Screening by Ministry should be for suicide ideation, not self-harm

Dear Editor,

The Mental Health Unit of the Ministry of Health (MOH) has indicated that it will be implementing a self-harm screening tool that will identify and counsel persons who have attempted suicide or practised self-harm. Reacting to this announcement, The Caribbean Voice’s (TCV) technical team member and mental health specialist, UK-based Dev Ramdass pointed out, “Self-harm is thought to be directly linked with suicide but this isn’t the case. The two are actually as different as night and day. Unfortunately the two oftentimes get grouped together because both are inflictions of pain and sometimes people who begin with self-harm may later commit suicide. Generally people who self-harm do not wish to kill themselves; whereas suicide is a way of ending life.” Incidentally this distinction is quite clear in our training programmes (and information dissemination), points out TCV’s Director of Training, Leslyn Holder.

Given this reality TCV finds it strangely puzzling that the MOH seeks to screen for self-harm rather than for suicide ideation (distinctions that are made in our training programmes and advocacy) as is the global practice. Such screening:

Ø Asks about a history of psychiatric illness and substance abuse and a history of suicidal ideas and attempts.

Ø Uses the CAGE questionnaire (a short, simple questionnaire, used extensively worldwide) to screen for alcohol abuse.

Ø Performs a mental status examination, with emphasis on mood, affect and judgement.

Ø Identifies symptoms associated with suicide

Ø Reviews risk factors associated with suicide

We also strongly suggest that the process of crafting the screening tool should:

Ø  Include input from stakeholders such as social workers, psychologists, psychiatrists as well as NGOs and others involved in suicide prevention activism.

Ø Be tested in a focus group to eliminate unintended consequences, especially with respect to language use.

Ø Be piloted with a group from a suicide cluster area and one from a non-cluster area to fine-tune its efficacy.

Furthermore, as pointed out above, a synthesized treatment plan must be in place, otherwise  the screening becomes an exercise in futility. Such a plan must include treatment for low self-esteem and depression, and must address the factors that trigger suicide, especially alcoholism, and abuse –child, sexual and gender based.

More importantly TCV strongly urges that suicide prevention and the overall approach to address mental health would be best executed through the integration of mental health care into the physical health care system, as recommended by the World Health Organization, especially for small economies like Guyana. This cost effective process will ensure that mental health services are available across the nation on a continual basis and as a regular component of health care services offered on a daily basis nationwide.

The reality is that suicide prevention needs an integrated approach, as is the practice in many nations worldwide. Michael C. Klein, a clinical psychologist at New York University’s health centre, and co-principal investigator of the National College Depression Partnership, explains why this may be. Klein believes that the best way to address suicide “is to focus on secondary prevention and take an integrated approach…The idea is to create gateways into the care system from services that are being used more frequently.” The physical health care system is obviously the most significant gateway. Simultaneously, proactively addressing the factors that impact suicide, especially abuse, (child, gender based, sexual) and alcoholism, is another component of the integrated approach, best executed through collaboration with all stakeholders, especially NGOs, Faith Based Organizations and Community Based Organizations in a concerted manner.

In effect, a limited, ad hoc, random approach is an exercise in futility. Thus, for example, randomly placing probation officers in selected areas will have reduced effect. So too any plan or programme that is limited in terms of scope, location, execution, duration and follow up or that has the wrong focus. On the other hand, with respect to suicide prevention, depression and mental health issues on the whole, piggy-backing training and information dissemination on other training programmes, can be very cost effective yet have a nationwide reach, especially since various training programmes are carried out across the nation by government and other entities on an ongoing basis.

Piggybacked training can be similar to The Caribbean Voice’s approach, which, dictated by limited resources, comprises five training modules as a way of preempting attempted suicide and arming citizens with skills and know how to be the first line of offence against depression, abuse and other mental health pathologies. These training programmes, offered free, conducted by highly trained and experienced mental health experts and facilitators and currently carried out across five regions in Guyana, with plans to expand them into other regions, are:

Ø  The Youth and Student Workshop, already presented to a number of schools and youth groups and endorsed by the Ministry of Education which plans to make it part of the Health and Family Life Education curriculum in schools. Already offered to a number of schools and youth groups, this workshops is slated next for West Berbice and East Coast Demerara youth groups, schools and youth leaders

Ø  A Teacher Training Workshop, which was launched on March third this year on the East Bank of Demerara and which has already been requested by a number of schools. This too has been endorsed by the Ministry of Education, which has offered to collaborate and get social workers involved in its implementation.  This programme is next slated for the East Coast of Demerara.

Ø  A Train the Trainer Workshop, which was launched in collaboration with Imam Bacchus & Sons at Affiance, Essequibo, on February 25th this year. This workshop trains others to become trainers for gatekeepers and to turnkey their training to their various communities and entities with which they are associated. The demand for this programme is also great and it will be taken to all regions over time. Next stop is March 29th at the Berbice Chamber of Commerce & Development Association Members Hall in New Amsterdam with A. Ally & Sons being the main sponsor.

Ø  An Employee Mental Health Workshop, which helps workers at various companies to be able to deal with stress and challenges and emotional and psychological issues. This was launched on March 25th in Georgetown at the offices of the Guyana Times/TVG and is being offered to businesses nationwide. The next stop is the offices of Global Printing & Health International.

Ø  A Community Outreach, launched in 2014 at Black Bush Polder and since taken to a number of communities, often in collaboration with other NGOs, Community Based Organizations and/or Faith Based Organizations. Next stop is Wales, where the scope for widespread depression exists as a result of the closure of the sugar estate.

With respect to myths and misinformation, TCV joins with other stakeholders and professional authorities in emphasizing that, contrary to what some propagate, depression does not discriminate.  According to writer and psychologist, James Karman, “Depression affects men and women from all backgrounds, in all professions, and at all stages of life. Even people whose lives are exciting and full can experience depression.” He also explained that, “Depression often is a normal reaction to life events such as death, changes in health, job loss, and divorce. But it also can result from a biologic predisposition, hormonal changes, and family history. Some people experience seasonal affective disorder (SAD) ― a condition in which  sadness becomes more severe at different times of year.“

Meanwhile, the Caribbean Voice is pleased to report that in 2015 Guyana moved to number two from a high of number one in terms of suicide rate globally. The actual rate was reduced from 44 per 100,000 to 36 per 100,000.And we believe that that figure may be even lower today because of the intense work being done by The Caribbean Voice and other stakeholders. We pledge to continue our work until this rate is reduced to single digits.

For additional information/clarification or to request any of our training programmes, please contact Christena Lallchan at 646-4601, Nazim Hussain at 644 1152, 646 4669 or send email to caribvoice@aol.com.

Yours faithfully,

Annan Boodram

The Caribbean Voice

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