of suicide risk factors that are relevant to the context and their alleviation by implementing appropriate interventions. Suicidal behaviours are complex. There are multiple contributing factors and causal pathways to suicide and a range of options for its prevention. Usually no single cause or stressor is sufficient to explain a suicidal act. Most commonly, several risk factors act cumulatively to increase an individual’s vulnerability to suicidal behaviour. At the same time, the presence of risk factors does not necessarily lead to suicidal behaviour; not everyone with a mental disorder, for instance, dies from suicide. Effective interventions are imperative as they can mitigate the risk factors identified. Protective factors are equally important and have been identified as improving resilience. Therefore, enhancing protective factors is also an important aim of any comprehensive suicide prevention response.

Risk factors

A wide spectrum of risk factors has been recognized and key ones are grouped into areas that span across; systemic, societal, community, relationship (social connectedness to immediate family and friends) and individual risk factors that are reflective of an ecological model.

It is important to note firstly that the risk factors listed are far from exhaustive. Many others exist that may be classified and categorized differently. The importance of each risk factor and the way it is classified will depend on each context. These factors can contribute to suicidal behaviours directly but can also contribute indirectly by influencing individual susceptibility to mental disorders. It would be a mistake to assign a clear distinction between the areas identified. Just as each individual risk factor interrelates with others, the areas are not mutually exclusive. It is far more useful to view the areas as moving from systemic through to individual. Specific risk factors could actually sit within more than one of the areas simultaneously.

For instance, loss of a job or financial support could influence a person individually and could lead to the deterioration of immediate relationships, but it could also be linked to an economic recession at systemic level. The groups assigned help to simplify the exhaustive risk factors that exist and to identify relevant interventions more easily.

Interventions

Evidence-based interventions for suicide prevention are organized in a theoretical framework that distinguishes between universal, selective and indicated interventions.

The interventions are of three kinds:

1. Universal prevention strategies (Universal) are designed to reach an entire population in an effort to maximize health and minimize suicide risk by removing barriers to care and increasing access to help, strengthening protective processes such as social support and altering the physical environment.

2. Selective prevention strategies (Selective) target vulnerable groups within a population based on characteristics such as age, sex, occupational status or family history. While individuals may not currently express suicidal behaviours, they may be at an elevated level of biological, psychological or socioeconomic risk.

3. Indicated prevention strategies (Indicated) target specific vulnerable individuals within the population − e.g. those displaying early signs of suicide potential or who have made a suicide attempt.

Given the multiple factors involved and the many pathways that lead to suicidal behaviour, suicide prevention efforts require a broad multisectoral approach that addresses the various population and risk groups and contexts throughout the life course.

Health system and societal risk factors:

·         Barriers to accessing health care

·         Access to means

·         Inappropriate media reporting and social media use

·         Stigma associated with help-seeking behaviour

Relevant interventions for health system and societal risk factors:

·         Mental health policies

·         Policies to reduce harmful use of alcohol

·         Access to health care

·         Restriction of access to means

·         Responsible media reporting

·         Raising awareness about mental health, substance use disorders and suicide

Community and relationship risk factors:

·         Disaster, war and conflict

·         Stresses of acculturation and dislocation

·         Discrimination

·         Trauma or abuse

·         Sense of isolation and lack of social support

·         Relationship conflict, discord or loss

Relevant interventions for community and relationship risk factors:

·         Interventions for vulnerable groups

·         Gatekeeper training

·         Crisis helplines

Individual risk factors:

·         Previous suicide attempt

·         Mental disorders

·         Harmful use of alcohol and other substances

·         Job or financial loss

·         Hopelessness

·         Chronic pain and illness

·         Family history of suicide

·         Genetic and biological factors

Relevant interventions for individual risk factors:

·         Follow-up and community support

·         Assessment and management of suicidal behaviours

·         Assessment and management of mental and substance use disorders

Protective factors

Strong personal relationships

Religious or spiritual beliefs

Lifestyle practice of positive coping strategies and well-being

Mental Health Unit, Ministry of Health Kenya