Suicide Prevention

Suicide takes the lives of thousands of people worldwide, leaving behind an aftermath of confusion and grief. Suicide is one of the top 20 causes of mortality.1 Worldwide, more deaths have occurred by suicide than by homicide and war combined.2

Over the last 100 years, Hungary has experienced the highest suicide rate in the world (27 per 100,000 people),3 while Latin American and Muslim countries report the lowest rates (6.5 per 100,000).4 In the United States, suicide takes the lives of more than 33,000 people each year and is the 10th leading cause of death.5

Suicide is costly to society because it increases the use of health services and leads to a loss of productivity. The estimated cost is $1.5 million per completed suicide, constituting 1.5% of the global burden of disease and more than 20 million disability-adjusted life years lost (years of healthy life lost).6

Psychiatric disorders are present in 90% of suicides.4,6 Depression is a major contributor.7 Other contributing factors are unemployment, alcoholism and substance abuse. Academic factors also contribute to suicide attempts, due to a conception of diminished purpose in life among people who have a lower education.1

The strongest empirical support for suicide prevention is for the restriction of means to commit suicide.1,4,6,8 Unplanned or briefly planned suicides tend to use the method most readily available, so poor access to means may be a substantial impediment.2,4,6,9

Contributing Factors
Psychiatric disorders, including depression, are chronic and recurrent. Better access to mental health treatment is essential to decreasing suicide.4,6,9 Many people at high risk may not opt for help or referral due to the stigma associated with mental illness.4,6,10-12 A need exists to link people at risk to support systems that foster confidentiality, privacy and trust.4,10-12

Preventive measures can reduce the morbidity and mortality that stem from suicidal thoughts. Recognition of risk factors and provision of early intervention can prevent this behavioral public health crisis. Ram et al1 found that suicide attempters perceived that their attempt could have been prevented. Publicity campaigns and community and professional education programs can be effective in preventing suicide.13,14 Best practices include training of primary care providers, improving access to care, and restricting lethal means of suicide.3,4,6,8

Although the concept of empathy and support are certainly not new in any health setting, appreciation of these concepts and timing of suicide prevention measures may make the difference between someone completing suicide or reaching out for help.15,16 People who have access to mental health services and seek adequate treatment and assessment in a timely manner decrease their risk of suicide.1,4,6,9,11,17,18

Three Areas for Prevention
A review of the literature published over the past decade highlights evidence in three important areas of suicide prevention. Prevention or reduction in the number of suicides was demonstrated when access to a specific suicide method was restricted, when telephone contact or other means of contact was utilized, and when educational intervention targeted primary care providers.

SEE ALSO: Adult Suicide

Much of the literature agrees that best practice includes restricting access to means for suicide.1,2,4,6,8,9,14 Studies show that suicide attempts are often method-specific, and that poor access to means can be a substantial impediment.2,6,8,19 Studies also agree that the media plays a substantial role in suicide prevention.4,6,9,11,13,20 A negative influence can occur when the media glamorizes suicide. The literature suggests that responsible reporting or no reporting of suicide is the guideline that should be followed.4,13

Telephone-based collaboration has led to significantly fewer suicides.18 Improved linkages to outpatient mental health treatment have been a positive result of telephone intervention15 and have made a significant difference in decreasing the rate of reattempted suicide and suicide completion.7,14,18 A contact-based intervention via telephone call tends to be viewed as a gesture of caring by the patient.7,18,21 A supportive approach with good contact and collaborative problem solving are empirically effective in suicide prevention.21

Telephone-based interventions can produce encouraging results as long as the listener provides compassion and care with a genuine interest and empathy.6,7,17 Gatekeepers, people who are recognized by a person with suicidal intent as someone to reach out to for help, also play a part in reducing suicidal behavior.4,12,13 Research shows that long-term contact and telephone-based intervention improve linkage to outpatient mental health treatment and has a positive influence on preventing death from suicide.22,23

One study suggested telephone intervention as a low-cost program.Many researchers agreed that telephone intervention and follow-up contact could reduce rates of suicide, reduce hospital readmission, and increase treatment adherence.1,4,6,7,16-18,20,21,24 However, studies of crisis telephone calls found no standardized protocols and that quality differs greatly from center to center.10,14 Most crisis centers have no monitoring of quality assurance, and those attempting to help may do more harm than good.

The literature suggests that the Internet may also prove to be a tool that people use to reach out when in crisis.2,4,11,20,24 The concern among researchers is that the Internet is not regulated, and that the therapeutic value of information found there is questionable. Globalization and cultural awareness may hinder some people from receiving help during a crisis situation. Additional research is needed in this area.

Research shows that suicide rates may decrease after educational interventions targeting primary care providers.3,4 Psychiatric disorders are underrecognized and undertreated in primary care.4,9 Fewer than 1 in 6 patients was receiving adequate antidepressant treatment from a primary care provider when they committed suicide.25 The education of primary care providers to recognize and treat depression can reduce the number of suicides.3,4 Generally, the literature shows that primary care providers, gatekeepers and community education endeavors are effective at several levels and appear to reduce suicides.4,6,9 Mixed results have been noted in youth suicide prevention programs.6

A Synergistic Effect
Many of the reviewed articles concluded that multiple factors in prevention may have a synergistic effect. Most of the literature agreed that it is difficult to demonstrate the effectiveness of a specific treatment. The logistical demands and financial requirements for research are daunting. Large sample sizes are needed to assess a change in the relatively low suicide base rate. Other researchers agree that the lack of randomized controlled trials (RCTs) demonstrating effectiveness of specific treatment is due to methodological challenges that are formidable. RCTs produce the most compelling evidence, but the use of a control group is difficult in this type of research.

Health policy initiatives for the prevention of suicide have been initiated in several countries.3,4,6,7,12 The World Health Organization has identified six basic steps for suicide prevention, but there is no proof that they work.13 Unequivocally, a multi-layered suicide prevention intervention decreased the risk of suicide.26

The review and synthesis of the literature identified three important areas of suicide prevention. There is a general consensus that restricting access to suicide methods, telephone contact and an educational intervention targeting primary care providers may pay high dividends in suicide prevention. Innovations for providing support and reinforcement of help-seeking behaviors can enhance health intervention or provide treatment as usual. Even a brief information session followed by contact using a systematic approach had a positive influence on preventing death by suicide, and telephone intervention is a useful strategy for delaying further suicide attempts.7,22A primary care-based intervention produced a greater decline in suicide rates, and restricting access to lethal means was found to prevent suicide.3,4,19

Suicide is a significant health issue in all countries. Increased education and awareness programs could increase suicide prevention. The taboo of suicide makes it challenging and time consuming to follow up with people who engage in self-harm; this population is difficult to engage in research. Ideally, further study of morbidity and mortality associated with suicide and suicide attempts should be guided by specific testable hypotheses with a sizeable population to allow for generalizability and reliable results. As clinical research continues, additional opportunities exist to enable exploration of interventions that are multimodal and evidence-based.

Jane Ackerley is a psychiatric-mental health nurse practitioner at La Frontera Arizona Behavioral Health in Tucson, Ariz.

References
1. Ram D Darshan M S Rao T S Honagodu A R 2012 Suicide prevention is possible: A perception after suicide attempt.Ram D, et al. Suicide prevention is possible: A perception after suicide attempt. Indian J Psychiatry. 2012;54(2):172-176.

2. Florentine J B Crane C 2010 Suicide prevetnion by limiting access to methods: A revie of theory and practice.Florentine JB, Crane C. Suicide prevention by limiting access to methods: A review of theory and practice. Soc Sci Med. 2010;70(10):1626-1632.

3. Szanto K Kalmar S Hendin H Rihmer Z Mann J J 2007 suicide prevention program in a region with a very high suicide rate.Szanto K, et al. A suicide prevention program in a region with a very high suicide rate. Arch Gen Psychiatry. 2007;64(8):914-920.

4. Mann J J Apter A Bertolote J Beautrais A Currier D Haas AHendin H 2005 Suicide Prevention Strategies: A systematic review.Mann JJ, et al. Suicide prevention strategies: A systematic review. JAMA. 2005;294(16):2064-2074.

5. Suicide: Statistics, warning signs and prevention. http://www.livescience.com/44615-suicide-help.html

6. Van der Feltz-Cornelis C M Sarchiapone M Postuvan V Volker D Roskar S Grum A THegerl U 2011 Best practice elements of multilevel suicide prevetnion strategies: A review of systematic reviews.Van der Feltz-Cornelis CM, et al. Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews. Crisis. 2011;32(6):319-333.

7. Cebria A I Parra I Pamias M Escayola A Garcia-Pares G Punti JPalao D J 2012 Effectiveness of a telephone management programme for patiens dicharged form an emergency department after a suicide attempt: Controlled study in a Spanish population.Cebria AI, et al. Effectiveness of a telephone management programme for patients discharged from an emergency department after a suicide attempt: Controlled study in a Spanish population. J Affect Disord. 2012;147(1-3):269-276.

8. Yip P S Caine E Yousuf S Chang S S Wu K C Chen Y Y 2012 Means restriction for suicide prevention.Yip PS, et al. Means restriction for suicide prevention. Lancet. 2012;379(9834):2393-2399.

9. Judd F Jackson H Komiti A Bell R Fraser C 2021 profile of suicide: Changing or changeable.Judd F, et al. The profile of suicide: changing or changeable? Soc Psychiatry Psychiatr Epidemiol. 2012;47(1):1-9.

10. Borschmann R Hogg J Phillips R Moran P 20111 Measuring self-harm in adults: A systematic review.Borschmann R, et al. Measuring self-harm in adults: A systematic review. Eur Psychiatry. 2011; 27(13):176-180.

11. Eagles J M Carson D P Begg A Naji S A 2003 Suicide prevention: A study of patients’ views.Eagles JM, et al. Suicide prevention: A study of patients’ views. Br J Psychiatry. 2003;182:261-265.

12. Isaac M Elias B Katz L Y Belik S L Deane F P Enns M W Sareen J 2009 Gatekepper training as a preventative interventon for suicide: A systematic review.Isaac M, et al. Gatekeeper training as a preventative intervention for suicide: a systematic review. Can J Psychiatry. 2009;54(4):260-268.

13. Goldney R D 2005 Suicide prevention: A pragmatic reiview of recent studies.Goldney RD. Suicide prevention: A pragmatic review of recent studies. Crisis. 2005;26(3):128-140.

14. Mishara B L Martin N 2012 Effects of a comprehensive police suicde prevention program.Mishara BL, Martin N. Effects of a comprehensive police suicide prevention program. Crisis. 2012;33(3):162-168.

15. Asarnow J R Baraff L J Berk M Grob C S Devich-Navarro M Suddath R Tang L 2011 emergency department intervention for inking pediatric suicidal patients to follow-up mental health treatment: Intervetntion leads to higher rated of care among suicidal youth.Asarnow JR, et al. An emergency department intervention for linking pediatric suicidal patients to follow-up mental health treatment. Psychiatr Serv. 2011;62(11):1303-1309.

16. Cooper J Hunter C Hons B A Owen-Smith A Gunnell D Donovan JKapur N 2011 “Well it’s like someone at the other end cares about you.” A qualitative study exploring the views of users and providers of care of contact-based interventions following self-harm.Cooper J, et al. “Well it’s like someone at the other end cares about you.” A qualitative study exploring the views of users and providers of care of contact-based interventions following self-harm. Gen Hosp Psychiatry. 2011;33(2):166-176.

17. Deuter K Procter N Rogers J 2013 emergency telephone conversation in the context of the older person in sucidal crisis: A qualitative study.Deuter K, et al. The emergency telephone conversation in the context of the older person in suicidal crisis: A qualitative study. Crisis. 2013;34(4):262-272.

18. Hailey D Roine R Ohinmaa A 2008 effectiveness of telemental health applications: A review.Hailey D, et al. The effectiveness of telemental health applications: A review. Can J Psychiatry. 2008;53(11):769-778.

19. Cox G R Owens C Robinson J Nicholas A Lockley A Williamson MPirkis J 2013 Interventions to reduce suicides at suicide hotspots: A systematic review.Cox GR, et al. Interventions to reduce suicides at suicide hotspots: A systematic review. BMC Public Health. 2013;13(214):1-12.

20. Lester D 2008 use of the internet for counseling the suicidal individual: Possibilities and drawbacks.Lester D. The use of the internet for counseling the suicidal individual: possibilities and drawbacks. OMEGA. 2008;58(3):233-250.

21. Mishara B L Chagnon F Daigle M Balan B Raymond S Marcoux IBerman A 2007 Comparing models of helper behavor to actual practice in telephone crisis intervention: A silent monitoring study of calls tothe U.S. 1-800-SUICIDE Network.Mishara BL, et al. Comparing models of helper behavior to actual practice in telephone crisis intervention: A silent monitoring study of calls to the U.S. 1-800-SUICIDE Network. Suicide Life Threat Behav. 2007;37(3):291-307.

22. Fleischmann A Bertolote J M Wasserman D De Leo D Bolhari J Botega N J Thanh H T 2008 Effectiveness of brief intervention and contact for suicide attempters: A randomized controlled trial in five countries.Fleischmann A, et al. Effectiveness of brief intervention and contact for suicide attempters: A randomized controlled trial in five countries. Bull World Health Organ. 2008;86(9):703-709.

23. Li Z Page A Martin G Taylor R 2010 Attributable risk of psychiatric and socio-economic factors for suicide from individual-level, population-based studies: A systematic review.Li Z, et al. Attributable risk of psychiatric and socio-economic factors for suicide from individual-level, population-based studies: A systematic review. Soc Sci Med. 2010;72(4):608-616.

24. Krysinska K E De Leo D 2007 Telecommunication and suicide prevention: Hopes and challenges for the new century.Krysinska KE, De Leo D. Telecommunication and suicide prevention: Hopes and challenges for the new century. OMEGA. 2007;55(3):237-253.

25. Mann JJ, Currier D. Prevention of suicide. Psychiatric Ann. 2007;37(5):331-339.

26. Knox K L Litts D A Talcott G W Feig J C Caine E D 2003 Risk of suicide and related adverse outcomes after esposure to a sucide prevention programme in the US Air Force: Cohort study.Knox KL, et al. Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study. BMJ. 2003;327(7428):1376.

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