Why are suicides rates so low?

By Andria Kades

Figures released this week showing that Cyprus has the lowest suicide rate in the whole of the European Union may not accurately reflect what appears to be an enviable statistic, mental health experts have warned.

For a start, not all suicides may be reported as such, while the figures do not show the levels of attempted suicides and other forms of serious self-harm.

On the face of it the figures are certainly encouraging. According to research published by Eurostat, in 2015 four in every 100,000 took their own lives in Cyprus – the lowest in the EU. Greece had five suicides and Italy six per 100,000.

On the other end of the scale was Lithuania with 30, by far the highest rate of death due to intentional self-harm among all the member states. The average suicide rate stood at 11 per 100,000 in the EU.

In total, 40 people in Cyprus killed themselves in 2015, 31 of whom were men and nine women.

In 2016, there were 36 suicides and the same number in 2017.

By the end of May 2018, there had been 15 suicides.

The reasons given for Cyprus’ low suicide rate are straightforward: the close-knit structure of family life, sunny weather and small distances between people which lessen feelings of loneliness and isolation.

But the stigma associated with suicide and mental illness in general remain, despite massive progress in recent years in terms of people being more open about mental health issues. This casts doubts over how accurate the numbers might be.

The stigma in Cyprus’ culture and religion, may in some cases mean deaths caused by suicide are recorded under something different out of fear, according to University of Cyprus chair of the psychology department and associate professor Georgia Panayiotou.

Traditionally, the church does not carry out the liturgy if someone takes their own life as it is viewed as a sin. Though the past few years have seen an easing of the iron tradition, the stigma is very much alive.

This means there is no way to know exactly how many more suicides have taken place.

Psychologist and associate professor at the University of Nicosia Andreas Anastasiou said “it wouldn’t surprise me if this happens.”

But even if some suicides are misreported, the fact remains that figures are low, and the obvious reasons for this should not be understated according to Anastasiou.

There is a clear link to the weather. Sun almost all year round means people are far less likely to have seasonal affective disorder (SAD), a kind of depression that is more apparent during the winter time.

Reduced sunlight can affect the brain’s hypothalamus from working as it should, in turn impacting the levels of melatonin and serotonin produced, which affect mood and sleep.

The culture of the island is also strongly linked to the low suicide rates.

“Cyprus is a collectivistic country and there is a lot of social support,” Anastasiou said.

Loneliness and lack of social support during difficult times is often a reason some may turn to suicide but the close-knit structure of family bonds in Cyprus, coupled with the smaller geographical distances is a huge help, according to Panayiotou.

For instance, someone with a mental health issue may have someone to go with them to a psychologist’s visit, someone to remind them to take their medication and someone to help them look after their family, she added.

“There are no extreme phenomena of loneliness.”

According to Anastasiou the stigma associated with mental health is slowly being erased. “It is far more acceptable,” to get help than it used to be, he said.

This is partly through word of mouth and people talking to each other. One person may need help and will hear from someone else who received treatment and this in turn encourages them.

This can also be attributed to many of Cyprus’ young having gone abroad.

But both Anastasiou and Panayiotou agree that a close-knit society can on some level also exacerbate the very situations it helps to avoid.

“You can however get depressed in a collectivist society,” Anastasiou said. The culture is somewhat of a double-edged sword: though it offers the close support it can also have an adverse effect in that people are always acutely aware of people’s opinions.

What the neighbour, family and friends will say has always been an endemic way of thinking on the island “but if you change your behaviour because you’re afraid what someone else will say you will become a symptom of someone else’s sickness,” Anastasiou said.

Someone’s decision of who they are is not based on self-exploration “but based on what other people want them to be”.

This in turn extends to relationships and marriage because the individuals haven’t properly explored who they are.

Cyprus Samaritans have been operating for 20 years

According to Panayiotou, the stigma also prevents people from essentially calling things by what they really are. “There may be people suffering from a serious mental illness but the social context and sometimes even health professionals may minimize it into something milder, like anxiety, which may mean that signs of serious distress can go unnoticed and help may not be sought out”

“Stigma is sometimes present even in institutions knowledgeable about research. There are times when we carry out questionnaire research. Institutions that review these research may ask us to remove questions about suicide thinking it may encourage someone to end their life – however, asking is the only way to find out if there is a problem, she insists.”

What cannot go unreported are the effects of the financial crisis that hit Cyprus in 2013 which created new problems and brought out issues that had been previously brushed under the carpet.

According to Anastasiou “the financial crisis made problems that were already there come up (to the surface).”

For instance, someone may have had problems with their wife but held a good job, had good income and lived a relatively enjoyable life, so their domestic issues weren’t that obvious.

When that person lost their job however, he couldn’t provide for his family and those issues become stronger stress factors.

Director of Nicosia general hospital psychiatric clinic Kyriaki Epaminonda Klose told the Sunday Mail that since the crisis, the number of attempted suicides has risen.

Dealing with these problems on a day-to-day basis as part of her job, she said “there might be cases every other day,” with people coming in, mostly for taking an overdose.

Though it is mostly women who make attempts to take their life (men are more likely to succeed), Klose said there are people of all ages and economic backgrounds that come through the emergency department after an attempted suicide.

She said there was an overdose case on Friday and another just two days previously.

“There might not be a case every day but every two days, yes.”

The problems range from financial to family issues, but there are many times when the person attempting suicide regretted their decision when they felt the effects kick in and reached out for help thus preventing the worst-case scenario.

Another concern for Anastasiou is substance abuse. Anastasiou said drugs may induce more panic and even lead up to people hearing voices in their head eventually pushing them over the edge.

But what help is available?

A quick search online for suicide help brings up two results. In Greek, news articles related to suicide come up and in English, a helpline ran by the Cyprus Samaritans charity.

Running for 20 years, the helpline is not exclusively for suicide related issues but can also provide help to anyone which needs it.

It is operated by 50 specially trained volunteers between 4pm to 12am.

Director for Cyprus Samaritans Robbie (Russel) Robinson told the Sunday Mail they offered the help in Greek, English and German as well as an email service which has been gaining traction by younger people who are more IT friendly.

Of course, this leaves a very obvious gap –if someone has suicidal thoughts before 4pm and needs help, there is no suicide specific hotline to call.

The charity of course does the best it can with the resources it has available. “We don’t get any grants from anywhere so we have to fund our lines.”

Their main source of income comes from charity shops they have across the country selling clothes or other items.

Panayiotou said it wouldn’t be a bad idea to have a 24 hour hotline although there are other lines available (for instance the youth help line or the number for help against domestic violence) which operate 24 hours a day and deal with suicide related issues without exclusively branding themselves as suicide helplines.

Klose brings up another point – though a hotline would no doubt be helpful, she has her doubts on whether the Cypriot culture would be open to the idea of calling a stranger – perhaps even out of fear the person that picks up the phone will be someone they know.

From her own experiences “I haven’t heard someone say they’d call a stranger.”

More often, they’ll prefer to turn to family or friends.

The experience at the Samaritans however is slightly different.

“We’ve seen an increase in the number of calls and especially from Cypriots,” Robinson said.

This may be largely due to the fact that the charity has been around for so long and word is now getting round, but also because there is not always an obvious place for people to turn to.

“We get about 80 calls per week,” he told the Sunday Mail though the calls range from anything to someone losing their cat to someone being at the end of their tether.

Some are regular callers and some are one-off’s, he stipulated.

“It can be anything from bereavements, to drugs, drink, family abuse, bullying, lost jobs, homelessness,” Robinson said but the key is that the charity is not judgemental.

“What we do is we listen to people. The people that need help are at the end of their tether. We don’t offer advice, we just listen,” and really that’s what a lot of people need – someone to hear them out.

“Mental health needs to be viewed like a broken leg. If something happens to your leg, you’ll go fix it. Just because you can’t see the mental health problem doesn’t mean it should be ignored.”

Although the charity is now trying to cooperate with local municipalities across the country so word can spread, help available to the public lies either through the private sector where according to Anastasiou there are several professionals available 24/7 or the state sector.

Klose outlined outpatient clinics in all cities have psychiatrists, psychologists and community support workers that can visit patients at home to monitor their progress and help out.

Asked whether there was adequate staffing, Klose said there were certainly less personnel than other specialties. “We have very few psychiatrists.”

Mental health professionals are also on call at the emergency department Klose said as there are instances when people will come to a hospital and express their wish to end their life in a bid to get help.

Panayiotou said there are services available – most universities offer counselling centres with fully trained psychologists and NGOs also help.

But of course more services are needed.

“It is very important to have access to highly credential, competent professionals who also know how to make a very good, accurate and reliable assessment, especially about suicide,” said Anastasiou.

As Cyprus becomes more Westernised, the stigma attached to mental health is reduced however the isolation in people’s lives may increase and may give rise to more mental health issues associated with lack of social support, Panayiotou said.

What is key however, Anastasiou stipulated is that “it’s not a weakness to seek help. Rather, it takes a lot more strength,” and helps people get on a better path.

Where you can call for help:

Cyprus Samaritans helpline: 8000 7773 (available 4pm – 12am)

Domestic violence support (offered by Spavo association) : 1440 (24 hours)

Child and teen helpline: 116111 (available Monday to Friday between 12pm – 8pm

and Saturdays between 09:30 – 14:00)

Emergency services: 112 or 199

Cyprus youth organisation helpline (drugs, relationships, family problems, bullying, depression, grief, sexuality and any other problems): 1410 (available Monday to Friday between 10am to 11pm and Saturday / Sunday between 3pm-11pm)