Suicide and self-harm behaviour highlights the importance of having a fully functional crisis team. These teams ensure that in that critical period, in those 2-3 weeks where people are still vulnerable, the crisis team can take care of and support the person in the community. Again, once we have better local demographic community data, then we can fine tune our services.

Locally, the oldest and longest standing sole 24/7 crisis team is Crisis Resolution Malta (CRM), which also does philanthropic work. It is a multidisciplinary team made up of psychiatrists, psychotherapists, doctors, lawyers, spiritual leaders, social workers, psychiatric nurses, and even people in the community. We now have a pilot project going on, where we’ve just finished training Qawra parish volunteers in risk management. These lay people will be our eyes and ears in the community i.e. they will be our crisis team in that catchment area bearing our support and supervision.

Malta needs to go beyond an emergency service to a fully-fledged national crisis team. It needs to be based at MDH, with sentinels and professionals overlooking major sectors - polyclinics, parishes, groups, offices, clubs etc. The idea is that everybody becomes a crisis team member to know who to refer and where to refer.

Ultimately what we aspire to is to stop suicide which is a preventable tragedy. It is also the mother of all stigmas in mental health. We can prevent it and we must prevent it as it leaves a transgenerational legacy of pain and suffering where the loved ones of the person are themselves at risk of suicide, mental health issues and social marginalization.

This can be achieved by awareness and outreach campaigns and activating the National Suicide Prevention Strategy which incorporates crisis teams.

In keeping with the strategy, there has also been another major breakthrough to nationalise the suicide crisis line. At the moment we are in discussions with the President of Malta, who, being a doctor himself has had to deal with the pain pertaining to suicides.

He has shown constant support and is very keen to nationalise this crisis line in collaboration with authorities and stakeholders such as Psychiatrist John Mifsud and Mental Health Commissioner Dr. John Cachia. We will also be inviting all stakeholders to contribute towards this, to specialise our service and help those in need in the quickest, and most efficient and evidence-based way possible. CRM is furthermore collaborating with the Samaritans and the Befrienders UK which are international organisations who train staff manning crisis lines.

At present, CRM – which has its own 24/7 crisis line - collaborates with and receives referrals from other entities like the formidable Kellimni.com, Appogg, Victim Support, the Police, Richmond Foundation and others who do a lot of good work. Presently Malta doesn’t have a sufficiently known and dedicated national suicide crisis line that specialises in suicidal and self-harm behaviour. We plan to address this in the near future. Having fixed crisis telephone booths at suicide hotspots as well as a crisis centre is also on the cards.

Why is it important to nip mental health issues in the bud? A paper in the British Journal of Psychiatry, 2018, speaks about the correlation between declining academic performance and increased suicidal behaviour in early adulthood (Rahman et al). Likewise, Huang, in the same journal, speaks about ADHD associated with increased suicide attempts and self-harm. Wilkinson (also in the same journal), speaks about recurrent self-harm which doesn’t lead to suicide, before the age of 14, which is associated with future depression and eating disorders. This all shows, the importance of early detection for suicide prevention, as endorsed by WHO.

Let us not forget that the biggest predictor of suicide is a history of self-harm; let us not forget that if I self-harm once, I am 100 times more likely than the general population to commit suicide.

Let us not forget that if I commit suicide, my loved ones have a 60% chance of dropping out of education, which again is a risk factor for self-harm, and an 80% chance of losing their job. The latter also have an increased chance of mental health problems and suicide.

Another article, by Pitmann, in the same journal mentioned above, underlines the importance of policy and a national suicide prevention strategy. An article in the British Journal of Psychiatry, April 2019, speaks about self-harm in older adults - it says that this is associated with being lonely, loss of control, feeling they’re a burden on others and also physical burdens like pain (Troya et.al.).

A study by Lorant, British Journal of Psychiatry, April 2018, shows that those with the lowest educational group and those in lowest socioeconomic groups, are at increased risk of suicide. Let’s not forget that healthcare professionals need support due to pressure of work as do bankers and other professionals. They too are at risk of adopting a ‘stoic and martyrdom’ attitude succumbing to isolation and suicide as discussed in the Psychiatric Bulletin (Gerada,2018).

Another study done by Lombardo in April 2019, in the Psychiatric Bulletin, speaks about clinical decision making in Crisis Resolution and Home Treatment Teams. We need to have a fully functional crisis team that resolves and provides home treatment. Factors which need to be tackled by the crisis team include: consent by patient and significant others and professionals, the diagnosis, the cause of the crisis, whether there are protective or risk factors and the experience of the patient in previous interactions in mental health, among others.

There is an editorial in the Psychiatric Bulletin, April 2018, by Stallman, who speaks about how if you do a Google Scholar search for help-seeking and mental health, you will get over 2 million hits. This reflects the wish for people to reach out. This is not surprising as there has been a lot of effort to raise awareness in the past decade.

But we need to move from awareness to action. A suicide crisis line and an adequately resourced national crisis team are two sure concrete ways to decrease self-harm and suicidal behaviour locally.

This is where the cure starts.

There are studies to show that clinicians who are exposed to suicidal cases may feel anxious and intimidated, that they are not properly trained and that if the person does commit suicide then they will get the blame or lose their job. For this we have in mind a Crisis Management Course, spearheaded by CRM, and ongoing training by international bodies.

We need to have a paradigm shift, which shifts from a sole diagnostic approach to a present-needs approach i.e. what are the person’s needs right now? A needs assessment would determine whether the person has 1. low needs (can cope independently after talking about the problem), 2. moderate needs (needs additional professional support such as crisis teams, psychologists etc.), or 3. high needs (more intensive supervised support or hospitalisation). The person can be helped through caring (listening), collaborating (identifying existing coping strategies and reinforcing them) and connecting (with higher intensity support like crisis teams).

In the Psychiatric Bulletin, August 2013, a study by Lloyd-Evans states that more people are using crisis teams in the UK. The researchers claim that such teams are understaffed and that there is lots of variability in how they work, but the bottom line is that they contribute positively to preventing worsening ill health.

They help people in crisis and though they may not always decrease the admissions, they do have a benefit for those who are vulnerable. The study concludes that there is a need for action from policy makers to ensure appropriate services are provided to the vulnerable in times of crisis.

In summary there are many ways we can prevent suicide - by having media campaigns, adopting and promoting healthy lifestyles, preventing access to suicide means, having a suicide crisis line and by seeking novel treatments to curb suicidal thinking and behaviour in the context of a national suicide prevention strategy.

 

 

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 1 was published last Sunday