There are a number of ways that substance use might be implicated in self-harm (Breet &
Bantjes, 2017; Hawton & van Heeringen, 2009; Wilcox et al., 2004). As an illustration, some
18 ways in which substance use is associated with self-harm are briefly discussed below. In Chapter 5, I offer a detailed insider view of the different ways in which substance use was implicated in the medically serious self-harm of patients who presented for treatment at the hospital.
There is a considerable body of literature to show that individuals who use alcohol are at elevated risk for engaging in self-harm. Disinhibition produced by substance use facilitates the shift from suicide ideation to attempt, often impulsively. Acute use of substances, particularly alcohol, is known to increase impulsivity; psychological distress (i.e. feelings of hopelessness and loneliness); aggressiveness (toward other and the self); and inhibition of coping skills (Hufford, 2001; Wojnar et al., 2009). There is also some evidence that substance intoxication at time of the suicidal behaviour is associated with methods that result in damage of body tissue (i.e. firearms) (Conner, Li, Meldrum, Duberstain, & Conwell, 2003), suggesting that individuals who engage in suicidal behaviour while intoxicated might be more likely to engage in medically serious self-harm. Fewer studies have investigated the association between drug use and suicidal behaviour. For example, data from longitudinal studies in Australia and New Zeeland showed that age of starting drug use is an important factor to consider since daily cannabis use before the age of 17 years was associated with an increased risk of suicide attempt (OR=6.83, 95% CI 2.04-22.90, p<0.05) (Silins et al., 2014). The findings from this study highlights the importance of efforts that reduce adolescent cannabis use.
Similar characteristics have been observed among individuals who report chronic substance use when compared to individuals who report AUS. Findings from developed countries suggest that those with CSU are more likely to be unemployed, have a history of childhood trauma, and report higher scores of anger, impulsivity, and aggression (Haw et al., 2001; Roy, 2003). Social withdrawal, breakdown of social bonds, and social marginalization
19 associated with chronic substance use could also serve as risk factors for suicidal behaviour (Pompili et al., 2010). The combination of co-morbid chronic substance use and psychiatric disorder (e.g. personality disorder or major depressive disorder) is also known to be a strong predictor of repetition of self-harm (Finkelstein et al., 2016). The association between acute or chronic drug use and self-harm has not been studied sufficiently in SA. This is important given the high rates of substance use such as cannabis, cocaine, heroin, and TIK (crystal
methamphetamine) in SA (van Heerden et al., 2009).
Limited studies have investigated substance-induced psychotic disorder (SIPD). The available published research specifically reports a link between the use of methamphetamine and SIPD, with higher rates of SIPD among drug users who report a younger age of onset and more frequent drug use (Hides et al., 2015). Lifetime diagnosis rates of SIPD are estimated to range between 16% and 39% among methamphetamine users (Hides et al., 2015). Findings from psychiatric patients in Taiwan reported that continuous use of methamphetamine and poly-substance use were predictors of suicide attempts among drug users with SIPD (Wang, Chiang, Su, Lin, & Chen, 2012). A Finnish study reported that a younger age, poly-substance use, depressive symptoms, and physical violence against others were strong correlates of suicide attempts among individuals with a diagnosis of SIPD (Suokas et al., 2010). Few studies have investigated the role of substances in the association between SIPD and self-harm.
Substance use may play an indirect role in self-harm when an individual has to deal with the difficulties of other people’s substance use (Norström & Rossow, 2016). Parental substance use is known to play a role in offspring suicidal behaviour (Brent & Mann, 2005; Glowinski et al., 2001; Gould et al., 1996; Statham et al., 1998).
20 1.1.7 Suicide prevention in South Africa
In recent decades, there has been a steady increase in the development and
implementation of national suicide prevention strategies across HICs, while LMICs continue to lag behind. Effective prevention initiatives require consistent and reliable information on SIB in order to identify high-risk groups and to explore trends that might inform the development and evaluation of timeous and adequate suicide intervention or prevention (Schlebusch, Burrows, &
Vawda, 2009). During 2012, the WHO reported that none of the countries in the African region, including SA, had a formal national suicide prevention plan (WHO, 2014a). In 2013, the World Health assembly proposed action for WHO Member States to reduce suicide by developing and implementing comprehensive national strategies for suicide prevention (WHO, 2013). At the time of this PhD study, no formal national strategy for suicide prevention exists in SA. However, Schlebusch (2012) has identified some priorities and prevention strategies in an effort to propose a framework for a national suicide prevention strategy in SA.
There were 28 countries in 2012 known to have suicide prevention strategies (WHO, 2014a). Regarding LMICs, Bhutan (Dorji et al., 2017), Iran (Malakouti et al., 2015), and Sri Lanka (De Silva et al., 2016) are among the few countries that have some form of national prevention strategies. The process of establishing a national suicide prevention strategy requires a participatory approach between multiple and diverse stakeholders. This means that
stakeholders from government, non-government organizations, and health, non-health sectors need to pool their resources and skills to work toward the communal goal of suicide prevention.
For effective suicide prevention, national suicide prevention objectives could include, among others, enhancing surveillance and research, identifying vulnerable groups, encouraging
responsible reporting by the media, restricting access to means of suicide, creating awareness of
21 environmental and individual protective factors, and reducing stigma pertaining to suicide (Khan
& Syed, 2011; WHO, 2014a).
Although there are a number of general principles for suicide prevention in the literature, no two strategies can be identical due to the influence of the cultural and social context in which the behaviour occurs (WHO, 2014a). However, strategies developed elsewhere might be helpful if the goals, objectives, and interventions followed in suicide prevention are tailored according to the context in which they are implemented.