The Malta Independent 13 November 2019, Wednesday

Suicide: ‘Game changing strategies’ and ‘World first’ Maltese treatment – Part 1

Sunday, 16 June 2019, 10:39 Last update: about 6 months ago

Mark Xuereb

Unfortunately, and contrary to popular belief, when spring morphs into summer and most people are looking forward to fun and holidays, others are thinking about suicide. This is part of an ongoing intervention campaign that Crisis Resolution Malta (CRM) is publishing on social media.

It is a known fact that, statistically, people who are suffering from either depression – or depression in the context of Bipolar Disorder – are at an increased risk of self-harm and suicide during the change of season. We don’t know exactly why this happens but we think that ,as many start to go out more, wear brightly coloured clothes, plan their holidays, have fun in the sun, go to parties etc., etc., others – who are depressed – harbour distorted negative automatic thoughts that are triggered: e.g. “I can never manage to enjoy myself” or “I’m not good enough” or “I’ll never get out of this.”


This thought process in turn triggers core beliefs, such as: “I’m useless… hopeless…I can never be treated…my problems are insurmountable…I’m a burden to others… therefore I deserve to die”.

Another theory relates to the length of day and night. We know that melatonin in the brain controls the day/night cycles but it also has an impact on moods. As the summer days get longer, this fluctuation in melatonin may adversely affect mood and precipitate suicidal behaviour.

Suicide is the second leading cause of death among 15 to 29-year-olds worldwide; 79 per cent of global suicides occur in low and middle income countries. Every year, 800,000 people commit suicide in the world: one every 40 seconds. For every one person, there are another 20 people trying, and for each of these people who commit suicide or are trying to, there are six loved ones who are influenced in some way or other for life. In Malta, CRM research has shown that there are 1,000 Maltese and Gozitans who think about suicide annually.

Recently, the Malta Mental Health Commission produced excellent research about admissions related to suicide and completed suicide. These people and their loved ones go through a lot of suffering but we must not forget to redress the balance and carry out research by looking into self-harm and suicidal behaviour in the community. These people – who constitute the majority of those 1000 people per year –  also suffer a great deal.

So how are we going to address these issues? First of all, it is important to get the demographics right. We need more local prevalence studies which tell us who is at risk, what age groups are involved, their gender, where they’re located, how they do it and why, etc. But we now need to have that research carried out in the community and not just extrapolated from foreign research.

With this in mind, we are pioneering a national suicide and self-harm standardised database to collect statistical data and demographics on all those who self-harm and commit suicide in the Maltese Islands. This data will then be collated into an annual self-harm and suicide report for Malta and Gozo in keeping with a National Self-harm and Suicide Prevention Strategy. There is a draft strategy which I prepared upon recommendation by fellow psychiatrist head (Dr Anton Grech) and the then CEO of Mount Carmel Hospital (Dr Clifton Grima).

This annual report will not be inventing the wheel, as this is what is done annually in other countries – including England and Wales. World suicidology expert and Oxford University Professor Keith Hawton has been collecting this data for over 25 years. These reports will give Malta and Gozo a roadmap in order to continually monitor, fine tune and, if necessary, improve the services. This tailor-made, dynamic action plan will fit in the context of a broader National Mental Health Strategy, which will also help us compare our data to foreign research and learn from each other.

However, we need to move beyond mere theory. It is not enough to have demographic or prevalence studies. We now have to shift and focus on interventional studies. To date, there has been no acute effective treatment for this preventable tragedy. Medication takes between two and four weeks to work, therapy likewise. ECT takes one to two weeks to work. These standard treatments carry potential side-effects such as anaesthesia, liver problems, weight gain, memory problems, sexual dysfunction and constipation, among others. So we really are lacking in terms of interventional studies to treat suicide rapidly and effectively.

Today we are humbled by the fact that we have a ‘made-in-Malta’ breakthrough to treat suicidal behaviour acutely using theta burst transcranial magnetic stimulation (ΘTMS). The Neuromodulation Clinic based at the Da Vinci Hospital, in Birkirkara has been working quietly behind the scenes for the past two years on a pilot interventional study. Our study reduced suicidal behaviour by up to 56 per cent within 24-72 hours.

What is ΘTMS? Our brain produces naturally occurring waves, including Θ waves, which denote the electromagnetic activity in the brain. Their presence is an indicator of insight, creativity, focus and inspiration, among others. For the physics minded, you know that where there is a conductor with a current, there is a naturally occurring magnetic field around it. Our brain has neurons that are current-carrying wires. These neurones therefore bear a measurable electric and magnetic field around them (of the order of 10-5 Tesla, the latter being the unit of magnetic field strength), which include theta waves.

ΘTMS uses an ingenious principle, called electromagnetic induction, discovered by Michael Faraday in London in 1831. Farady’s principle involves applying a pre-set changing magnetic field to a wire to induce an electromotive force or current in the conductor (in our case, the neurone). An external magnet is applied to produce theta waves close to certain parts of the brain that are known to be the brain’s portal to mood and suicidal thinking. In so doing, this harmless, non-invasive and safe treatment induces the nerves deep within the brain to regrow and reconnect by a principle known as neuroplasticity.

Healthy brain functioning requires principally three things: 1. healthy neurotransmitters (chemicals) in the right amount; 2. healthy nerves and 3. healthy contacts (a.k.a. synapses). If any of those are imbalanced then the brain cannot function optimally. It is pointless having the right chemicals if we have a damaged or disconnected nerve. An unhealthy nerve does not have the right current or electromagnetic field.

The novelty of ΘTMS lies in the fact that we can now make people better after just a nine-minute treatment, which takes place daily for three days. People walk in, do ΘTMS and walk out to carry on with their day. They feel better within hours and we know this by carrying out our mental state examinations and questionnaires.


Anybody who is unwell, please reach out to Crisis Resolution Malta (Facebook): we are here to help 24/7. Call 9933 9966 or email [email protected]


Dr Xuereb is a UK trained Crisis Psychiatrist who has run Crisis Teams for the past 10 years. Part 2 will be published next Sunday


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