1 00:00:05,550 --> 00:00:09,180 Welcome to Science with Sanjula where we talk about anything global health. 2 00:00:09,810 --> 00:00:13,590 My name is Sanjula Singh and I am a researcher at the University of Oxford. 3 00:00:14,220 --> 00:00:19,320 Join me as I speak to world leading scientists who tackle today's biggest challenges in health care. 4 00:00:20,070 --> 00:00:28,530 Please note the following episode contains potentially triggering content, as it includes discussions about mental health, self-harm and suicides. 5 00:00:29,830 --> 00:00:34,629 I am honoured to introduce the guest of today's podcast to you, Professor Keith Hawton, 6 00:00:34,630 --> 00:00:42,730 who is a Professor of psychiatry and consultant psychiatrist and Director of the Centre for Suicide Research at the University of Oxford. 7 00:00:43,450 --> 00:00:47,980 He's often regarded as the number one expert on suicide and suicide prevention worldwide. 8 00:00:48,370 --> 00:00:52,120 So please join me in welcoming Professor Hawton. Thank you. 9 00:00:53,420 --> 00:00:59,900 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. 10 00:01:00,710 --> 00:01:07,520 So when and what initiated your interest in psychiatry and later, more specifically in self-harm and suicide? 11 00:01:08,900 --> 00:01:17,120 Well, if I go back to my university days, I began intending to study zoology, which I did start. 12 00:01:18,320 --> 00:01:28,580 And then I got attracted to experimental psychology and indeed spent a couple of years in that area. 13 00:01:29,060 --> 00:01:40,670 And during that time we had lectures from psychiatrists, and I found the whole subject fascinating and decided I wanted to be a psychiatrist. 14 00:01:41,390 --> 00:01:50,480 I was offered a position after I'd done my psychiatric training on a research project on self-harm or attempted suicide. 15 00:01:51,050 --> 00:01:55,879 And I thought, Well, I'll do this for a couple of years and I'll do something else little, 16 00:01:55,880 --> 00:02:02,630 knowing that it would become the mainstay of my working life for many decades thereafter. 17 00:02:03,110 --> 00:02:06,620 And if I may ask, how many years ago were you in medical school? 18 00:02:06,830 --> 00:02:11,660 Oh, gosh, so we're were talking back in the 1960s. Before I was born. 19 00:02:11,690 --> 00:02:20,960 Yes. And how did society think about mental illness at that time and how did that change over over the past years? 20 00:02:21,230 --> 00:02:24,740 There were a lot of negative attitudes towards mental illness. 21 00:02:25,160 --> 00:02:34,520 People were scared of mental illness back in those days, I think over the years, that's changed. 22 00:02:35,930 --> 00:02:45,830 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. 23 00:02:46,340 --> 00:02:49,370 So I think there's been a positive shift. 24 00:02:50,270 --> 00:02:56,030 It's not perfect by any means, but I think there has been a pretty major shift over the decades. 25 00:02:56,510 --> 00:03:02,810 Could you please explain to me what may be the best way to refer to self-harm and suicide? 26 00:03:03,260 --> 00:03:09,200 One of the difficulties we get into is people often talk about someone committing suicide, 27 00:03:09,740 --> 00:03:16,340 and that goes back to when suicide was an illegal act or attempted suicide was an illegal act. 28 00:03:17,390 --> 00:03:21,080 And that, in this country, ceased to be the case in 1961. 29 00:03:21,320 --> 00:03:25,810 But that term still used. But it's it's upsetting for relatives. 30 00:03:25,820 --> 00:03:33,620 They often object to it because it implies something, you know, almost a criminal act rather than an act of desperation. 31 00:03:33,770 --> 00:03:44,060 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. 32 00:03:45,100 --> 00:03:51,370 What do we know about the statistics of self-harm and suicide in adolescence? 33 00:03:51,640 --> 00:03:54,670 Suicide is somewhere between second and third 34 00:03:54,670 --> 00:03:59,440 most common cause of death in young people. Wow, it's such a striking number to me. 35 00:03:59,440 --> 00:04:03,100 Yeah, it's a major, major problem. 36 00:04:04,390 --> 00:04:12,840 As you move into adulthood, particularly in males in this country, suicide is the most common cause of death 37 00:04:12,850 --> 00:04:16,570 in males between 35 and 54. 38 00:04:16,810 --> 00:04:25,150 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. 39 00:04:25,630 --> 00:04:33,940 Comparing hospital data with data from surveys, particularly in surveys done in schools. 40 00:04:34,450 --> 00:04:44,650 We've estimated that something like one in eight of individuals who self-harm in the community actually end up coming to clinical attention. 41 00:04:44,980 --> 00:04:51,190 And why do you think that is? Do you think there's a stigma maybe or shame that people may experience and 42 00:04:51,190 --> 00:04:56,050 therefore that young people are afraid to to share these feelings or experiences? 43 00:04:56,080 --> 00:04:59,649 Well, certainly that's true, indeed. 44 00:04:59,650 --> 00:05:04,150 You know, people often hide hide evidence of of self-harm. 45 00:05:05,500 --> 00:05:11,260 And I think shame is is an important part of it. 46 00:05:12,850 --> 00:05:17,799 But of course, the difficulty there is it means, you know, people are less likely to seek help, 47 00:05:17,800 --> 00:05:23,290 be it from friends or be it through clinical agencies or GP's. 48 00:05:23,590 --> 00:05:26,049 Should we talk about self-harm and suicide 49 00:05:26,050 --> 00:05:33,340 as something that is very strongly correlated, as in people who self-harmed in the past are more likely to die by suicide, 50 00:05:34,060 --> 00:05:40,900 or are these regarded as two separate entities? It depends what what end of the telescope you're looking through. 51 00:05:41,440 --> 00:05:45,340 So if you are looking at it from the point of view of suicide, 52 00:05:45,760 --> 00:05:56,010 we know that self-harm or attempted suicide has very has very often occurred in the history of people who die by suicide. 53 00:05:56,530 --> 00:06:04,120 Maybe some 50 to 60% or more have had some sort of acts of self-harm before actually dying of suicide. 54 00:06:04,630 --> 00:06:09,820 On the other hand, if you look at it the other way round in terms of people who self-harm, 55 00:06:09,820 --> 00:06:14,200 particularly self-harm in the community and don't come to clinical attention, 56 00:06:14,680 --> 00:06:20,890 the incidence of suicide, while it's increased compared with the general population, it's still uncommon. 57 00:06:21,280 --> 00:06:26,559 And so one doesn't want to give the impression and particularly scare people that, you know, 58 00:06:26,560 --> 00:06:31,720 any act of self-harm means that person is on a trajectory to end up ending their lives. 59 00:06:32,260 --> 00:06:39,910 And I am aware that there are often multiple problems at the same time which then may lead to these behaviours. 60 00:06:40,540 --> 00:06:44,920 Could you tell me a little bit more about what those problems might be? 61 00:06:45,400 --> 00:06:50,530 I mean, one of the key areas is, of course, mental health problems, particularly depression, 62 00:06:51,130 --> 00:07:02,590 anxiety disorders, eating disorders, major psychotic disorders and bipolar disorder. 63 00:07:02,770 --> 00:07:09,040 These are all have significant associations with both suicide and self-harm. 64 00:07:10,240 --> 00:07:13,720 And then there are the social problems that people may face. 65 00:07:14,140 --> 00:07:27,040 And of course, these might be very recent problems, acute life events such as breaks up relationships, abuse, similar experiences like that. 66 00:07:27,370 --> 00:07:32,860 Or they may be historical problems that which have left this person vulnerable. 67 00:07:33,130 --> 00:07:44,710 And we know that times of economic downturn so like recessions can lead to increases in suicide and also self-harm. 68 00:07:44,860 --> 00:07:48,490 Do we know if there are any genes that cause self-harm or suicide? 69 00:07:49,300 --> 00:07:56,890 Well, we don't know anything about specific, specific genes, and there's no robust scientific evidence about specific genes. 70 00:07:56,890 --> 00:08:07,660 But what we do know is that self-harm and both self-harm and suicide can be more common in certain families. 71 00:08:08,250 --> 00:08:15,850 And indeed, we did some work some years ago in Denmark using their wonderful national registers, 72 00:08:16,330 --> 00:08:26,970 where we showed that where people were adopted, young people were adopted, and they died by suicide, 73 00:08:28,030 --> 00:08:35,740 suicide was more like more common in their biological siblings than in their adopted siblings, 74 00:08:36,760 --> 00:08:44,680 which might be surprising because you think that they were being exposed to similar, you know, upbringing and maybe difficulties. 75 00:08:45,940 --> 00:08:53,140 That might have led to their behaviour, but that emphasised the fact that genetic transmission is really important. 76 00:08:53,440 --> 00:08:58,030 What is transmitted, we don't really know. I mean, obviously 77 00:08:58,030 --> 00:09:06,030 there's mental health problems and it may have something to do with a tendency towards aggression and 78 00:09:06,040 --> 00:09:13,120 which may lead to self aggression and other sort of personality factors which might influence risk. 79 00:09:13,510 --> 00:09:18,850 And in addition to all of these concepts that are often discussed when talking about these problems, 80 00:09:18,940 --> 00:09:22,780 one of them being something called contagious self harm behaviour. 81 00:09:23,380 --> 00:09:31,960 What does that mean? Well, we know that if people are exposed to self-harm or indeed suicide by other people, 82 00:09:33,430 --> 00:09:38,829 be it people in their social environment or people they might observe, 83 00:09:38,830 --> 00:09:45,400 you hear about through the media and so on, we know that that can increase risk of suicidal behaviour. 84 00:09:47,620 --> 00:10:02,620 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. 85 00:10:04,030 --> 00:10:09,280 So and we also know that suicide and self-harm can occur in clusters. 86 00:10:09,670 --> 00:10:18,310 We tend to think about, you know, clusters in a particular location, such as in a school psychiatric unit or in a locality. 87 00:10:18,790 --> 00:10:31,839 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, 88 00:10:31,840 --> 00:10:37,270 but they are geographically, you know, diverse and maybe not even in the same country. 89 00:10:37,990 --> 00:10:46,480 Unfortunately, there are people or indeed organisations that do promote suicide. 90 00:10:48,070 --> 00:10:52,240 Efforts are being made to try and stop that. 91 00:10:52,660 --> 00:10:56,739 That's very, very difficult. And why is it so difficult? Can't we make it illegal 92 00:10:56,740 --> 00:10:59,559 for example? The problem with making it illegal is, 93 00:10:59,560 --> 00:11:08,740 is you might have impacts on other communications about suicide and self-harm that may go on in social groups. 94 00:11:09,340 --> 00:11:16,630 And one of the concerns has been, you know, if you say, right, you shouldn't be talking about a specific method of suicide, 95 00:11:17,080 --> 00:11:21,100 but there might be an individual communicating their behaviour to others, 96 00:11:22,120 --> 00:11:27,280 not because they want them to, you know, do the same thing, but because they want help. 97 00:11:27,730 --> 00:11:32,260 And so one of the conflicts has been about, you know, how do you stop this? 98 00:11:32,440 --> 00:11:38,440 Having said that, we now have an online safety bill in this country going through parliament, 99 00:11:38,860 --> 00:11:46,360 which is aimed at stopping platforms which allow such promotion of behaviour, 100 00:11:46,690 --> 00:11:53,800 but trying not to sort of stop communication between individuals that might be about help seeking. 101 00:11:59,950 --> 00:12:06,430 Do we have good evidence from low to middle income countries on suicide, or are we actually lacking high quality data? 102 00:12:06,580 --> 00:12:12,020 It varies a lot. There are certain parts of the world where we have very little information. 103 00:12:12,040 --> 00:12:18,520 Africa. Most African countries. We don't have good data on suicides. 104 00:12:18,880 --> 00:12:27,580 And this is true of certain other countries, particularly where suicide is very negatively regarded. 105 00:12:28,030 --> 00:12:31,490 So people may try to hide the fact that, you know, 106 00:12:31,510 --> 00:12:39,640 people have died by suicide where there are strong religious objections against suicidal behaviour. 107 00:12:40,420 --> 00:12:48,219 People are making efforts to try and get better data, partly through interviewing families about deaths, 108 00:12:48,220 --> 00:12:54,520 because we know that official statistics are often rather poor. 109 00:12:55,570 --> 00:13:04,240 And yet when you interview families and what we call verbal, or using the verbal autopsy approach about all sorts of causes of death, 110 00:13:04,240 --> 00:13:11,350 but particularly about suicide, you get much more accurate figures and they tend to be probably double the official statistics. 111 00:13:11,620 --> 00:13:17,350 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. 112 00:13:17,560 --> 00:13:30,340 We did a very large trial in which farmers were given lockable storage boxes to keep their pesticides in because pesticides are, 113 00:13:30,430 --> 00:13:35,590 you know, have been used frequently for suicide in these areas. 114 00:13:36,040 --> 00:13:45,250 And we were actually able to do a trial where we had certain villages had these boxes, safety boxes. 115 00:13:45,280 --> 00:13:46,780 Other villages didn't. 116 00:13:47,260 --> 00:13:54,910 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. 117 00:13:55,270 --> 00:13:57,910 It surprised us a great deal. 118 00:13:58,540 --> 00:14:10,599 Having said that, what has been happening over several years, many years really in particularly in Sri Lanka, is that the more dangerous pesticides, 119 00:14:10,600 --> 00:14:16,450 the more toxic ones have been withdrawn through national legislation, which meant that, 120 00:14:17,410 --> 00:14:21,580 you know, much fewer people are dying from this particular method of suicide. 121 00:14:21,580 --> 00:14:31,059 And it isn't that they're turning to other methods of suicide, it's had an absolute effect in terms of saving lives. 122 00:14:31,060 --> 00:14:37,360 It's been estimated it saved over 90,000 lives in Sri Lanka over a 20 year period. 123 00:14:43,950 --> 00:14:49,410 Can we prevent suicide? Yes, certainly 124 00:14:49,650 --> 00:14:51,790 there's a lot we can do in the way of prevention. 125 00:14:51,810 --> 00:15:00,719 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. 126 00:15:00,720 --> 00:15:07,830 And what then one can do for individuals to try and reduce their risk. At the population level, 127 00:15:08,010 --> 00:15:14,160 this would include, for example, prevention programs through school education about mental health, 128 00:15:14,370 --> 00:15:22,620 which can include attention to self-harm, about restricting access to methods of suicide, 129 00:15:23,490 --> 00:15:33,690 for example, making places popular for suicide safer, restricting access to certain medications that are likely to be used for suicidal, 130 00:15:33,690 --> 00:15:37,950 acts. In terms of interventions at the individual level. 131 00:15:38,730 --> 00:15:45,360 And what is thinking there about specifically targeting people who are at risk, 132 00:15:45,990 --> 00:15:52,580 perhaps because of their mental health problems and also people who are engaged in self-harm? 133 00:15:53,400 --> 00:16:01,020 And we know that certain sorts of psycho social therapy, particularly psycho brief psychological therapies, 134 00:16:01,320 --> 00:16:06,750 can be effective in reducing risk of repetition of self-harm. 135 00:16:07,320 --> 00:16:14,280 When sometimes people say to me, What do you think's the single most important thing about preventing suicide? 136 00:16:14,310 --> 00:16:20,580 Probably the most important thing is talking to people. Human connection. To have somebody by your side who listens to you. 137 00:16:20,610 --> 00:16:30,059 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, 138 00:16:30,060 --> 00:16:35,910 who do have a close family member or close friend, who are they are helping at this stage? 139 00:16:35,920 --> 00:16:39,150 Because I can imagine they may feel hopeless at some point. 140 00:16:39,540 --> 00:16:44,920 Well, yes, indeed. I think one shouldn't do this alone. 141 00:16:44,940 --> 00:16:52,800 I think if you are trying to support someone who's maybe suicidal and or has been suicidal, 142 00:16:53,220 --> 00:17:02,270 to be able to turn to others that can support you without you necessarily revealing who the person is. 143 00:17:02,280 --> 00:17:04,590 I mean, they may, you know, may not want you to do that, 144 00:17:05,490 --> 00:17:13,590 but I think looking after your own needs is going to enhance your ability to provide effective support for others. 145 00:17:14,340 --> 00:17:22,770 I have been told that you wrote a book that is currently being given to all people in the UK who experience suicide bereavement. 146 00:17:23,160 --> 00:17:28,740 What can you do or what can we all do to support people who are experiencing bereavement? 147 00:17:30,120 --> 00:17:41,340 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. 148 00:17:42,360 --> 00:17:51,540 I think they appreciate is being able to read about the experiences that people have had or have when someone's died by suicide, 149 00:17:51,540 --> 00:17:54,480 and then recognising what they're experiencing, 150 00:17:54,720 --> 00:18:04,830 which may be, you know, incredibly distressing feelings and thoughts that other people have similar experiences, 151 00:18:05,070 --> 00:18:08,400 but these can change over time and so on. 152 00:18:08,580 --> 00:18:21,120 And also having recommended sources of help, be they formal sources of help through organisations or through talking to other people. 153 00:18:21,420 --> 00:18:25,740 For some people that will be enough. For others, they may need specialist help. 154 00:18:25,920 --> 00:18:30,600 And I've also read that many people who experience bereavement, they have a sense of guilt. 155 00:18:31,290 --> 00:18:34,410 What would you say to those people who may have these thoughts? 156 00:18:34,620 --> 00:18:39,570 It is a natural phenomenon to think, you know, I surely I could have done something to prevent this. 157 00:18:40,140 --> 00:18:48,810 But by and large, I think that that probably isn't true and that, you know, 158 00:18:48,810 --> 00:18:53,970 there wasn't anything they probably could have done at that particular point. 159 00:18:54,180 --> 00:19:01,500 And how would they have known? People so often say, I had no idea that this person was thinking about suicide. 160 00:19:02,490 --> 00:19:09,630 Do you sometimes feel because it's quite a heavy topic, that sometimes that gets to you and touch your emotions as well? 161 00:19:10,290 --> 00:19:19,260 Well, I think in order to do the research in this field, you have to develop some detachment to be objective. 162 00:19:20,340 --> 00:19:33,569 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. 163 00:19:33,570 --> 00:19:44,660 And maybe because of similarities with someone, you know, maybe, you know, a relative or you even start thinking about your own children. 164 00:19:44,670 --> 00:19:50,129 And in this context, it certainly happens. 165 00:19:50,130 --> 00:19:51,230 And I think that's important. 166 00:19:51,240 --> 00:20:02,190 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. 167 00:20:02,490 --> 00:20:11,490 The final question of this podcast what your personal and professional advice be for students and young professionals worldwide? 168 00:20:12,180 --> 00:20:23,280 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, 169 00:20:23,280 --> 00:20:39,030 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. 170 00:20:39,030 --> 00:20:47,220 And that's how life develops and that's how we sort of move forward and develop experience, develop skills. 171 00:20:47,490 --> 00:20:57,090 I would also say getting the life balance as we talk about, a life outside of work is, is really important. 172 00:20:59,650 --> 00:21:03,100 Thank you very much for listening to today's episode of Science with Sanjula. 173 00:21:03,520 --> 00:21:06,670 If you are looking for help for yourself or for a loved one. 174 00:21:07,150 --> 00:21:11,350 There are resources available to you, some of which are listed in the show notes. 175 00:21:12,430 --> 00:21:19,630 Next week, we'll be talking with Dr. Keren Papier. We'll be talking about the associations between diet and health. 176 00:21:20,170 --> 00:21:21,430 Please tune in next week.