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There were, on average, 2.3 and 2.8 attempted suicides and deaths by suicide in the Garden Route District over the 3-year study period, respectively.

Death by suicide in South Africa (SA) accounted for more insurance-related death claims than trauma, crime and motor vehicle accidents in 2024 ( Bhana, 2025). Globally, suicide accounted for 727 000 deaths in 2021-with an estimated 20 attempted suicides per suicide ( Caulkins, 2022)-greater mortality than war, homicide and HIV/AIDS. This equates to one suicide for every 100 deaths ( World Health Organization, 2025). The global age-standardised suicide rate in 2021 was estimated at 8.9 per 100 000, whereas the Africa region recorded 11.5 per 100 000. SA recorded 23.5 per 100 000 population, equating to almost 14 000 deaths by suicide per annum, placing SA third highest in suicide rates in Africa ( World Health Organization, 2024, 2025). Significantly, suicide was the third leading cause of death amongst people aged 15-29, while globally, suicide ranked as the 21 ^st leading cause of death in 2021 ( World Health Organization, 2024, 2025). Suicide and suicidality have become a public health burden and an under-researched priority in low-and middle-income countries (LMICs) ( Pompili, 2022).

SA endures a quadruple disease burden, the effects of which are compounded by poverty, crime and inequality ( Ataguba et al., 2015; Burns, 2011) while producing numerous societal-level socioeconomic risk factors for mental illness exacerbation ( Motsoaledi & Matsoso, 2013). SA is deeply embedded in the social determinants of health, which indirectly affects the social determinants of mental health ( Compton & Shim, 2017). Sixty three percent of South Africans live in poverty; 31.9% are unemployed ( The World Bank, 2024; World Bank Group, 2020); a rape case is estimated to take place every 12 minutes ( Action Society, 2024; Egenasi et al., 2024; Gass et al., 2010); 86 murders, 88 attempted murders and 595 assault cases are reported to happen daily ( Prinsloo et al., 2022) and 18.9% of the population abuse alcohol and/or drugs ( Myers et al., 2022). These nuanced social constructs are all social antecedents for suicidality and suicide by aiding in the exacerbation of poor mental health, expediting pathways to suicidality.

Deinstitutionalisation through the Mental Health Care Act 17 of 2002 provided no compensatory mental health care community service or prioritisation of mental health through a health care plan at a provincial level ( Burns, 2011; Lund et al., 2011, 2012). Thus, EMS is de facto relied upon as a primary health care point for all poor mental health sequalae and related emergencies ( Tilley, 2021; Van Huyssteen, 2016). Notably, SA has multi-cultural challenges which can aggravate the need for urgent western mental health care ( Kirmayer, 2022; Kootbodien et al., 2020; Maharajh & Abdool, 2005; Motsoaledi & Matsoso, 2013), and complicate health seeking behaviour further. This suggests that all South African prehospital Emergency Care (EC) Providers are required to assess, treat and transport mental healthcare consumers with suicidality by navigating their social determinants of mental health while experiencing a mental health treatment gap. The lack of mental healthcare consumer compliance is further compounded by the loss of trained EC providers, psychologists, psychiatrists and mental healthcare providers ( Bateman, 2015; Burns, 2011; Jacob & Coetzee, 2018; Majiet et al., 2025).

Caulkins (2022) posits that suicide is looked at as ‘ syndemic’, rather than syndromic, and illuminates intersectionality as an interdisciplinary technique to advance further understanding of suicidality behaviours ( Caulkins, 2022). Syndemic theory elucidates how combining cultural factors and two or more physiological factors manifests a public health challenge and builds on the social determinants of health theory ( Caulkins, 2022). Considering syndemic theory as a theoretical lens for system level responses to suicide may have value for manifesting suicidality awareness from an African/LMIC perspective, notwithstanding that research on suicide and suicidality has low reporting rates in Africa ( World Health Organization, 2025) and is poorly represented in prehospital emergency care research.

There is limited empirical evidence describing suicidality typology in the South African prehospital EMS research. By appraising suicidality typology and epidemiologically descriptive evidence, the scope of the concern for the prehospital space becomes apparent. This has the potential to influence the building of suicidality capacity and knowledge for EC provider praxis. Thus, the question that arises is: What is the typology of suicidality within the prehospital, rural EMS context? The aim was to appraise suicidality case frequency and suicide typology for the EMS with the objectives being to estimate the scope of the suicidality challenge faced by a jurisdictional EMS and its care providers.

Over the 3-year period of sampled healthcare consumers who presented to the WCEMS, 14% (n = 412) presented with suicidality and death by suicide, while 63% (n = 1890) presented with mental illness sequela, considered stereotypical mental illness antecedents associated with deaths by suicide ( Kułak-Bejda et al., 2021). These were overdose/DSP, substance abuse, depression, anxiety, self-harm, bipolar disorder, schizophrenia and PTSD ( Table 1). There were, on average 2.8 deaths by suicide (n = 102) and 2.3 attempted suicides (n = 83) per month in the Garden Route District between 2017 and 2019. Gender and age associations were used to illuminate the suicidality and the death by suicide case load burden that EC providers from the WCEMS face. Prehospital EC providers were expected to respond to 412 (n) suicidality and death by suicide healthcare consumers from the census population of 2 976 (N) emergencies over the 3-year period ( Tilley, 2025).

There was a range of death by suicide and suicidality typologies in the Garden Route District over the 3-year study period, presenting in 14% ( n = 412) of IMRs sampled (representing health care consumer engagement). Death by suicide took place on average 2.8 ( n = 102) times a month, and attempted suicide 2.3 ( n = 83) times a month, and roughly 6.3 ( n = 227) health care consumers presented to the WCEMS with suicidal ideation monthly. Notably 63% ( n = 1890) of IMRs (health care consumers) presented with mental illness sequela, often related to suicide and suicidality victims’ medical history ( Klonsky et al., 2016; Kułak-Bejda et al., 2021). Significantly, in the same sample, males were five and two times more likely to die by suicide and attempt suicide than females, respectively ( Tilley et al., 2023). Males appeared more likely to use asphyxiation/hanging, while females used overdose or poisoning as a means of death by suicide in the study site ( Tilley et al., 2023). This dataset identified the risk of death by suicide, in a LMIC, to increase with age, until a peak age of 41 and decreases thereafter, making death by suicide risk the highest at 41 years of age. The median ages for death by suicide and attempted suicide were 36 years and 30 years, respectively. Notably in LMICs, suicide is a major public health issue, with 77% to 88% of global suicides occurring in these settings. While suicide rates increase with age in many regions, LMICs show a significant, distinct peak in suicide mortality among young adults, particularly those aged 15–29 years and 30–49 years ( Vijayakumar et al., 2016).

The data analysis provided similar inferences already denoted in articles on suicide globally, with asphyxiation/hanging being the most common method, and men being the most likely to die by suicide ( Klonsky et al., 2016; Kootbodien et al., 2020; Rahman et al., 2017; Ritchie et al., 2015). However, the presence of suicidal ideation, attempted suicides, cutting self-harm and overdose/DSP in the dataset is what was illuminating. Understandably, antecedents for suicidality ( Klonsky et al., 2016; Lim et al., 2019), individuals who inflict non-suicidal self-injury (disorder) are at risk of suicide attempts ( Brager-Larsen et al., 2024), while suicidal ideation and progression into suicide attempts are two phenomena that produce predictors towards death by suicide ( World Health Organization, 2014). Using the ideation-to-action framework, literature suggests deliberate self-harm and depression to be early and accurate indicators for suicidal ideation and suicidality ( Klonsky et al., 2016). The mental illness sequela from the dataset could suggest that, through better medical surveillance, more effort could be put into early suicide detection, knowing that PTSD, bipolar disorder, depression, substance abuse and suicidal ideation are associated with suicide deaths ( Klonsky et al., 2016). Prehospital emergency medical care provides health action to health conditions through emergency medicine in a time sensitive approach with universality and responsivity ( Christopher et al., 2014; Naidoo, 2017; Tilley et al., 2023) and can recognise the patterns and needs of mental healthcare consumers from an early stage to interrupt suicidality and limit access to methods of harm ( Florentine & Crane, 2010).

This dataset does not explain the perceptions prehospital EC providers have towards health care consumers who have suicidal ideation, suicidality and have attempted suicide. In various articles prehospital EC providers have explained to feel misconstrued on the concept of mental illness, self-harm and suicidality, often feeling lost and depleted by lack of legislation and policy, treatment protocols, training, guidance and personal negative conflict on own perceptions of attending mental health emergencies rather than trauma/medical emergencies ( Evans et al., 2018; O’Sullivan, 2014; Rees et al., 2015, 2018; Stander et al., 2021). In a study done in the same province in SA, it was found that 80% of the prehospital EC providers in the study had no prior training to manage suicidal health care consumers, seldom using formal suicide evaluation and capacity check tools, while implying negative feelings and connotations towards attempted suicide victims ( Evans et al., 2018). Inevitably, this lack of compassion, training and knowledge provides a precarious situation for prehospital EC providers, as this could prevent early mental health surveillance and suicidality interruption. A lack of praxis and management of suicidality and death by suicide caseload could put the EC provider helpless, creating an emotional backlash with direct or vicarious traumatisation to the EC provider. Notably, prehospital EC providers have disclosed battling with lasting visions from death by suicide scenes and battling with anxiety, PTSD and depression ( Padmanabhanunni & Pretorius, 2025; Rothes et al., 2020).

WCEMS prehospital EC providers locate in the suicide and suicidality burden and need to consider analytical clinical decision making ( Emond et al., 2024) in managing and treating mental healthcare consumers while considering the societal, cultural, religious and socioeconomic risk factors synonymous with suicide in SA ( Kootbodien et al., 2020). SA is precariously placed in the mental health milieu, with deinstitutionalisation and no appropriate policy and compensatory community mental health care services created ( Motsoaledi & Matsoso, 2013; World Health Organization, 2003). Atrocities from apartheid, poverty and inequality create exponential societal risk levels for suicidality and suicide, placing the prehospital EC provider and EMS at the forefront of mental health and suicidality emergencies. Located in the forefront of this caseload, prehospital EC providers need to have capacity to manage, treat and transport these health care consumers, have potential to interrupt suicidality by limiting access to harmful methods ( Florentine & Crane, 2010), contribute to social capital through latent capacity ( Tilley et al., 2023) while minding risk of direct and vicarious self-traumatization ( Sandford et al., 2021).

This socioeconomic landscape renders the concept of further research into Trauma Informed Care (TIC) as an interlude to disrupt negative postulation to suicidality, whereby understanding that childhood traumatic experiences can show signs of future mental health challenges, as most (mental) health is affected by past trauma ( Melillo et al., 2025; SAMHSA, 2014). Understanding and researching the benefits of TIC could be purposeful in an approach to management and training for healthcare consumers and EC providers respectively. The illumination of TIC and a syndemic approach to suicide could be associated with a dignified response to managing a marginalized group and the risk of vicarious traumatization of the EC provider ( Sandford et al., 2021). Subsequently, a syndemic approach to suicide ( Caulkins, 2022) in Southern Africa could be associated with interrupting suicidality, protecting people living (and dying) with such risk. Suicidality and suicide phenomenon is a complexity of challenges and the syndemic approach shows intersectionality to these challenges. The syndemic approach looks at suicide as a combination of challenges like culture, poverty, socioeconomic circumstances, mental illness, violence, trauma, chronic pain and stigma which amplify each other ( Caulkins, 2022). By manifesting research into the syndemic approach, the EMS could reflect this approach through training EC providers to identify suicidality as a product of behavioral, clinical and social challenges whereby TIC, medical treatment and referral pathways are tailored to mitigate risk of harm.

Tilley et al. (2023) described the Deliberate Self-Harm burden for the prehospital EMS; however, the novelty in this paper lies in the typological disaggregation of suicidality and death by suicide within EMS records. The authenticity of this research elucidates the suicidality burden faced by the South African prehospital EMS. Death by suicide and suicidality typology in the EMS have not been previously assessed in SA, illuminating a research and practice problem space. This study describes the prehospital suicide and suicidality burden for the WCEMS. Prehospital EC providers need to retain the praxis, training, emotion, policies and legislation to comprehensively manage, treat and transport healthcare consumers with suicidality ( Simpson et al., 2025) and that this proven challenge could require lateral deliberation ( Emond et al., 2024). This documented death by suicide and suicidality typology presents a novel and fundamental understanding of the prehospital suicidality problem space definition. This study quantifies the burden for the EMS; however, it provides no solution to training, management, treatment, or EC provider perception towards death by suicide and suicidality. Further study is required on EC provider stigmatisation towards death by suicide and suicidality, while auditing the need to assess policy, praxis, medical surveillance, EC provider clinical competency capacity and suicidality victim perspectives, as healthcare consumer level interventions on strategic suicide prevention have aided in the reduction of suicide attempts ( Zarska et al., 2023).

Ethics was granted for this study through the Research Ethics Committee of the Cape Peninsula University of Technology (CPUT/HW-REC 2019/H17). Permission for access to the Western Cape National Health Research Database was obtained from the Western Cape Government (WC_201911_033).