Gonzalo Martínez-Alés, 33 years old and born in Madrid, says that the greatest fear of a psychiatrist is that one of his patients manages to take his own life.
From the first months of exercise he realized that the problem of suicide is "huge", "it is always flying over your head", he confesses.
In January he joined the CAUSALab of the Harvard University School of Public Health, a center that uses data to investigate what works in medicine with the aim of helping administrations design effective public policies.
The also epidemiologist, who was involved from his first years of career in the analysis of suicide prevention programs and their real effects - he spent four years with one of the reference teams of Columbia University -,
Martínez-Alés, who lives in Boston, explains that the social context and the type of society determine what can work when trying to stop suicide attempts.
Thus, for example, in the United States the formula would be to restrict the use of weapons to the general population, since it is one of the main means used in the country.
In China or India it has already been shown that stricter regulation of the use of pesticides has reduced suicide rates.
In Spain, where studies on the main causes have increased in recent years, it is early to find a clear measure.
For now, facilitate an appointment with a mental health specialist within seven days of the first suicide attempt.
In July the psychiatrist co-directed the seminar
What to do in the face of the epidemic of suicidal behavior in young people?
, organized by the Universidad Internacional Menéndez Pelayo in Santander, and responded to questions from this newspaper.
Ask.
Why are adolescents especially vulnerable to suicide?
Response.
It is not accurate to say that they are more vulnerable, they die less by suicide than any other age group.
In Spain it is the elderly, the elderly, who are most affected.
What makes the difference is that the death of a young person in those circumstances can be more tragic.
Adolescents are quite dependent on their context, families, socioeconomic security... It may be that this context in advanced societies is no longer as secure as it used to be, especially in homes with fewer resources.
Mental health crises in adolescents appear as a symptom of the economic impoverishment of societies.
To this is added that in other stages of life you are more capable of regulating yourself emotionally.
P.
The group most affected by deaths by suicide are men over 65 years of age, but in attempts there has been a dramatic upturn in young people, cases have tripled since 2006 to exceed 2,000 in 2020. How do you explains why a teenager wants to take his own life?
A.
That is
one of the fundamental questions in the field of suicide that remains unanswered.
There is a small group of patients in whom mental illness plays a predominant role.
Schizophrenia usually appears at these ages and the greatest risk is concentrated at the beginning of the disease, where despair overwhelms them.
In the bulk of patients who experience suicidal ideation there are no clear genetic components, it is an investigation that is underway.
Yes, there are aspects of family grouping, coexistence, customs... the determinants or the causes on which more can be acted upon are of a social nature.
It is a time of transition towards greater independence in which there are sudden changes and not everyone knows how to face socioeconomic or relational challenges.
Q.
What points are you currently studying regarding suicide in the CAUSALab?
A.
There
we invent, develop and implement epidemiological and statistical methods to try to clarify what measures work in medicine: what drugs, what interventions, what public policies... The program has existed since the 1980s and the line on suicide and schizophrenia started in 2019. Right now I am participating in two avenues of suicide research.
One tries to identify the population causes of the increases: we look at which groups are produced to find clues that differentiate one era from another.
In the United States, for example, in the year 2000 the rates were much lower than in 2020, we try to look at what has happened to vulnerable groups, such as young African Americans, where the increases are most concentrated.
The most accepted hypothesis there, although still discussed,
is that the progressive erosion of the middle classes is leading to greater lack of protection.
On the other hand, we are looking at what interventions work to stop suicide attempts.
Q.
Could you give an example of an effective measure?
A.
In this field, recent years of research suggest that the first thing a person at risk of suicide should have is the ability to ask for help.
Maintaining contact with those patients is effective.
You call that kid, you write to him, you are close to him from the health services.
It works because, in case the person feels unwell again, it reminds them how to ask for help.
In addition, it allows to reevaluate the severity every x time.
It has also been seen that it works to be summoned to a medical center soon after an attempt.
The Community of Madrid does it in the following seven days.
Those days are very risky, there is guilt, shame, and you have to be very close.
P.
Is there any country where public prevention policies have already worked?
R.
There are several successful experiences.
Iceland chose to open sports centers at night to reduce alcohol and drug use, linked to suicide in young people.
In the United States, efforts are being made to help people store weapons better, because the issue of restricting their use is very sensitive.
In England, access to paracetamol was regulated with smaller blister packs.
Suicide and liver transplants fell.
The most paradigmatic case is that of pesticides in India and China, where they have prohibited you from taking them home, they must be stored in a work space or in a locker.
The effectiveness of training professionals who are not mental health specialists but who can accompany a person during a crisis, for example the police, firefighters or teachers, has also been shown to be effective, they are called
gate keepers
(in Spanish, guardians).
Our investigations have shown us that the suicidal crisis is short, half of the population that tries it does it in short circuit, it lasts about 10 minutes.
If as a government I manage to prevent you from doing it, I will have done well.
The positive fact is that more than 90% of the people who try it do not repeat it.
Q.
What psychotherapies are effective?
R.
There are some with enough scientific evidence, such as suicide-specific CBT.
It is a cognitive-behavioral therapy that tries to systematize how that person will ask for help in a new crisis.
It also identifies what happened before the ideation with the people around them and what to do so that it does not happen again.
For example, if you drink after an argument and that has led to an attempt, that consumption should be avoided.
Then there is DBT, dialectical-behavioral, which adds more components of reflection that come from psychoanalysis, goes deeper into the root of the problem.
In the last 25 years it has been shown that this therapy is very successful in adolescents, it fits with their vital moment.
They get hooked, they like it and they find answers to their questions.
Anyway,
In both cases, it is not yet clear whether these therapies have an added benefit to the formula of maintaining contact, which is essential, and generate higher costs.
It is difficult to prove it and the health systems do not know if they have to bet on this or not.
These two factors mean that these therapies are not widespread in public health in Spain, or almost anywhere in the world.
In addition, these therapies have the added difficulty for the system of having therapists dealing with suicidal people in a sustained manner, something very hard and that wears out a lot.
or almost anywhere in the world.
In addition, these therapies have the added difficulty for the system of having therapists dealing with suicidal people in a sustained manner, something very hard and that wears out a lot.
or almost anywhere in the world.
In addition, these therapies have the added difficulty for the system of having therapists dealing with suicidal people in a sustained manner, something very hard and that wears out a lot.
The psychiatrist Gonzalo Martínez-Alés, in Santander.Juan Manuel Serrano Arce
Q.
The so-called security plan is one of the widespread protocols in different countries.
It is effective?
R.
It is a simple document, the first thing that is done before discharging a person who goes to the emergency room for an attempt.
The psychiatrist and the patient analyze together what happened so that he reached the moment of ideation, what reasons he has for recovery.
All this, which must be done slowly for an hour and a half and is very therapeutic, is captured on paper that the patient will use if the triggers appear again.
It specifies which people you can call or go to or what activities you can do at that time.
They are clear steps to move away from the moment of risk and ensure that you will survive.
After that you have to make sure that the patient will go to the consultation, they have to go with a fixed date and time.
That's where the barriers come in.
A week later they recover and see no point in going to the appointment.
Although in many countries,
Q.
If countries don't make sure that tracking is easy to access, inequity comes into play.
R.
This is known as the Theory of Fundamental Causes.
Socioeconomically disadvantaged people always die earlier, they have less life expectancy.
The privileged one will use his knowledge, contacts and his money to stay healthy: he is the one who quits smoking first, the one who has a more balanced diet.
This is more serious in the United States.
An example: before there was no racial difference in deaths from breast cancer and now there is.
Mammography —which is paid for there or is done with private insurance— is very effective and there white women are more capable of having it done each year than black women.
If we transfer this to suicide, if in the discharge report instead of giving him the appointment you put where he has to call, you open the door for the one who knows to call or pull a medical relative or friend and the other never does.
Not making the patient choose works best.
It will not lead to inequities.
Q.
What do psychiatrists do to cope with the emotional impact of treating such seriously ill patients?
A.
Supervision is essential.
It consists of telling the case to another colleague and working out what may be blocking you with the case.
It can be done in a group, it helps to clarify what the next steps are or how it can be improved.
Whenever someone dies, it is treated in a meeting, it is a therapeutic experience for us, to feel accompanied and share that weight.
Q.
Do you practice
mindfulness
?
A.
Mindfulness is a
psychotherapeutic
adaptation of an ancient meditation practice.
It seemed that it was effective in reducing anxiety or insomnia, and little by little evidence is emerging that it is not the most appropriate for some mental health situations.
In the case of suicide, it has been shown that patients are happy to receive this type of therapy, but it has also been seen that coping strategies based on awareness work less well in times of crisis.
There the best thing is a directed distraction, especially the one that favors the sensation of mastery, doing something that you are good at.
If you want to recommend
mindfulness
to a patient at risk of suicide, make sure you train in practice at a time of low risk.
You have to master it a lot for it to be useful to you in a moment of gravity.
A very recent clinical trial at the University of Oxford, in which a group of 8,700 adolescents was divided into two groups and some were given
mindfulness
and the others were not, has shown that those who received it had worse results in depression.
I would ask for caution.
Nothing is valid for everyone.
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