The Atlantic: Is it possible to eliminate suicide?
Sweden has dramatically reduced traffic-accident deaths. Can it stop people from killing themselves?
Road safety: It’s become one of Sweden’s most successful exports—right up there with flat-pack furniture and affordable fashion. Back in 1997, the Swedish parliament adopted a policy known as “Vision Zero,” premised on the idea that traffic deaths and serious car accidents are unacceptable and that the state should go to great lengths to help citizens avoid them. Today, the approach has been embraced everywhere from the European Union to New York City and San Jose. Just in recent weeks, Qatar hosted a vision-zero conference and Singapore unveiled a vision-zero campaign for the workplace.
There’s a logic behind this imitation. Sweden has engineered one of the world’s lowest traffic-related fatality rates thanks to educational campaigns, new vehicle technology, surveillance systems, and infrastructural innovations, including pedestrian bridges and bike-lane barriers. Fewer than three out of every 100,000 Swedes die in road accidents each year, compared with more than 11 in the United States. As The Economist noted about Sweden last year, “Although the number of cars in circulation and the number of miles driven have both doubled since 1970, the number of road deaths has fallen by four-fifths during the same period.”
But in Sweden, Vision Zero thinking—the idea of aiming for a society free from serious accidents and for systems “designed to protect us at every turn”—has also come to permeate spheres far beyond roads and traffic. This year alone, demands for similar initiatives have come from the Swedish Life Rescuers’ Association (whose members want a Vision Zero approach to drowning accidents), the National Association of Pensioners (a Vision Zero scheme to prevent falls among the elderly), and a coalition of construction workers’ associations and unions (a Vision Zero plan to eliminate construction-site accidents). Sweden’s minister for employment recently vowed to develop a Vision Zero program to eliminate fatal accidents at Swedish workplaces because “nobody should have to die on the job.” And in February, Ebba Busch Thor, the current leader of Sweden’s Christian Democrat Party, called for a Vision Zero approach to abortion.
The healthcare sector is not immune. In 2008, Sweden’s then center-right coalition government announced a Vision Zero approach to suicide prevention. “No one should have to end up in such a vulnerable situation where the only perceived way out is suicide,” the plan stated. “The government’s vision is that no one should have to take their own life.” The government summarized the national campaign in a nine-point program with broad strategies like reducing “alcohol consumption in the general population and in high-risk groups” and harnessing “medical, psychological, and psychosocial measures.” These strategies have had some concrete effects. For instance, the goal of “reducing access to means and methods for committing suicide” has altered Swedish cityscapes, leading to initiatives like mounting fences along bridges to discourage people from jumping off of them.
But so far, there’s little evidence that the program has achieved measurable success in eliminating suicides or even driving down the suicide rate. Around 1,400 to 1,500 people kill themselves every year in Sweden, a country with a population of 9.6 million. The suicide rate was declining for several decades prior to the 2000s, when the rate plateaued at roughly 20 suicides per 100,000 citizens aged 15 and above. (Suicide is an especially touchy subject in Sweden; a government website debunks the perception that “Swedes are suicidal,” noting that the country “ranks outside the world’s top 40” for suicides per capita and tracing the myth to Dwight Eisenhower claiming that the Swedish welfare system had spawned “sin, nudity, drunkenness and suicide.”) Sweden witnessed its lowest suicide rate since 1980 in 2011, when 1,378 people killed themselves. But that number then rose to 1,600 in 2013. Today, suicide is the most common cause of death for Swedish men and women aged 15 to 24. In the 15-to-44 age group, suicide is the most common cause of death among men and the second-most common cause of death among women.
Some attribute this lack of success to the nine-point plan’s vague objectives. In a 2012 op-ed, Alfred Skogberg, president of the non-profit organization Suicide Zero, called for practical, targeted measures like airbags on the front of trains in case someone jumps on the tracks, suicide-safe exhaust pipes for cars, tougher rules for selling painkillers to young people, and four mandatory therapy sessions for individuals who have attempted suicide. Skogberg pointed out that while five times more Swedes die from suicide than from traffic accidents, the state allocates 3 million Swedish krona per year (roughly $360,000) to the National Center for Suicide Research and Prevention of Mental Ill-Health—the authority responsible for suicide research and prevention programs—while investing between 100 and 150 million krona per year in traffic-safety research. With such insufficient investment, Skogberg said, the vision of eliminating suicide will prove elusive. (Kerstin Evelius, the Swedish government’s coordinator for psychiatric health, told me that the 3 million krona given to the center is just a fraction of the government’s investments in suicide-prevention efforts, which are also dispensed at the regional and local levels.)
Skogberg isn’t alone in his critique of the government’s suicide-prevention efforts. The Swedish mental-health charity Mind supports the zero-suicide vision but maintains that not enough has been done to achieve it. The organization’s director, Carl von Essen, suggested a series of reforms in a 2014 op-ed, including formulating indicators and annual targets like halving the number of suicides in the country by 2025. Von Essen, who recently participated in a government-commissioned inquiry to improve the zero-suicide plan, takes issue with critics who say that the goal of eliminating suicides is unrealistic. “There are countries with lower suicide rates than Sweden, so it is entirely feasible to reduce suicide mortality further here, too,” he told me.
But other mental-health professionals have questioned the very premise of the Vision Zero approach, which is animated by the idea that the state has a duty to prevent individuals from harming both others and themselves. One such critic is David Eberhard, the chief physician at a psychiatric clinic in Stockholm, the Swedish capital. He told me that the country’s Vision Zero schemes are the ultimate proof of Swedes’ “addiction to safety” and of the Swedish state’s tendency to intervene in the personal lives of its citizens.
In his 2007 book I Trygghetsnarkomanernas Land (In the Land of the Safety Addicts), Eberhard argued that Swedes have developed an unhealthy avoidance of accidents and hazards at all costs, which has made them less capable of dealing with life’s risks and misfortunes. Cushioned by well-intentioned government authorities who are ready to ban anything with a whiff of danger about it, citizens lose both resilience and personal autonomy, Eberhard suggested.
Indeed, the Swedish Civil Contingencies Agency—a government body responsible for public safety, emergency management, and civil defense—recently launched campaigns to encourage Swedes to take more individual responsibility in times of emergency or crisis. In an agency survey, a majority of heads of local and regional emergency-management authorities said they believed most citizens would cope on their own for a maximum of 24 hours in the event of a crisis like a flood or wildfire. Respondents thought that at most half of all Swedes would help neighbors or strangers in the event that heat, water, or electricity were cut off. The others would expect someone else—a government official—to rush to their aid. The implication was that an over-reliance on the authorities might be hampering communal solidarity, individual resiliency, and plain decency.
Eberhard believes the zero-suicide program is not only unrealistic but also undesirable. “Of course all of us who work within psychiatry want to reduce suicide rates, but Vision Zero is a fantasy dreamt up by politicians with a lack of insight into science and into how psychiatry works,” he said.
Eberhard claimed that success in cutting suicide rates across the Western world in recent decades has largely been the result of two factors: antidepressants and early medical intervention. Excessive prescription can be a problem, he conceded, but radical improvements in treatments for depression and mental disorders, along with social shifts, have helped remove the stigma of seeking help.
Vision Zero schemes may seem like noble quests, he argued, but they constitute infinite pursuits for which citizens may pay a heavy price. “If we were to take this vision to its extreme, logical conclusion, then essentially the only way the state could reach the zero figure would be by forever bombarding psychiatric care with enormous amounts of money and locking up anyone who has ever mentioned having a thought about suicide,” said Eberhard, invoking a “logical conclusion” that, admittedly, hasn’t come to pass yet.
Already, Eberhard added, the zero-suicide plan has pushed many psychiatrists to embrace the precautionary principle: “Today, we’re simply too scared to release emotionally unstable patients—or those suffering from what is known as borderline personality disorder—because there is this pressure to prevent suicide at all costs, and so doctors and carers are afraid of being blamed if something happens to the patient once he or she leaves the hospital. The result is that, today, our institutional-care facilities are not mainly filled with people suffering from major depression, as was the case two decades ago, but with people who suffer from personality disorders, a milder diagnosis.”
Admitting such patients infringes on individual autonomy, Eberhard continued. But that’s not all. For patients who suffer from borderline personality disorder rather than clinical depression, in-patient care may prove an inappropriate and even dangerous intervention. Eberhard pointed to research showing that patients are particularly at risk of attempting suicide just after being released from the hospital. The experience exacerbates the fear of abandonment that many of these patients grapple with, since they abruptly go from having 24-7 care to being sent home alone with only occasional telephone contact with medical staff.
Another psychiatrist, Herman Holm, has drawn similar conclusions. In a 2011 article, Holm noted that, compared with 15 years earlier, Swedish women aged 16 to 24 were twice as likely to receive hospital care following suicide attempts or self-harm. While many benefit from such care, studies also show that many continue to harm themselves inside the clinics, which leads to more severe interventions like forced medication and the use of restraints. (Last summer, two psychiatric-care providers in southern Sweden launched a campaign to end the use of restraints by, of all things, demanding a Vision Zero approach to the practice, which politicians have since taken up.)
The larger question at the heart of the debate is whether Sweden’s innovative approach to road safety can be grafted onto suicide prevention. While there are concrete ways to steer drivers toward exercising more caution on the roads and to pressure car manufacturers into adding safety features to vehicles, the underlying causes of suicide are less tangible. To prevent drivers from accidentally killing pedestrians, you can lower the speed limit or introduce speed bumps. But what are the smart solutions to the existential ailments that lead people to harm or even kill themselves? How do you engineer away the anxiety, loneliness, social alienation, trauma, or psychiatric disorders that drive people to such extreme acts?
Alfred Skogberg of Suicide Zero has faith in the Swedish government’s ability to do exactly that. He argues that individuals do not choose to commit suicide. Instead, suicides are “psychological accidents.” As such, they should be regarded as just as unacceptable and preventable as road or workplace accidents.
Evelius, the Swedish government’s psychiatric-health coordinator, made another argument. “Critics say the zero vision is hard to reach, but on the other hand it is hard to see what other goal we should have as a society,” she observed. “I mean, how many suicides should we say are acceptable?”
But Eberhard doesn’t buy it, and he warns against overlooking the element of choice in such decisions. He cited the effort to suicide-proof bridges with fences. “People don’t try to kill themselves because there are bridges around, they kill themselves because they feel bad,” he said. “So we can make it harder to attempt suicide by jumping off bridges, but that won’t stop people from trying to end their own lives. They will likely do it some other way instead—by throwing themselves in front of a train, for instance. So does that mean we should get rid of trains?”