Suicide remains a serious public health problem both globally and in South Africa. There are more than 700,000 suicides annually worldwide. World Suicide Prevention Day on 10 September provides an opportunity to think again about what public health measures are needed to reduce suicide rates in South Africa.   

People engage in suicidal behaviour for a range of different reasons and with a range of different motives and intentions, including the desire to escape intolerable emotional or physical pain and feelings of isolation, hopelessness, or perceptions of being a burden on others.  

Feeling trapped in an intolerable situation with little hope or expectation of receiving help can be another driver of suicidal behaviour. Self-destructive thoughts and impulses can also be triggered by experiences of thwarted belonging and being ostracised or feeling disconnected from oneself and others.

Although often overlooked in suicide prevention, alcohol use is an important but potentially modifiable risk factor for suicide and self-harm. One meta-analysis showed that there is an almost seven-fold increase in risk of non-fatal suicidal behaviour following any acute alcohol use compared to those who did not drink alcohol, while after heavy alcohol use the risk is approximately 37 times greater.

Some studies suggest that on average 37% of people dying by suicide have alcohol in their bloodstream at the time of death. A recent large study in Sweden found that having an alcohol use disorder significantly increases the risk of suicide even after accounting for other factors like serious mental illness.

Read more in Daily Maverick: Suicide nation: We are humans, not numbers

Suicide and alcohol abuse links

There are various ways in which alcohol use can increase the risk of suicide. For example, alcohol-use disorders can precipitate or aggravate symptoms of depression which in turn leads to feelings of hopelessness, isolation, and social withdrawal, thus increasing the risk of suicide. Alcohol-use disorders also lead to economic problems such as unemployment and disrupt interpersonal relationships which contributes to isolation, disconnection, and marginalisation, all of which are strongly associated with suicide.

Chronic and acute alcohol abuse use leads to impairments in cognitive functioning, such as problem-solving difficulties, impaired judgement and decision-making, disinhibition, and impulsivity, all of which increase the likelihood of suicidal behaviour when one is facing an emotional crisis.

Restricting access to and consumption of alcohol while increasing access to effective treatments for alcohol use disorders could be very effective suicide-prevention strategies. It is not easy to prove that restricting access to alcohol leads directly to reductions in suicide rates at a population level, partly because it is methodologically challenging to set up the kinds of experiments that would be needed to prove a causal relationship.

Nonetheless, there is indirect evidence that strongly suggests that public health measures to reduce alcohol consumption will lead to a decline in suicides.

For example, there is consistent evidence that youth suicide rates declined significantly when the minimum drinking age was raised from 18 to 21 across all states in the USA in the late 1970s and early 1980s. Conversely, in Canada, there was a significant increase in hospital admissions for injuries related to suicidal behaviour among young adults when the minimum drinking age was lowered.

Researchers who assessed the effect of Russian alcohol policies implemented in January 2006 found that regulatory changes aimed at controlling the volume and quality of alcohol products and sales resulted in a 9% reduction in suicides among men, but had no effects on suicide rates among women.

SA turns a blind eye

There are well-established public health strategies to reduce alcohol consumption at a population level, including raising the legal drinking age, banning alcohol advertising and marketing, increasing alcohol prices through minimum unit pricing legislation and taxes, restricting physical availability by limiting the density of alcohol outlets and curtailing trading hours, and zero-tolerance drink-driving laws. 

But the government in South Africa has dragged its heels in using these approaches to curtail alcohol consumption, preferring instead to leave it to the alcohol industry to regulate itself and relying on substance abuse awareness programmes like Ke-Moja. The lack of political will to tightly regulate alcohol, not only in South Africa but also worldwide, is partly due to public pressure and alcohol consumers’ desire to maintain the status quo, but especially due to the influence of powerful alcohol industry interests.

Of course, tackling alcohol consumption is not the only way to reduce suicide rates. We should also ensure greater access to effective and affordable treatments for mental health problems, increase economic prosperity and employment opportunities, build safer communities and create opportunities for people to find meaningful connections and a sense of belonging.

Nonetheless, it makes sense to prioritise reducing hazardous alcohol use as part of an integrated multi-level suicide prevention strategy in South Africa. First, there is convincing evidence that alcohol use is causally associated with suicidal behaviour.

Second, we have well-established effective strategies to reduce alcohol consumption so we know what needs to be done.

Third, reducing alcohol consumption will have other far-reaching public health consequences, including a reduction in non-communicable diseases and non-natural deaths and injuries.

Suicide is preventable and help is available. Anyone who is experiencing suicidal thoughts should talk to someone they trust, consult their doctor, or make contact with one of the 24-hour support lines, such as the South African Depression and Anxiety Group (0800 567 567) or LifeLine (0861-322-322). Reach out, ask for help, stay connected. DM

Prof Jason Bantjes is a Chief Specialist Scientist in the Mental Health, Alcohol, Substance use and Tobacco Research Unit at the South African Medical Research Council (SAMRC), a registered psychologist, and an honorary Professor in the Department of Psychiatry and Mental Health at the University of Cape Town (UCT).

Prof Charles Parry is the Director of the Mental Health, Alcohol, Substance use and Tobacco Research Unit at the SAMRC, a registered psychologist, and an Extraordinary Professor in the Department of Psychiatry at Stellenbosch University (SU).

Prof Mort SilvermanA is an Adjunct Assistant Professor of Psychiatry, Department of Psychiatry and Behavioural Sciences, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA and former Editor-in-Chief of “Suicide and Life-Threatening Behavior” (the scientific journal of the American Association of Suicidology).

The views expressed here do not necessarily reflect those of the SAMRC, UCT or SU.