Welcome to Science with Sanjula where we talk about anything global health.
My name is Sanjula Singh and I am a researcher at the University of Oxford.
Join me as I speak to world leading scientists who tackle today's biggest challenges in health care.
Please note the following episode contains potentially triggering content, as it includes discussions about mental health, self-harm and suicides.
I am honoured to introduce the guest of today's podcast to you, Professor Keith Hawton,
who is a Professor of psychiatry and consultant psychiatrist and Director of the Centre for Suicide Research at the University of Oxford.
He's often regarded as the number one expert on suicide and suicide prevention worldwide.
So please join me in welcoming Professor Hawton. Thank you.
So I would like to start by getting to know you a little bit better before diving into the heavy topic of today's episodes.
So when and what initiated your interest in psychiatry and later, more specifically in self-harm and suicide?
Well, if I go back to my university days, I began intending to study zoology, which I did start.
And then I got attracted to experimental psychology and indeed spent a couple of years in that area.
And during that time we had lectures from psychiatrists, and I found the whole subject fascinating and decided I wanted to be a psychiatrist.
I was offered a position after I'd done my psychiatric training on a research project on self-harm or attempted suicide.
And I thought, Well, I'll do this for a couple of years and I'll do something else little,
knowing that it would become the mainstay of my working life for many decades thereafter.
And if I may ask, how many years ago were you in medical school?
Oh, gosh, so we're were talking back in the 1960s. Before I was born.
Yes. And how did society think about mental illness at that time and how did that change over over the past years?
There were a lot of negative attitudes towards mental illness.
People were scared of mental illness back in those days, I think over the years, that's changed.
People are more willing to talk about it. People are much more willing to come out about their own mental health problems, either current or past.
So I think there's been a positive shift.
It's not perfect by any means, but I think there has been a pretty major shift over the decades.
Could you please explain to me what may be the best way to refer to self-harm and suicide?
One of the difficulties we get into is people often talk about someone committing suicide,
and that goes back to when suicide was an illegal act or attempted suicide was an illegal act.
And that, in this country, ceased to be the case in 1961.
But that term still used. But it's it's upsetting for relatives.
They often object to it because it implies something, you know, almost a criminal act rather than an act of desperation.
So what may be a better way to talk? Well, we tend to sort of encourage people to talk about die by suicide, as, you know, that sort of terminology.
What do we know about the statistics of self-harm and suicide in adolescence?
Suicide is somewhere between second and third
most common cause of death in young people. Wow, it's such a striking number to me.
Yeah, it's a major, major problem.
As you move into adulthood, particularly in males in this country, suicide is the most common cause of death
in males between 35 and 54.
We now know that a lot of self-harm, particularly in young people, occurs in the community but doesn't come to the attention of clinicians.
Comparing hospital data with data from surveys, particularly in surveys done in schools.
We've estimated that something like one in eight of individuals who self-harm in the community actually end up coming to clinical attention.
And why do you think that is? Do you think there's a stigma maybe or shame that people may experience and
therefore that young people are afraid to to share these feelings or experiences?
Well, certainly that's true, indeed.
You know, people often hide hide evidence of of self-harm.
And I think shame is is an important part of it.
But of course, the difficulty there is it means, you know, people are less likely to seek help,
be it from friends or be it through clinical agencies or GP's.
Should we talk about self-harm and suicide
as something that is very strongly correlated, as in people who self-harmed in the past are more likely to die by suicide,
or are these regarded as two separate entities? It depends what what end of the telescope you're looking through.
So if you are looking at it from the point of view of suicide,
we know that self-harm or attempted suicide has very has very often occurred in the history of people who die by suicide.
Maybe some 50 to 60% or more have had some sort of acts of self-harm before actually dying of suicide.
On the other hand, if you look at it the other way round in terms of people who self-harm,
particularly self-harm in the community and don't come to clinical attention,
the incidence of suicide, while it's increased compared with the general population, it's still uncommon.
And so one doesn't want to give the impression and particularly scare people that, you know,
any act of self-harm means that person is on a trajectory to end up ending their lives.
And I am aware that there are often multiple problems at the same time which then may lead to these behaviours.
Could you tell me a little bit more about what those problems might be?
I mean, one of the key areas is, of course, mental health problems, particularly depression,
anxiety disorders, eating disorders, major psychotic disorders and bipolar disorder.
These are all have significant associations with both suicide and self-harm.
And then there are the social problems that people may face.
And of course, these might be very recent problems, acute life events such as breaks up relationships, abuse, similar experiences like that.
Or they may be historical problems that which have left this person vulnerable.
And we know that times of economic downturn so like recessions can lead to increases in suicide and also self-harm.
Do we know if there are any genes that cause self-harm or suicide?
Well, we don't know anything about specific, specific genes, and there's no robust scientific evidence about specific genes.
But what we do know is that self-harm and both self-harm and suicide can be more common in certain families.
And indeed, we did some work some years ago in Denmark using their wonderful national registers,
where we showed that where people were adopted, young people were adopted, and they died by suicide,
suicide was more like more common in their biological siblings than in their adopted siblings,
which might be surprising because you think that they were being exposed to similar, you know, upbringing and maybe difficulties.
That might have led to their behaviour, but that emphasised the fact that genetic transmission is really important.
What is transmitted, we don't really know. I mean, obviously
there's mental health problems and it may have something to do with a tendency towards aggression and
which may lead to self aggression and other sort of personality factors which might influence risk.
And in addition to all of these concepts that are often discussed when talking about these problems,
one of them being something called contagious self harm behaviour.
What does that mean? Well, we know that if people are exposed to self-harm or indeed suicide by other people,
be it people in their social environment or people they might observe,
you hear about through the media and so on, we know that that can increase risk of suicidal behaviour.
We also know that it's much more likely to be a factor between people who are more like each other, be by gender sorts of lifestyle and so on.
So and we also know that suicide and self-harm can occur in clusters.
We tend to think about, you know, clusters in a particular location, such as in a school psychiatric unit or in a locality.
But of course, with social media and so on, we now know, becoming aware that sort of people may be self-harming or indeed die by suicide in a cluster,
but they are geographically, you know, diverse and maybe not even in the same country.
Unfortunately, there are people or indeed organisations that do promote suicide.
Efforts are being made to try and stop that.
That's very, very difficult. And why is it so difficult? Can't we make it illegal
for example? The problem with making it illegal is,
is you might have impacts on other communications about suicide and self-harm that may go on in social groups.
And one of the concerns has been, you know, if you say, right, you shouldn't be talking about a specific method of suicide,
but there might be an individual communicating their behaviour to others,
not because they want them to, you know, do the same thing, but because they want help.
And so one of the conflicts has been about, you know, how do you stop this?
Having said that, we now have an online safety bill in this country going through parliament,
which is aimed at stopping platforms which allow such promotion of behaviour,
but trying not to sort of stop communication between individuals that might be about help seeking.
Do we have good evidence from low to middle income countries on suicide, or are we actually lacking high quality data?
It varies a lot. There are certain parts of the world where we have very little information.
Africa. Most African countries. We don't have good data on suicides.
And this is true of certain other countries, particularly where suicide is very negatively regarded.
So people may try to hide the fact that, you know,
people have died by suicide where there are strong religious objections against suicidal behaviour.
People are making efforts to try and get better data, partly through interviewing families about deaths,
because we know that official statistics are often rather poor.
And yet when you interview families and what we call verbal, or using the verbal autopsy approach about all sorts of causes of death,
but particularly about suicide, you get much more accurate figures and they tend to be probably double the official statistics.
I was wondering if you could tell us a little bit about this case study I've been reading about on pesticides in Sri Lanka.
We did a very large trial in which farmers were given lockable storage boxes to keep their pesticides in because pesticides are,
you know, have been used frequently for suicide in these areas.
And we were actually able to do a trial where we had certain villages had these boxes, safety boxes.
Other villages didn't.
And sadly, at the end of this trial, which is probably the largest trial of its kind, there was no difference between the two areas.
It surprised us a great deal.
Having said that, what has been happening over several years, many years really in particularly in Sri Lanka, is that the more dangerous pesticides,
the more toxic ones have been withdrawn through national legislation, which meant that,
you know, much fewer people are dying from this particular method of suicide.
And it isn't that they're turning to other methods of suicide, it's had an absolute effect in terms of saving lives.
It's been estimated it saved over 90,000 lives in Sri Lanka over a 20 year period.
Can we prevent suicide? Yes, certainly
there's a lot we can do in the way of prevention.
I think it's useful to think in terms of what one can do at the population level to try and reduce risk of suicide and self-harm.
And what then one can do for individuals to try and reduce their risk. At the population level,
this would include, for example, prevention programs through school education about mental health,
which can include attention to self-harm, about restricting access to methods of suicide,
for example, making places popular for suicide safer, restricting access to certain medications that are likely to be used for suicidal,
acts. In terms of interventions at the individual level.
And what is thinking there about specifically targeting people who are at risk,
perhaps because of their mental health problems and also people who are engaged in self-harm?
And we know that certain sorts of psycho social therapy, particularly psycho brief psychological therapies,
can be effective in reducing risk of repetition of self-harm.
When sometimes people say to me, What do you think's the single most important thing about preventing suicide?
Probably the most important thing is talking to people. Human connection. To have somebody by your side who listens to you.
Exactly. And it doesn't have to necessarily have to be a professional expert. And are there anyways that we can help those people who may be listening,
who do have a close family member or close friend, who are they are helping at this stage?
Because I can imagine they may feel hopeless at some point.
Well, yes, indeed. I think one shouldn't do this alone.
I think if you are trying to support someone who's maybe suicidal and or has been suicidal,
to be able to turn to others that can support you without you necessarily revealing who the person is.
I mean, they may, you know, may not want you to do that,
but I think looking after your own needs is going to enhance your ability to provide effective support for others.
I have been told that you wrote a book that is currently being given to all people in the UK who experience suicide bereavement.
What can you do or what can we all do to support people who are experiencing bereavement?
Well, I mean, you talked about the book. I mean, I probably use the term booklet to be a bit more modest, but people do seem to appreciate it.
I think they appreciate is being able to read about the experiences that people have had or have when someone's died by suicide,
and then recognising what they're experiencing,
which may be, you know, incredibly distressing feelings and thoughts that other people have similar experiences,
but these can change over time and so on.
And also having recommended sources of help, be they formal sources of help through organisations or through talking to other people.
For some people that will be enough. For others, they may need specialist help.
And I've also read that many people who experience bereavement, they have a sense of guilt.
What would you say to those people who may have these thoughts?
It is a natural phenomenon to think, you know, I surely I could have done something to prevent this.
But by and large, I think that that probably isn't true and that, you know,
there wasn't anything they probably could have done at that particular point.
And how would they have known? People so often say, I had no idea that this person was thinking about suicide.
Do you sometimes feel because it's quite a heavy topic, that sometimes that gets to you and touch your emotions as well?
Well, I think in order to do the research in this field, you have to develop some detachment to be objective.
But that doesn't mean you become cold hearted. And certainly every so often you come across a case that really, you know, gets to you.
And maybe because of similarities with someone, you know, maybe, you know, a relative or you even start thinking about your own children.
And in this context, it certainly happens.
And I think that's important.
I mean, it's important, A, to be able to be be objective, but at the same time to be empathic with the issue and what people go through.
The final question of this podcast what your personal and professional advice be for students and young professionals worldwide?
My general advice would be go with your dreams that so often we have ideas in life and we think, Oh, I can't do that,
that's too challenging. But so often when we do take on things that appear to be maybe too challenging, too scary, we find that actually it's okay.
And that's how life develops and that's how we sort of move forward and develop experience, develop skills.
I would also say getting the life balance as we talk about, a life outside of work is, is really important.
Thank you very much for listening to today's episode of Science with Sanjula.
If you are looking for help for yourself or for a loved one.
There are resources available to you, some of which are listed in the show notes.
Next week, we'll be talking with Dr. Keren Papier. We'll be talking about the associations between diet and health.
Please tune in next week.