On April 8, 1962, about to turn 70, Juan Belmonte shot himself in the temple.
The poet Felipe Benítez Reyes tells in the prologue to a biography of the bullfighter that Spain went into mourning and the whole world began to make conjectures: “Tired of living?
Frustration in the face of a late crush?
Who knows.
Maybe he didn't even know it himself.
Perhaps no one seeks death for a specific reason or unreason, but rather death ends up imposing its own: urgency in the face of nothingness, relief from nothingness”, writes Benítez Reyes, who concludes by leaving what happened to him an enigma. that glorious and rich bullfighter who ended up shooting himself, “because who knows what happens inside nobody when they decide to be nobody”.
Benítez Reyes is partly right.
Much is still unknown about the motives of people who decide to take their own lives.
There is no detailed record of the causes of suicide and when one speaks, for example, that loneliness is behind many cases, it is speculation, at least as regards the intimate experience of the person who commits suicide. suicide.
However, we know that Belmonte accumulated several proven risk factors.
He was a man (they account for 75% of the cases), over 65 years of age (in Spain the elderly account for 30% of the cases and the age group with the highest prevalence), divorced (persons without a partner multiply by 3 .5 the suicide risk of married men) and who suffered from arteriosclerosis and prostate problems (some studies have linked up to 25% of suicides with chronic diseases).
Despite the fatalism that Benítez Reyes' prologue reveals, suicide is not an incomprehensible phenomenon about which there is nothing to do.
In Hungary, in the year 2000, 2,463 men (52.6 per 100,000 inhabitants compared to 12.6 in Spain) and 806 women (15.9 per 100,000) committed suicide.
Two decades later, in 2021, the number had been reduced by half: that of men to 1,203 and that of women to 358. A review of the Hungarian case indicates that during the previous decade, the number of psychiatrists had increased from 550 to 850, psychiatry departments from 95 to 139 and telephone lines to call if you have suicidal thoughts grew from 5 to 28. In addition, training programs were implemented to identify and manage these behaviors for health professionals.
The number, however, remains high.
Denmark is another success story in reducing suicide rates.
In 1980 it had a prevalence of around 30 suicides per 100,000 inhabitants, in 2000 it dropped to 15.6 and in 2019 it had already reached 10.7.
Among the reasons for the achievement, in addition to maintaining prevention policies for decades and creating a specific research center for the matter, is the improvement of access to psychiatric treatment for people at risk or the control of access to methods with which to commit suicide. .
An example of these measures was the legal reduction in the number of pills in paracetamol boxes, which reduced poisoning by this drug by 18.5%.
In countries like India, the ban and control of some pesticides, used in up to 30% of suicides, also significantly reduced deaths.
In Spain, however, there has been no progress in the last twenty years.
A study recently presented in Madrid shows that in 2021 4,003 people took their lives, 6.5% more than in 2018. The analysis, which covered the last twenty years, shows a fluctuation with peaks of 8.39 suicides per 100,000 in 2000, 8.36 in 2014 and 8.4 in 2021, and a minimum of 6.72 in 2010. The figures are lower than those of Denmark or Hungary, but despite the fact that in Spain suicide kills almost three times as many people than traffic accidents, no government has implemented a national suicide prevention strategy, ignoring advice from the World Health Organization almost a decade ago.
Efforts to combat problems are in the hands of the autonomous communities.
Experts, despite the trend of the last twenty years,
Víctor Pérez Sola, director of the psychiatry service at Hospital del Mar, in Barcelona, talks about the Suicide Risk Code, a program in operation in Catalonia since 2014, which tries to identify and follow people at risk.
"One of the factors for which there is evidence is that having had a suicide attempt multiplies by 50 the probability of trying again," says Pérez Sola.
This means that it is important to keep a close eye on these people, something that is done with phone calls and facilitating access to psychiatric treatment.
As a general rule, when a person at risk of suicide is identified, a visit with the psychiatrist is scheduled in less than 72 hours if they are minors and in less than 10 days if they are older.
In Catalonia they usually continue with this code at about 30.
But it is very difficult to control the population at risk with the resources dedicated to it in Spain.
Javier Jiménez, clinical psychologist and honorary president of the Association for Suicide Research, Prevention and Intervention (AIPIS), denounces that the number of trained professionals is clearly insufficient to cover the needs in Spain.
“Now it has been normalized that appointments are given for 10 months or a year from now and that the second appointment is for three months later.
And also, appointments have gone from being one hour to 40 or 30 minutes, ”he laments.
To identify people at risk, where you look has also been expanded.
"Of the people who have tried, only 35% had had a relationship with the mental health network, but they had contacted their family doctor or social services on many occasions due to loneliness or economic problems," says Pérez Sola. .
This point shows the importance of expanding suicide prevention training beyond psychiatrists or clinical psychologists.
As in all public health problems, prevention goes far beyond what can be done in hospitals, as mentioned by Gonzalo Martínez Alés, a psychiatrist at the Harvard University School of Public Health.
As happened with traffic accidents, policies that reduced deaths in traffic accidents by 80% in 30 years required population policies.
"In public health, I think we still don't know what to do, although we have some ideas," he acknowledges.
As the researcher explains, “in Spain there are no clear elements on which action could be taken, such as firearms in the US [omnipresent and related to half of the suicides] or pesticides”.
In fact, continues Martínez Alés, "the method most used in Spain is hanging, which, on the one hand,
One of the methods that have proven effective in countries where they have been implemented are telephones to care for people with suicidal thoughts.
In Spain, in 2022, the 024 telephone was launched. A good idea that experts criticize for its form of application, for the lack of preparation of the people who attended it and for paying a salary with which it is difficult to attract psychiatrists or psychologists prepared clinicians.
Along these lines, Julio Bobes, professor of psychiatry at the University of Oviedo, points out that "a telephone was created, which was something we asked for, but later its management was handed over to an institution that is not primarily healthcare and that did not have experts in the attention”.
A new tender is now being prepared.
Bobes wrote an editorial in the Revista de Psiquiatría y Salud Mental in 2014 entitled “Suicide prevention in Spain: An unmet clinical need”.
Almost a decade later, he believes that "it is still an unmet need."
“The rates have risen continuously and we have gone from being a country with low rates according to WHO criteria to being a country with medium rates,” she asserts.
“We have done few and insufficient things”, she adds.
Among those that have improved, the psychiatrist highlights the improvement in data collection, but warns that the reasons for the fluctuations between years are still unknown.
Javier Jiménez stresses the lack of knowledge to interpret many phenomena.
“We don't know the real number of suicides, let alone attempted ones.
We don't know why people commit suicide.
For 20 years,
They ask us why there are more suicides in Asturias or Galicia than in other regions of Spain and we have no idea.
What are the main reasons why people commit suicide?
We do not know.
We only know five pieces of information: age, sex, autonomous community, method of suicide and month in which they committed suicide.
There is no more data and to take effective preventive measures we need to know the possible causes that have led a person to commit suicide ”, he sums up.
For Bobes, as for many of his colleagues, beyond all the measures that can be applied in prevention, the first step is to take the problem seriously, believe that it is possible to tackle it and dedicate the necessary resources.
“With the traffic it was seen that if resources are dedicated it is possible to lower mortality rates.
In suicide, we have seen that many communities have plans that are very well planned, but they do not have a single euro to carry them out.
In general, there is talk of planning, but there are no important items for the application.
In suicide, we are still in the awareness and awareness phase, then we will have to put the numbers ”, he concludes.
Martínez Alés believes that, although sometimes there is no precise data that relates some policies with the decrease in suicides, common sense can also be used.
"A good public health and social security system has a protective effect and in the US it has been seen that in areas where Medicare coverage [health coverage for people with fewer resources] is expanded, suicides decrease."
In addition to dedicating resources to mental health, not having saturated primary care physicians can make it easier for them to have time to train in suicide prevention and to pay attention to the cases that are presented to them in the consultation.
As the figures for the last 20 years suggest, the battle against suicide has yet to be fought.
Data such as those from Denmark or Hungary show that it is a health problem that can be fought against, although there are also data that suggest that, like almost all health problems, tackling them goes far beyond doctors and patients.
Émile Durkheim, in his 1897 study on suicide, observed that in Catholic countries, with closer social ties than Protestants, people killed themselves less.
Now, in Muslim countries, with health systems much worse than those of the Nordic countries, there are much lower suicide figures, something that may be real or, as in Catholic countries, partly due to the fact that many cases are not registered by the taboo of suicide.
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