By Aria Axarli
There is an underlying and often uncomfortable truth about suicide; it is more than just an individual issue.
Illustration by Kathy Katella on Yale Medicine. A visual representation of Health Equity, as described by Onyema Ogbuagu, an infectious diseases specialist: “Equity means that people have to get what they need to achieve the same results.”
With September 10th marking World Suicide Prevention Day and World Mental Health Day following closely, we are reminded of the significant threat that suicide still poses to global health today, as the third leading cause of death among 15–29-year-olds worldwide, according to the World Health Organization. (1) While discourse on the determinants and prevention of suicide flourishes, it tends to focus on the individual—highlighting warning signs for parents, educators, and loved ones to recognize, or pointing to available self-help resources. Although these aspects of suicide prevention are undeniably valuable, there is an underlying and often uncomfortable truth about suicide: it is more than just an individual issue. Suicide is deeply connected to and rooted in systemic inequalities that disproportionately affect marginalized populations worldwide. Yet, suicide is often not treated as the multifaceted equity issue that it is.
In this article, I will try to shed light on the uncomfortable realities around suicide as one of the most significant contemporary global health threats. I will also argue for a more equitable approach to suicide prevention policy—one that addresses disparities across populations and targets its systemic root causes.
- Geography of Inequality
According to the World Health Organization (WHO), more than 720,000 people die due to suicide every year, and even more attempt to do so. (1) Out of those, 73% of global suicides occur in low- and middle-income countries (LMICs), emphasizing the disproportionate burden of suicide. (1)
In addition to disparities across populations, global suicide statistics reveal significant gender differences. Men are more likely to die by suicide, whereas women report higher rates of suicide attempts. (2) International variations in this gender gap in suicide have been linked to varying levels of gender inequality, which can be better understood by examining the gender norms in play. (3) The example of the Southeast Asian region, which accounts for approximately 50% of deaths by suicide among women in LMICs, highlights the vulnerability of women to suicide due to sociocultural factors, including limited agency, restrictive patriarchal norms gendered practices of early marriage and dowry, pressure towards child-bearing, gender-based violence, and domestic abuse (4).
Systemic barriers to care, especially in LMICs, can limit access to healthcare. In these settings, women may avoid seeking help due to fears of victimisation or shame. (5) The case of Indian women living in low-resource settings exemplifies a particularly vulnerable group in terms of accessing mental healthcare. Their overrepresentation in diagnostic categories such as depression can be attributed to trauma rooted in patriarchal norms, gender-based discrimination, violence, and conflicting societal expectations and roles. (6)
Conversely, norms and perceptions around “masculinity” can have various implications for men, from shaping mental health perceptions to discouraging help-seeking behaviours and reinforcing maladaptive coping strategies when dealing with psychological challenges. (4) Particularly in cultures emphasizing traditional masculinity, men often face mental health stigma. The fear of “otherness” due to mental struggles, reinforced by gender norms, can ultimately impact their willingness to seek help.
According to the WHO, vulnerable populations exposed to conflict, violence, disaster, abuse, and discrimination—such as refugees, migrants, and LGBTI individuals—are also disproportionately affected by high suicide rates. (1) A striking example of this inequality is seen in the alarmingly high suicide rates among Indigenous populations globally, from Australia to Canada. These communities have long faced the enduring effects of colonial trauma, marginalisation, and economic disadvantage, while also dealing with the fragmentation of their Indigenous identity and the ever-evolving divide between Indigeneity and contemporary colonial influences.
These populations’ experience of social discrimination and being systemically “othered” within one’s society, including the educational system, employment opportunities, and healthcare, is another significant determinant of ill mental health, not only due to chronic stress and experiences of trauma but also due to isolation and lack of access to all aspects of social life that promote mental well-being. After all, social “safety nets”—such as relationships with friends, neighbours, co-workers, and family members—can play a crucial role in reducing isolation, fostering emotional expression, and supporting coping strategies, which can help protect against suicide. The absence of these support systems can be detrimental, as is often seen in migrant and refugee populations.
- The “Treatment Gap” in Mental Healthcare
To better understand global inequities in suicide prevalence and prevention, it is essential to explore the social determinants of health—the conditions in which people are born, grow, live, work, and age. (7)
Even though suicide is often thought of as rooted in mental illness, social factors like poverty, unemployment, access to education and healthcare, social isolation, discrimination, violence, and systemic abuse wield a major influence. The positive correlation between poverty and suicide is a prime example of how societies have historically failed and continue to fail their most vulnerable members. Despite our knowledge that economic hardship and its consequences exacerbate psychological health, mental healthcare remains largely inaccessible to those who need it most.
One of the most glaring inequities in mental health is seen in LMICs, where over 75% of people dealing with mental illness do not have access to any form of mental healthcare, highlighting the “treatment gap” that exists for mental illness worldwide. (8) In fact, globally, only 2% of national health budgets go to mental health, with this figure being significantly lower in LMICs. (9) For the minority that does receive mental healthcare, said care is often unaffordable and geographically inaccessible due to being concentrated in urban areas, leaving rural populations underserved. According to UNICEF, in 2023 there was an average of 0.1 psychiatrists per 100,000 population across the African region. (10) This shortage is linked to multiple crises, including political instability, armed conflicts, disease outbreaks, and, most significantly, low international prioritisation of financing and investment in healthcare systems that address local needs.
Discussions around leveraging telehealth to assist rural and low-resource settings, where mental healthcare is often inaccessible or nonexistent, have gained particular traction, especially given the usage of remote digital healthcare during the COVID-19 pandemic. However, such initiatives in rural settings and LMICs are still plagued by the inaccessibility of adequate, up-to-speed technological infrastructure and digital literacy to benefit users.
- Addressing Stigma and Suicide Awareness
As we consider the many intricate ways in which societies have systemically failed to protect their own, we cannot deny the role of stigma as one of the most pervasive and resilient barriers to suicide prevention. Not only does it prevent or even exclude individuals from seeking mental healthcare, but it also influences the way health systems evaluate and respond to users’ needs, leading to disparities and unequal treatment.
There seems to be a reciprocal cause-and-effect relationship between stigma and suicidality, offering a valuable anthropological lens for exploring diverse cultural perspectives on suicide and mental illness globally. Mental illness across cultures can be intricately connected to negative connotations and assumptions around personal value, success, identity, familial honour, and religious guilt, leading to internalised shame, with individuals viewing their struggles as moral failings or reflections of weakness.
Despite advancements in awareness and treatment in Western societies, stigma is still perpetuated in ways that mirror the attitudes that different cultures and societies are often criticized for. In fact, the assumption that stigmatizing attitudes towards suicide are only prevalent in non-Western societies is one that can be easily overruled. This becomes evident when we delve deeper into the assumptions we make, both consciously and subconsciously, in Western contexts when dealing with our own or other’s struggles with suicidality and mental illness.
Within healthcare settings, stigma can have a major impact on mental healthcare delivery and reinforce inequalities within the healthcare sector. Marginalised groups are more vulnerable to experiencing dismissal and devaluation of their experiences by healthcare professionals, who are often affected by systemic failures in the education and healthcare sectors. (11) These failures prevent them from receiving adequate, holistic, and empathetic training and adopting human-rights-based and patient-centred approaches to their practice. As a result, many professionals remain limited by rigid, narrow, and outdated medical perspectives, leading to implicit bias and culturally insensitive approaches to suicide prevention and mental health promotion.
Illustration by Monica Garwood
- The Way Forward
Ensuring equity in suicide prevention calls for global collaboration and action across many fronts. At its heart, it requires us to reconsider how we approach mental health, especially for underserved populations across the world who take on the global burden of mental illness, yet whose needs are often overlooked.
To achieve meaningful progress, local communities must be at the centre of discussions, shaping solutions that reflect their unique realities. The WHO’s Comprehensive Mental Health Action Plan 2013-2030 underscores the importance of community-based approaches to mental health equity, advocating for integrated mental health and social services that are accessible, culturally competent, and destigmatizing. (12)
Public health policy changes are also essential in addressing inequities in suicide prevention. Integrating mental health services into primary healthcare, while also prioritizing global health initiatives and increasing funding for local governments, can significantly enhance prevention efforts. Key initiatives can span from the decriminalization of suicide, strengthening mental health legislation, launching awareness campaigns, and incorporating mental health education into school curricula.
Governments and international organizations have a key role to play in promoting health equity in suicide prevention. WHO’s “LIVE LIFE” Implementation Guide for Suicide Prevention urges countries to take action, outlining a comprehensive, evidence-based national strategy that can be scaled up globally, focusing on policy reforms, reducing access to lethal means, such as toxic pesticides and firearms, and providing support for vulnerable populations. (13)
The recent series “A Public Health Approach to Suicide Prevention”, published in The Lancet Public Health, showcases the critical role that comprehensive public health approaches can play in strengthening prevention efforts by including broader societal measures to address the social determinants of suicide—such as financial hardship, domestic violence, and substance abuse. Suicide prevention needs to extend beyond the health sector, involving policymakers in areas like finance, education, and social services. Creating space for people with lived experiences of suicide to share their expertise is also pivotal, as their perspectives can enhance the relevance of prevention efforts and guarantee that they are grounded in the true needs of end-users. Strengthening interdisciplinary collaboration in suicide prevention to mitigate risk factors will allow for more equitable interventions, particularly in LMICs, where the suicide burden remains disproportionately high. (14)
As we look ahead into the future of global mental health, it becomes clear that achieving health equity in suicide prevention is not just a public health imperative, but also a matter of social justice. Only by fostering equitable global health collaborative action that addresses the social determinants of health, can we reduce the devastating impact of suicide worldwide and move closer to achieving health equity for all.
Resources:
- World Health Organization. Suicide [Internet]. World Health Organization. World Health Organization; 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/suicide
- World Health Organization. Global Health estimates: Leading Causes of Death [Internet]. World Health Organization. 2020. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death
- Chang Q, Yip PSF, Chen YY. Gender Inequality and Suicide Gender Ratios in the World. Journal of Affective Disorders. 2019 Jan;243:297–304.
- Seidler ZE, Dawes AJ, Rice SM, Oliffe JL, Dhillon HM. The Role of Masculinity in men’s help-seeking for depression: a Systematic Review. Clinical Psychology Review. 2016 Nov;49:106–18.
- Naslund JA, Deng D. Addressing Mental Health Stigma in low-income and middle-income countries: a New Frontier for Digital Mental Health. Ethics, Medicine and Public Health. 2021 Dec;19:100719.
- Maitra S, Brault MA, Schensul SL, Schensul JJ, Nastasi BK, Verma RK, et al. An Approach to Mental Health in Low- and Middle-Income Countries: a Case Example from Urban India. International Journal of Mental Health. 2015 Jul 3;44(3):215–30.
- World Health Organization. Social Determinants of Health [Internet]. World Health Organisation. 2021. Available from: https://www.who.int/health-topics/social-determinants-of-health
- European Commission. Final Report Summary – EMERALD (Emerging Mental Health Systems in low- and middle-income countries) [Internet]. Available from: https://cordis.europa.eu/project/id/305968/reporting/de
- World Health Organization. WHO Report Highlights Global Shortfall in Investment in Mental Health [Internet]. http://www.who.int. 2021. Available from: https://www.who.int/news/item/08-10-2021-who-report-highlights-global-shortfall-in-investment-in-mental-health
- UNICEF. Mental Health a Human right, but Only 1 Psychiatrist per 1,000,000 People in sub-Saharan Africa – UNICEF/WHO [Internet]. http://www.unicef.org. 2023. Available from: https://www.unicef.org/esa/press-releases/mental-health-a-human-right
- World Health Organization, Mental Health and Poverty Project. Mental Health and Development: Targeting People with Mental Health Conditions as a Vulnerable Group. 2010.
- World Health Organisation. Comprehensive Mental Health Action Plan 2013 – 2030 [Internet]. http://www.who.int. 2021. Available from: https://www.who.int/publications/i/item/9789240031029
- World Health Organization. LIVE LIFE: an Implementation Guide for Suicide Prevention in Countries [Internet]. http://www.who.int. 2021. Available from: https://www.who.int/publications/i/item/9789240026629
- The Lancet Public Health. A Public Health Approach to Suicide Prevention. 2024; Available from: https://www.thelancet.com/series/suicide-prevention
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