Despite three reports on suicide this week, we don't know why 444 people took their own life last year. Shane Hegarty reports
Lucy lost her father and her boyfriend, William, to suicide. "I was young when my father died, and while I knew the word 'suicide', I didn't understand what it was to feel such feelings of despair that could lead to suicide, so I had a very protracted grief. I was consumed with the idea that my daddy would never be coming home, but the philosophical questions about why came only later in my life.
"I hate simple reasons for why. It is like a fingerprint, each suicide is so unique. Every circumstance is different, the things in a life leading to that point are different. I saw that when William died; he and my father didn't die for the same reason. William's death had a more immediate and profound effect on my life. I understood the full weight of suicide straight away. From the first second, the questioning began, a craving for meaning, why this beautiful human being had not only gone but had chosen to leave."
Ciara O'Connor of the Bereaved by Suicide Foundation (Console), says: "It is so difficult to even try and come up with an answer, especially when the one thing on everyone's lips is always 'why, why, why'. All the academic studies and statistics are fine, but they can't articulate what people are feeling when they choose to die."
This week alone there were three reports on suicide, introducing new statistics and asking how we might solve this modern tragedy. The figures are stark. There were 444 deaths by suicide in the State in 2003. It accounts for 30 per cent of deaths among 15- to 24-year-olds. There were 10,000 cases of self-harm seen at Irish hospitals last year and 9 per cent of young people say they have engaged in self-harming behaviour. While our overall suicide rate is not among the highest in the EU, we have one of the worst rates among young men.
Yet, for all the available information, much remains unknown. Because suicide affects many sections of society, devising a coherent strategy is difficult. The nature of the problem makes scientific study difficult, so research remains patchy. And while the overall suicide rate in Ireland has declined marginally over the last two years, and is down from the 514 suicides in 1998, no one knows whether this is part of a trend, or just a blip.
The Youth Suicide Prevention report, published this week by the Institute of Public Health in Ireland and the Health Development Agency in Northern Ireland, emphasises these problems. A review of international research, it concludes that risk factors can include family conflict; exposure to violence; a family history of suicide; social class; substance misuse; same-sex orientation; mental illness; and having the means to carry out a suicide. There is even some evidence, much of it anecdotal, suggesting that suicide is "contagious".
Lucy recalls that after William died she wrote a poem, in which she said he "had given me all he no longer wanted. All his agony and despair. The most awful part was that he wanted to go. That's the crux of it and why it is so different to any other bereavement."
She felt guilty for not recognising the signs. "I felt like I'd blood on my hands, that it was down to me."
But as she grieved, Lucy says, she finally reached a point at which she knew there would be no simple answer and that she knew then that she could "live with the questions".
"No one can be responsible for knowing the inner world of a person, no matter how hard they try." She says now she lives life "for three people. When you have the strength to get through it, it doesn't leave you. It makes you a stronger person".
The Youth Suicide Prevention report finds much of the research on prevention is weak or inconclusive, but among its recommendations are: intervention in the general circumstances of young people's lives; targeting at-risk groups; education and coping skills training; and helping young people over several years of their lives.
A report on self-harm was launched at the National Symposium on Young People's Mental Health in Cork on Thursday. Among those attending was Geoff Day, chairman of the National Suicide Review Group (NSRG), jointly established by the health boards in 1998. He says, "We often perceive young people from an adult position, so it's very useful to see the report and to listen to young people talking about what might be done."
The report, he says, builds a picture of a "hidden group" who harm themselves, usually in secret. And while most young people are happy with their lives, a significant minority exhibit worrying behaviours that need to be picked up on. "A lot don't report to hospitals, so it's a challenge to find ways to get to these people." Day points to the example of the North-Eastern Health Board, of which he is assistant chief executive. It employs psychiatric nurses at hospitals in Drogheda and Dundalk to follow up on the discharge of people who had arrived in hospital with self-inflicted injury. This approach, he says, has led to a reduction in the rates of those repeating the self-harm. Given that about half of those who die by suicide had made a previous attempt, it is a promising approach.
Most Irish policy on suicide stems from a 1998 report by the National Task Force on Suicide and, according to the Government, €17.5m has been spent on prevention programmes since then. The NSRG's 2004 report says there is a balance between general strategies in education and health promotion, and intervention among high-risk groups. "There is no one formula to get the rate down," adds Day.
A reluctance to talk about the problem makes school programmes difficult because of a fear that mentioning suicide makes young people aware of it, although Day emphasises that there is no evidence that talking about suicide leads to suicide.
Meanwhile, we may not even know the true statistics. The suicide review group is trawling two years of Garda reports, which often list suicide as cause of death even if a coroner later dismisses that for lack of evidence. There is also the feeling that the number of deaths among elderly people may be under-reported; that GPs may list an accidental overdose as responsible for death when it may have been deliberate.
It is not just an Irish problem. Every 40 seconds a person takes their own life somewhere in the world. In Canada, this week, a national strategy was launched to stem the 4,000-a-year suicide rate. It involves targeting vulnerable groups and doing follow-up checks on high-risk patients, as well as making specific recommendations regarding medication containers and carbon monoxide lock-off mechanisms in cars.
Next month, a conference run by suicide action group 3Ts will bring international experts together. According to Prof Kevin Malone, scientific director of 3Ts, "there are 3.5 million opinions, but almost no data on why suicide occurs in Ireland. We still have an enormous amount to learn, and it shouldn't take us 20 years. It didn't take the Celtic tiger 20 years to grow, and if it [ suicide] is an offshoot of success we must put the services in place to deal with it." He points to the Gotland study as a rare example of a controlled study. When GPs on the Swedish island of Gotland were given intensive training, there was an immediate fall in the overall suicide rate, although the male rate proved stubborn. Men, as Irish studies have confirmed, are less likely than women to visit a GP when depressed.
Other successful strategies include that undertaken in Finland, which has seen a decline in young male suicides since introducing a prevention programme in the 1980s.
Prof Malone also recommends interviewing people recognised as acutely suicidal, carrying out what he calls a "psychological autopsy" on why they reached that point. "We know the list of at-risk groups and we should focus our energy on them. We are still talking from a point of relative ignorance. We are still dealing with anecdotes and not the full picture," he says. "We need to travel upand down the country interviewing all those who have been affected and to get a clear picture. That will enable us to have a programme that is much better informed."
Ciara O'Connor also suggests this radical approach. "If the Government set up a forum and talked to all those who have attempted suicide and those bereaved by suicide, that is how we could learn. The cold numbers and statistics might lead to a psychological understanding of what is behind mental health problems, but it is no solace to those grieving. [The Government] needs to listen to people, and by piecing all these things together, that is how they will find out how to tackle it." She says suicide has to stop being a "dirty word" and that talking openly about the problem is key. "It doesn't matter whether we talk about it or not, suicide has been around for millennia. Some schools don't want to talk about it because they fear it will be mistaken for encouragement."
Meanwhile, she says, some GPs hand out anti-depressants hand over fist. "We need to educate people that there is so much help out there. That it's OK to be depressed and it's OK to talk about it. Often, they just don't know where to go." The Bereaved by Suicide Foundation is run by people bereaved by suicide and O'Connor says her work has taught her one valuable lesson which applies both to survivors and to those feeling suicidal. "It's important to stress that there is always hope."
• Bereaved by Suicide Foundation (Console) helpline: 1800-201-890 Samaritans: 1850-609090
• For information on the 3Ts conference, Suicide in Modern Ireland: New Dimensions, New Responses, Tel: 01-6703666
Some names have been changed