What can Spain do to tackle its growing suicide problem?

His parents found their son’s suicide note in time. He is 30 years old and has never been diagnosed with a mental illness, but he was preparing for his own death. He was finalizing the details and had even chosen a date to end it all.

After stumbling across the note, the man’s parents went to a mental health center to find out how to deal with their discovery.

“Many professionals still insist on an approach that isn’t helpful,” says Javier Jiménez, a clinical psychologist from the Association of Suicide Research, Prevention and Intervention (AIPIS) that provides voluntary assessments. “Like recommending that the person should not be asked directly if they wanted to commit suicide in case this gives them the idea. It’s not a good approach. You have to speak about it openly, without avoiding the word.”

The idea is to find a way of studying health data to help us understand mental health problems better

Julio Mayol, Director of Madrid's Hospital Clínico San Carlos

The family of the young man in question ended up at AIPIS in their quest for more personal and specific help than the mental health center had to offer. And after assessing their situation, AIPIS set about trying to stop their son from becoming one of Spain’s 10 daily suicide victims.

“In the last 20 years, we have switched from being a low risk country to a medium risk one and we are about to become high risk,” says Julio Bobes, a psychiatry professor at Oviedo University and member of the International Association for Suicide Prevention (IASP).

With a total of 3,910 deaths in 2014, suicides have hit a record high for a third year running, replacing traffic accidents as Spain’s principal cause of unnatural death. It also means with there are more suicides in Spain than Greece. And as the situation becomes increasingly critical, calls for action become louder and more urgent.

Need for centralized approach

The health care departments of Spain’s autonomous regions are responsible for developing their own suicide detection and prevention methods. But as there is no central mandate, some regions act and others do not, according to Bobes who adds that the disparity among the regions is tremendous.

And while Asturias and Galicia are currently at the top of Spain’s suicide league table, Catalonia is leading in the field of prevention with a regional plan to assess suicide risk throughout the region, although it is still too soon to measure its success.

Catalonia is leading in the field of prevention with a regional plan to assess suicide risk throughout the region

“They haven’t pumped in much money and no one has been employed specifically; the program aims to make use of existing resources to detect people at risk and to monitor them,” says Victor Pérez Sola, head of psychiatry at Barcelona’s Hospital del Mar and advisor to the Catalan regional government on suicidal behavior.

Although other communities such as Madrid and Asturias have their own strategies, many experts have been calling for years for the authorities to heed recommendations from the World Health Organization (WHO) and implement a national policy. This is not, however, currently on the political agenda and while the Ministry of Health has set up agreements on the issue, attempts to carry them through have been consistently thwarted.

After a WHO conference in Helsinki where, for example, European representatives agreed the issue had been ignored for too long and figures should be reduced with the drafting up of national policies by 2010, the impetus in Spain was stalled by a simple lack of organization.

“It took us two years just to translate the signed document into Spanish,” recalls Bobes. “Two key years were lost before putting it into practice but little progress was made even then due to the crisis in 2009, which became an excuse for the authorities to do nothing.”

In the last 20 years, we have switched from being a low risk country to a medium risk one and we are about to become high risk

A similar fate befell a proposal passed by Congress in 2012, presented by the then-leader of the pro-European party UPyD, Rosa Díez.

“They backpedaled. Some regions such as Andalusia voted against [the plan] and it was as good as dead in the water,” says Javier Jiménez, who was asked to join the commission to develop the initial draft of the preventative policy.

Although many of the private and state initiatives such as the Hope Phone Line are worthwhile in themselves, Jiménez believes they fail to get to the root of the problem. “Spain has pilot programs,” he says. “But only in a few hospitals, such as Código 100 de la Fundación Jiménez Díaz or 12 de Octubre.”

The psychologist explains the existing programs are very basic tools aimed primarily at people at risk from repeat suicide attempts. “But that's not enough,” he says. “You also have to watch out for those at risk who have not yet tried to take their own lives. We need more resources – it's a very complex problem.”

Suicides have hit a record high for a third year running, and are Spain’s main cause of unnatural death

The lack of strategic coordination is also due to a lack of transparency in the suicide figures. The only official figures come from the INE (National Statistics Institute), with the most recent being from 2014. Many communities such as Madrid did not give accurate figures and others, according to experts, produced no figures at all. “Each of us live in our own Tower of Babel and so it's impossible to know exactly what's happening,” says Bobes. “In order to prevent suicides, we first have to be clear about the circumstances and exactly how many there are.”

Víctor Pérez Solá proposes a national strategy that allows each region a degree of autonomy to adapt it to its own needs. “I am in favor of a realistic focus,” he says. “There should be a basic strategy at the national level, with sufficient funds and human resources, which obliges communities to establish procedures according to their needs… a suicide in Extremadura, for example is not going to be the same as one in Madrid.”

A taboo topic

Experts are unanimous in calling for more money and higher staffing levels, as well as better coordination between autonomous communities and more social awareness about mental health. As many as 90% of people who commit suicide are mental health patients, and this is a problem that urgently requires funding.

“The laughable amount of funds allocated to psychiatry compared to those for cancer has often been remarked upon,” says Blanca Reneses, head of psychiatry at the Hospital Clínico San Carlos in Madrid.

“There is a great deal of room for improvement,” agrees the hospital’s director, Julio Mayol. “To establish effective preventative measures, we need research. And that means statistics, which in turn means money. Clinical depression is one of the world’s main suicide triggers. It is far more prevalent than cancer or neurological disease and it has major repercussions but it doesn't get the attention it deserves. Suicide is just one way of expressing it.”

We need a basic strategy at the national level, with sufficient funds and human resources Victor Pérez Sola, head of psychiatry at Barcelona’s Hospital del Mar

Most of the experts point to the effectiveness of traffic campaigns in reducing fatalities on the road as an argument for employing similar measures for preventing suicide. “Death by suicide is as avoidable as death on the road,” says Víctor Pérez Solá. “We need more awareness and more publicity campaigns, although that alone will not be enough to reduce the numbers.”

Pérez proposes a simpler measure – talking about suicide. The wall of silence surrounding the issue has made it invisible. It’s the silent death no one wants to hear about. And while experts agree the media needs to be cautious when providing information and follow guidelines such as not offering details of methods nor glorifying the act, they are not convinced that avoiding the issue does anything to arrest the trend.

“Ten times more people die from suicide as domestic violence and it is the main cause of death among young people. But nobody knows this because it’s not discussed,” says Pérez.

Javier Jiménez explains how a Madrid secondary school which has seen five suicides in the last five years rejected the ASIPI’s offer of a talk on detecting risk factors. “They argued that we would alarm both students and their parents,” says Pérez. “How is an association for its prevention going to cause alarm? The alarm bells are already ringing but they don’t want to hear them.”

There is a general consensus among experts that the contagious aspect of suicide has become exaggerated. “It’s like saying, don’t speak about domestic violence because it will give abusive partners ideas and they’ll beat up their wives,” adds Pérez.

Jiménez compares it to the situation several several centuries ago when the stigma of suicide meant families couldn’t bury their loved ones in a graveyard; or when they tortured the corpses of people who had committed suicide to serve as an example. “People who commit suicide are viewed as mad and beyond help. That’s how society appears to think,” he says, suggesting that the stigma has simply morphed into silence.

Big data to curb suicide rates

While there is no national policy on preventing and detecting suicide, there have been research initiatives in the last few years that are designed to enable the early detection of high-risk behavior. At Alicante University, for example, they are developing a tool to trace suicidal messages on Internet that will target adolescents – the highest risk group.

Another example of how big data can help with the early detection of suicides is HIKARI, a tool being developed in Spain by Madrid’s Hospital Clínico San Carlos together with Fujitsu. The tool’s creators hope to help healthcare professionals detect suicidal symptoms in their patients by using their health records.

 Spain’s autonomous regions are responsible for developing their own suicide detection and prevention methods

“The idea is to find a way of studying health data to help us understand mental health problems better,” says Julio Mayol, Director of Hospital Clínico San Carlos while the hospital’s head of psychiatry, Blanca Reneses, explains the research tool’s results will be made available to the public.

“To be able to predict and prevent, we need accurate statistics,” says Reneses, noting that most people who have committed suicide have previously been patients of the healthcare system and that the key is to detect who is at risk even when they have not expressed an explicit intention to take their own lives.

In the future, HIKARI will also be able to incorporate information leading to the detection of different factors influencing a potential suicide victim, with results available to the general public in the next few months. “We are still looking at whether, from reading certain information about a patient’s diagnosis and behavior, the machine is as reliable as a doctor,” says Mayol. “And right now it seems that artificial intelligence is pretty reliable.”

English version by Heather Galloway.