Year : 2021 | Volume
: 19 | Issue : 2 | Page : 145--148
Displaced, Dispossessed and Silenced: The Need for Suicide Prevention and Response for Conflict-affected Populations
Wendy Ager1, Rabih El Chammay2, Johanna Lechner3, Peter Ventevogel4, Lakshmi Vijayakumar5,
1 Editor in Chief, Intervention Journal, Amsterdam, The Netherlands
2 Psychiatrist, Psychiatry Department, Saint Joseph University Beirut, and Head of the National Mental Health Programme, Ministry of Health, Lebanon
3 Advisor GIZ Regional Program Psychosocial Support for Syrian and Iraqi Refugees and IDPs, GIZ, Amman, Jordan
4 Senior Mental Health and Psychosocial Support Officer, UNHCR, Geneva, Switzerland
5 Founder SNEHA and Head of Department of Psychiatry, VHS Chennai, Chennai, Tamil Nadu, India
MSc Wendy Ager
Intervention Journal, Nienoord 5-13, 1112XE Diemen
|How to cite this article:|
Ager W, El Chammay R, Lechner J, Ventevogel P, Vijayakumar L. Displaced, Dispossessed and Silenced: The Need for Suicide Prevention and Response for Conflict-affected Populations.Intervention 2021;19:145-148
|How to cite this URL:|
Ager W, El Chammay R, Lechner J, Ventevogel P, Vijayakumar L. Displaced, Dispossessed and Silenced: The Need for Suicide Prevention and Response for Conflict-affected Populations. Intervention [serial online] 2021 [cited 2022 Jan 17 ];19:145-148
Available from: https://www.interventionjournal.org/text.asp?2021/19/2/145/325801
Welcome to the second issue of Intervention for 2021. We are joining many people around the world in marking World Suicide Prevention Day by focussing a special section in this issue on suicide prevention and response.
We are also featuring a range of other articles. The first is a thought-provoking commentary by Cherepanov (pp. 149-154) concerning mental health interventions in complex political contexts. The second by Bunn et al. (see pp. 155-179) is an umbrella review of the evidence about supporting nonspecialists in delivering mental health interventions. The third by Akbay-Safi et al. (see pp. 180-186) describes the experiences of the INSAN Psychosocial Support Centre in implementing Problem Management Plus in training survivors of gender-based violence in Turkey in the face of the coronavirus disease 2019 (COVID-19) pandemic. We would welcome responses to all the issues raised in these articles.
The Special Section on Suicide Prevention and Response
Globally, suicide is a serious public health issue: close to 700,000 people die by suicide every year. For every suicide, there are many more who attempt suicide. In fact, suicide is one of the leading causes of death in the world, and every year more people die due to suicide than to malaria, HIV/AIDS, breast cancer or war/homicide. The World Health Organization (WHO) estimates that in 2019 more than one in every 100 deaths (1.3%) resulted from suicide (World Health Organization, 2021b). While overall the age-standardised suicide rate has decreased somewhat over the last decades, this is not observed in all countries. Among some groups, it is clearly increasing. For example, within white working class men in the United States, deaths of despair from suicide and abuse of alcohol and drug overdose have risen dramatically (Case & Deaton, 2020). Economic shocks in a country can make people desperate and increase mental illness such as depression and anxiety. The effects of the COVID lockdowns and related measures have severe impacts on people dependent on work in the informal economy and who cannot easily fall back on stable socioeconomic networks. As such, the measures meant to stop the spread of COVID-19 and to protect all have “shifted epidemic risk to the underprivileged” (Marmot, 2020). What this means for people affected by armed conflict including refugees is as yet unclear, but it is crucial to give more attention to suicide in these populations.
Suicide Among Refugee and Other Conflict-affected Populations
Data around suicidality among asylum seekers and refugees are sparse and at times inconclusive. Most of this evidence has been collected in high-income countries, with very little data available from low- and middle-income countries, which host 85% of the global refugee population. Refugees have increased risk factors for suicide including gender-based violence, torture, loss of loved ones, family separation, social isolation and poverty. Of particular concern are refugee children who have been exposed to violence. There is strong evidence that exposure to violence in childhood increases the risk of suicide later in life. The association between mental disorders and suicide is well documented. In general, the prevalence of mental health issues among refugees and other people affected by armed conflict and forced displacement is clearly increased compared to nonaffected populations (Blackmore et al., 2020; Charlson et al., 2019). Whether the suicide rates are also higher among refugees when compared with the general population is not completely clear. Several studies found high to very high levels of suicidal behaviour among refugees, ranging from 3.4% to 34% (Vijayakumar et al., 2021). However, refugees in Sweden had a lower risk of suicide than Swedish born, particularly for those who had arrived more recently. After several decades in Sweden, their suicide risk was like that of the Swedish-born population. Being a refugee in itself was not an additional risk factor for suicide (Hollander et al., 2020) except for asylum-seeking, unaccompanied, refugee minors, who had much higher risk compared to that of Swedish youth (Geirsdottir et al., 2021; Mittendorfer-Rutz et al., 2019). However, these data were collected from refugees who had been granted residence permits and did not have to fear for being sent back. Indeed, reports relating to suicide attempts in asylum seekers show a more complex picture. In The Netherlands, male asylum seekers had increased risk for death by suicide and asylum seekers from the Middle East and South-West Asia had a higher incidence of hospital-treated suicidal behaviour (Goosen et al., 2011). It has been well documented that long stays under adverse conditions in closed camps for asylum seekers are linked to increased risks for mental health crises including self-harm and suicide attempts (Sundram and Ventevogel, 2017; van de Wiel et al., 2021). Asylum processes are often lengthy and go with high levels of uncertainty. People who went through these processes often describe that they felt humiliated and dehumanized (Red Cross UK, 2021). Deteriorating economic circumstances and increasingly restrictive asylum procedures give ample reason to expect that in the wake of the pandemic suicide rates in asylum seekers/refugees will further increase (Mittendorfer-Rutz et al., 2020).
Specific Challenges in the Context of the Middle East
Breaking the silence and shifting awareness towards the efficacy and importance of suicide prevention are particularly challenging in contexts where religious, cultural and societal norms significantly shape the public consciousness. In the predominantly Muslim countries of the Middle East, and especially in those categorising suicide as a “criminal act”, stigma often translates into poor suicide surveillance systems, misreporting, underreporting and high barriers to accessing help (Eskin et al., 2019; Pritchard et al., 2020; Rezaeian & Khan, 2020; Zolezzi et al., 2018). Underreporting of suicide rates is of course not confined to the Middle East, but constitutes a major challenge in other regions of the world as well including in south-east Asia (Vijayakumar et al., 2020).
Regardless of reported rates, it is time that humanitarian activists, national decision-makers and donors acknowledge that risk factors for suicide are ubiquitous in the Middle East and take joint action to close the gap in service provision. Decades of armed conflicts have taken a heavy toll on the region’s economic and political situation and have forced millions of people into displacement. The public health crisis prompted by the COVID-19 pandemic has further exacerbated factors contributing to a sense of entrapment, such as unemployment, a lack of perspective, insufficient health care, (family) conflicts and experiences of rejection, separation, fear and grief. Several countries in the Middle East, including Lebanon, Palestine and Iraq, have recently adopted a national strategy for suicide prevention. Celebrating this crucial step forward, we are grateful for the submissions describing these positive developments in the region and elsewhere.
Introducing the Articles in the Special Section
We received a strong response to the call for articles for this special section and after reviewing all the submissions, we selected the 11 articles that are featured here. In a field where to speak the unspeakable is very challenging, we do hope that these articles will encourage more dialogue and build confidence among frontline staff, policymakers and the affected population that action is possible.
There are four articles on suicide prevention and response. Burgess et al. (pp. 187-196) present a preliminary theoretical framework for understanding suicide risk amongst LGBTQI refugees and asylum seekers and also provide some practice implications to support their needs. Zeinoun et al. (pp. 197-207) present an evaluation of Lebanon’s national helpline for emotional support and suicide prevention, focussing particularly on reduction of emotional distress among callers. As well as capturing the existing literature in this area, the article offers an example of a well-executed study with valuable findings for the field. Jabr and Helbich (pp. 208-214) describe the process of evolving a national plan in suicide prevention in Palestine. They report on suicide and suicide behaviour drawing on the wider literature in the region because of limited data being available for Palestine itself. Finally in this section, we have an article by Leiler et al. (pp. 215-223). This study aimed to assess both prevalence and factors associated with suicidal ideation among newly arrived refugees in Sweden. Symptoms of depression, anxiety and posttraumatic stress disorder, low physical and psychological quality of life, and being of young age were all independently associated with suicidal ideation.
There are five field reports. Mukasa and Snider (pp. 224-232) in their field report on South Sudanese refugees in the Moyo/Obongi Palorinya settlements in northern Uganda illustrate the many interlocking factors contributing to suicidal ideation, attempted and completed suicide among this population group. In their findings, they describe how war stressors (experiencing and witnessing violent acts), daily stressors, social fragmentation, normalised violence, social isolation, lack of economic opportunities, loss of assets and loss of confidence and hope contribute to escalating suicidality. Interestingly, the field report also refers to the psychosocial and economic impact of a reduction in funding for mental health and psychosocial support (MHPSS) programming, indicating the need for long-term funding to consolidate programme effects and respond to realities on the ground. In one of only two articles in the special section focussing particularly on young people, Eloul et al. (pp. 233-241) describe a programme for unaccompanied and separated children (UASC) in camps for Eritrean refugees in Ethiopia in response to a perceived increase in suicidal ideation and behaviour among minors. It included public awareness and stigma-reduction campaigns, psychoeducation aimed at both UASC and their caregivers, capacity building for humanitarian and community partners, group and individual counselling. They highlight the importance of working with such constructs as grief, guilt, attachment and identity. They recommend the coordinated development of a suicide prevention and response plan as a core component of any humanitarian response. Rosenbaum et al. (pp. 242-248) report on a study of MHPSS staff in Cox’s Bazar, Bangladesh in relation to barriers, attitudes, confidence and knowledge in responding to suicide risk. Humanitarian staff from multiple sectors reported low confidence or readiness to respond to suicide risk in the field. Training on suicide identification, intervention and response for such staff and related community gatekeepers is an urgent need in the Rohingya refugee response. Shrestha et al. (pp. 249-254) write about the challenges and lessons learned in Nepal in relation to suicide prevention in a context where MHPSS services are either not available at all or are limited in scope. They describe five priority areas for action in suicide prevention which were identified through local consultation. Marzouk (pp. 255-260) provides an overview of the work of International Organization for Migration (IOM) in suicide prevention in Iraq. The author presents a brief situation analysis of socioeconomic, cultural and political aspects related to the phenomenon of suicide in Iraq and then outlines the steps IOM has taken to support the government of Iraq in developing a National Suicide Prevention Strategy.
There are two personal reflections. In the first, Womersley (pp. 261-265) reflects on the experience of refugees in relation to trauma, shame and suicidality. The author brings a personal narrative too of the impact of dealing with this as frontline workers. In their contribution, Sevenants (pp. 266-270) brings personal reflections based on lived experience interlinked with views on adolescence and suicidality.
Addressing What Response is Possible in the Field in the Light of Challenges in Systems
Persons with lived experience can play a crucial role in guiding prevention efforts. Especially in humanitarian contexts, these efforts require that various stakeholders act in one breath. Among others, MHPSS professionals, health staff, journalists, police, teachers, researchers and faith leaders should therefore receive continuous training and supervision to reflect on their role in prevention and early response.
A recent review on evidence around suicide prevention in forcibly displaced populations identified very few good studies in refugee settings. Prevention programmes should use multiple strategies, but more operational research is needed to disentangle and evaluate the individual and combined impact of such interventions on suicide-related behaviours (Haroz et al., 2020). One promising intervention is the use of Brief Intervention and Contact which has shown good effects in a small study among Tamil refugees in India (Vijayakumar. et al., 2017).
When policymakers commit to the implementation of a national strategy, multi-sectoral networks can be more easily established and maintained (Arensman et al., 2020; World Health Organization, 2013). This in turn can facilitate the introduction of measures to improve data collection, centralise referral systems, issue binding media guidelines for responsible reporting and restrict access to the means of suicide. However, even if buy-in on a national level is not given, civil society organisations and humanitarian actors within the MHPSS and protection sector can support communities in developing preventative tools which take into account the legal framework and societal norms. For instance, this may include working with bereaved families and friends to raise community awareness or training pharmacists and teachers as “gatekeepers” in talking safely about suicide and in identifying early signs of suicidality (World Health Organization, 2021a). Forced displacement often leads to the disruption of supportive networks. The low sense of connectedness and communal belonging may predispose people to desperate acts of hopelessness (Ingabire & Richters, 2020). This makes the need for activities to strengthen the social fabric in displaced communities even more urgent (Chiumento et al., 2020). In contexts with scarce resources and lacking referral options, communities can be supported in building on their potential to listen to and care for each other − it is important though to simultaneously flag the need for mental health and the right to life as basic human rights.
Specific Considerations for Working on Prevention in the Middle East
In the Middle East, prevention activities need to consider stigma which often deprives those in need of help from being heard and lets those who lost a loved one grieve in secret. Correspondingly, anonymous services, such as helplines or remote MHPSS interventions, can have a stabilising − even life-saving − effect. When well-trained staff respond with a nonjudgemental, inclusive and empathic attitude, persons in distress may feel more understood than in their own social circles (Ferguson et al., 2021; Procter et al., 2021). Similarly, it is crucial to work with faith and community leaders on reducing the pressure and a notion of shame induced by religious and cultural norms and draw on the protective potential of religion and social ties (El Halabi et al., 2020). Sensitising journalists on their responsibility to protect their community members presents another important building block towards holistic prevention (Arafat et al., 2021).
Finally, suicide prevention programmes should be embedded within broader programmes for mental health promotion and mental healthcare reform with clear suicide prevention frameworks and, most importantly, need to be accompanied by advocacy to address the underlying drivers of suicide, which are related to social determinants of health and wellbeing such as economic disparities, loss of social connectedness and prospects to create stable livelihoods.
Wendy Ager would like to express her great thanks to the team of guest editors − Dr. Rabih El Chammay, Johanna Lechner, Dr. Peter Ventevogel and Dr. Lakshmi Vijayakumar − for their enthusiastic support and collective wisdom in reviewing and guiding the publication of the special section.
Financial support and sponsorship
We would like to acknowledge the generous financial support of GIZ Jordan for the costs of publishing the special section on suicide prevention and response.
Conflicts of interest
There are no conflicts of interest reported.
|1||Arafat S. M. Y., Ahmad A. R., Saeed A. K., Menon V., Shoib S., Kar S. K. (2021). Quality of media reporting of suicide in Iraq. International Journal of Social Psychiatry, 00207640211003928.|
|2||Arensman E., Scott V., De Leo D., Pirkis J. (2020). Suicide and suicide prevention from a global perspective. Crisis, 41, S3–S7.|
|3||Blackmore R., Boyle J. A., Fazel M., Ranasinha S., Gray K. M., Fitzgerald G., Misso M., Gibson-Helm M. (2020). The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis. PLoS Medicine, 17(9), e1003337.|
|4||Case A., Deaton A. (2020). Deaths of despair and the future of capitalism. Princeton University Press.|
|5||Charlson F., van Ommeren M., Flaxman A., Cornett J., Whiteford H., Saxena S. (2019). New WHO prevalence estimates of mental disorders in conflict settings: A systematic review and meta-analysis. The Lancet, 394(10194), 192–194.|
|6||Chiumento A., Rutayisire T., Sarabwe E., Hasan M. T., Kasujja R., Nabirinde R., Mugarura J., Kagabo D. M., Bangirana P., Jansen S., Ventevogel P., Robinson J., White R. G. (2020). Exploring the mental health and psychosocial problems of Congolese refugees living in refugee settings in Rwanda and Uganda: A rapid qualitative study. Conflict and Health, 14(77).|
|7||El Halabi S., El Hayek R., Kahil K., Nofal M., El Hayek S. (2020). Characteristics of attempted suicide in the Middle East and North Africa region: The mediating role of Arab culture and religion. Mediterranean Journal of Emergency Medicine & Acute Care, 1(3), https://escholarship.org/uc/item/65t69v795|
|8||Eskin M., AlBuhairan F., Rezaeian M., Abdel-Khalek A. M., Harlak H., El-Nayal M., Asad N., Khan A., Mechri A., Noor I. M. (2019). Suicidal thoughts, attempts and motives among university students in 12 Muslim-majority countries. Psychiatric Quarterly, 90(1), 229–248.|
|9||Ferguson M., Posselt M., McIntyre H., Loughhead M., Kenny M.-A., Mau V., Procter N. (2021). Staff perspectives of safety planning as a suicide prevention intervention for people of refugee and asylum-seeker background: A qualitative investigation. Crisis, Advance online publication. https://doi.org/10.1027/0227-5910/a000781|
|10||Geirsdottir G., Mittendorfer-Rutz E., Amin R. (2021, 2021/04/29). Risk of suicide attempt and suicide in young adult refugees compared to their Swedish-born peers: a register-based cohort study. Social Psychiatry and Psychiatric Epidemiology. https://doi.org/10.1007/s00127-021-02099-5|
|11||Goosen S., Kunst A. E., Stronks K., van Oostrum I. E., Uitenbroek D. G., Kerkhof A. J. (2011). Suicide death and hospital-treated suicidal behaviour in asylum seekers in the Netherlands: A national registry-based study. BMC Public Health, 11(1), 1–8.|
|12||Haroz E. E., Decker E., Lee C., Bolton P., Spiegel P., Ventevogel P. (2020). Evidence for suicide prevention strategies with populations in displacement: A systematic review. Intervention, 18, 37–44.|
|13||Hollander A.-C., Pitman A., Sjöqvist H., Lewis G., Magnusson C., Kirkbride J. B., Dalman C. (2020). Suicide risk among refugees compared with non-refugee migrants and the Swedish-born majority population. The British Journal of Psychiatry, 217(6), 686–692.|
|14||Ingabire C. M., Richters A. (2020). Suicidal ideation and behavior among Congolese refugees in Rwanda: contributing factors, consequences, and support mechanisms in the context of culture. Front Psychiatry, 11, 299.|
|15||Marmot M. (2020). Society and the slow burn of inequality. The Lancet, 395(10234), 1413–1414.|
|16||Mittendorfer-Rutz E., Amin R., Niederkrotenthaler T., Björkenstam E., Helgesson M., Qin P., Runeson B., Tinghög P., Mehlum L. (2020). Mental ill-health and suicidal behaviour in asylum seekers and refugees during the COVID-19 pandemic. Suicidologi, 25(1), 31–33.|
|17||Mittendorfer-Rutz E., Hagström A., Hollander A.-C. (2019). High suicide rates among unaccompanied minors/youth seeking asylum in Sweden. Crisis, 41(4), 314–317.|
|18||Pritchard C., Iqbal W., Dray R. (2020). Undetermined and accidental mortality rates as possible sources of underreported suicides: Population-based study comparing Islamic countries and traditionally religious Western countries. BJPsych open, 6(4), e56. https://doi.org/10.1192/bjo.2020.38|
|19||Procter N., Posselt M., Ferguson M., McIntyre H., Kenny M.-A., Curtis R., Loughhead M., Clement N., Mau V. (2021). An evaluation of suicide prevention education for people working with refugees and asylum seekers: Improvements in competence, attitudes, and confidence. Crisis, Advance online publication. https://doi.org/10.1027/0227-5910/a000777|
|20||Red Cross UK. (2021). David's story: waiting for asylum and feeling suicidal − or why immigration detention needs to change. https://www.redcross.org.uk/stories/migration-and-displacement/refugees-and-asylum-seekers/waiting-for-asylum-and-feeling-suicidal|
|21||Rezaeian M., Khan M. M. (2020). Suicide prevention in the Eastern Mediterranean region. Crisis, 41, S72–S79.|
|22||Sundram S., Ventevogel P. (2017). The mental health of refugees and asylum seekers on Manus Island. Lancet, 390, 2534–2536.|
|23||van de Wiel W., Castillo-Laborde C., Urzúa I. F., Fish M., Scholte W. F. (2021). Mental health consequences of long-term stays in refugee camps: Preliminary evidence from Moria. BMC Public Health, 21(1), 1–10.|
|24||Vijayakumar L., Daly C., Arafat Y., Arensman E. (2020). Suicide prevention in the Southeast Asia region. Crisis, 41, S21–S29.|
|25||Vijayakumar L., John S., Jotheeswaran A. (2021). Suicide among refugees: The silent story. In Bhugra D., Ayonrinde O., Tolentino E., Valsraj K., Ventriglio A., (Eds.), Oxford Textbook of Migrant Psychiatry (pp. 543-552). Oxford University Press.|
|26||Vijayakumar L., Mohanraj R., Kumar S., Jeyaseelan V., Sriram S., Shanmugam M. (2017). CASP–An intervention by community volunteers to reduce suicidal behaviour among refugees. International Journal of Social Psychiatry, 63(7), 589–597.|
|27||World Health Organization. (2013). Mental Health Action Plan 2013–2020. Author. http://www.who.int/mental_health/publications/action_plan/en/|
|28||World Health Organization. (2021a). LIVE LIFE: An implementation guide for suicide prevention in countries. World Health Organization. https://apps.who.int/iris/handle/10665/341726|
|29||World Health Organization. (2021b). Suicide worldwide in 2019: Global health estimates. Author.|
|30||Zolezzi M., Alamri M., Shaar S., Rainkie D. (2018). Stigma associated with mental illness and its treatment in the Arab culture: A systematic review. International Journal of Social Psychiatry, 64(6), 597–609.|