I’m of a mind to be a little controversial today. We’re all keen to stop people killing themselves – especially young people. We’re told therefore that we need to enhance mental health services for the youth, and hence the “Headspace” initiative in Australia, which gets bags of money and flash premises and great press…
And I’m betting will do 3/5 of sod-all for suicide rates.
Why do I say that? Mostly because I’m a grumping curmudgeon I suspect, but also because psychiatric illness (which surely is what mental health services deal with?? 
) is not the determinant of suicide rates.
“Whaaaaaaaat?” you say. “Butbutbutbut …” you might exclaim. You might mention the increased suicide rate in many psychiatric illnesses. True. You might make reference to studies of suicide/attempted suicide showing an increased rate of psychiatric illness. Also true enough. The thing is, that’s looking at individual cases, not at the overall suicide rate. The suicide rate varies with social factors (as discussed first (?) by Emile Durkheim), not with changes in psychiatric treatment (for example there was no appreciable change with the introduction of antipsychotics or antidepressants in the early 1950s, for example:
That’s from a 1963 paper by MacMahon, Johnson, and Pugh. Why so old? Because it breaks down the age bands, and covers the years of interest: The Great Depression, World War II, and the introduction of antidepressants and antipsychotics.
Here’s some Antipodean data, from the New Zealand Ministry of Health:
As you can see, there was no change in the suicide rates when we started actually treating psychiatric illness. The determinants of the overall suicide rate are social: economic, wars, social cohesion and so forth. From these graphs it is fairly apparent that men (who do drive the changes in the suicide rate, as the female suicide rate is pretty static, as you can see from the NZ data) were killing themselves more leading into and through the Great Depression (economic depression, not psychiatric, mind you 
), and then less so as World War II started brewing and then began. There was no further drop with the introduction of antidepressants. The suicide rate rises again as we move into the materialist 80s: money-driven, lacking social cohesion, rising unemployment – these are the things that would appear to be related.
To borrow a phrase from a supervisor of mine in my early days as a registrar: it’s about which end of the telescope you’re looking down. For an individual, the presence of psychiatric illness is very relevant to their risk of suicide. And indeed it is the only thing that we as psychiatrists can really have any impact on – and we do our utmost to do so. The other end of the telescope is the overall suicide rates, and they do not appear to be influenced by psychiatric illness or treatment to any significant degree. Rather social and economic change is what is needed to affect the overall rate of suicide.
And therein lies the rub. A politician who makes the sort of changes needed there would likely be “accused” of being a “socialist”, and would be pretty much destroyed by big business interests, and the people who do well out of our current materialistic society. It would also be very hard, and slow – taking much longer, I would think, than the few years a political party would remain in government. On the other hand, if they stand up proudly and talk about the millions of dollars they will put into “youth mental health” and “suicide prevention” … which means more money and bright shiny buildings for Headspace, they appear to be doing something, and everyone will say “gosh wow that’s a politician who cares”.
Of course this is a double fail in actual fact. Not only is better treatment of psychiatric illness (while a good thing, don’t get me wrong) unlikely to make a substantive dent in the overall suicide rate, the bright shiny boutique services like Headspace won’t have much of an impact on the individual risks either. Why do I say that? Because I work in the general adult acute service, and whenever the ‘S’ word is mentioned to someone working in one of these other services, they send the patient straight to us … to the busiest and most under-resourced part of the service (who don’t look to be getting any pot of money or other resources any time soon). So the new shiny well-resourced service deals with the less sick, and the most sick and at-risk come to the underfunded general service.
Conclusion:
So what would I like you to take away from this little whinge? A couple of things: firstly, that while psychiatric illness is indeed a risk factor for suicide in individuals, the overall rate of suicide in a population appears to be influenced much more by social and economic factors than by psychiatric illness or treatment; and secondly, that focus on better mental health services for special populations while neglecting the core services is not a helpful strategy, as it effectively reduces the amount and quality of care available to the sickest people.
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