Suicide prevention

As a suicide prevention initiative, this sign on the Golden Gate Bridge promotes a special telephone, available on the bridge itself, with which persons considering suicide can connect to a crisis hotline.

Suicide prevention is an umbrella term used for the collective efforts of local citizen organizations, health professionals and related professionals to reduce the incidence of suicide. Beyond direct interventions to stop an impending suicide, methods also involve:

  • Treating the psychological and psychophysiological symptoms of depression.
  • Improving the coping strategies of persons who would otherwise seriously consider suicide.
  • Reducing the prevalence of conditions believed to constitute risk factors for suicide.
  • Giving people hope for a better life after current problems are resolved.

General efforts have included preventive and proactive measures within the realms of medicine and mental health, as well as public health and other fields. Because protective factors such as social support and social engagement — as well as environmental risk factors such as access to lethal means — apparently play some significant roles in suicide prevention, suicide should not be viewed solely as neither a medical issue nor a mental health issue.[1][2] Suicide prevention is risky for health professionals in terms of practitioner emotional distress and risk for malpractice suits.[3]

Risk assessment

Warning signs

Being aware of the warning signs of suicide can allow individuals to direct people who may be considering suicide to get help.[4]

Warning signs include:[5]

  1. Suicidal ideation: thinking, talking, or writing about suicide, planning for suicide
  2. Substance abuse
  3. Purposelessness
  4. Anxiety, agitation and unable to sleep or not sleeping all the time
  5. Trapped
  6. Hopelessness
  7. Social withdrawal from friends, family, or society
  8. Anger, rage or seeking revenge
  9. Recklessness or impulsiveness
  10. Mood changes including depression

Additionally, the national institute for mental health includes feeling burdonsome, and strong feelings of pain--either emotional or physical--as warning signs that someone may intend attempt suicide.[4]

Some signs that someone may attempt suicide include:[4]

  1. strong feelings of pain, either emotional or physical considering oneself burdensome
  2. increased use of drugs or alcohol

Screening

The U.S. Surgeon General has suggested that screening to detect those at risk of suicide may be one of the most effective means of preventing suicide in children and adolescents.[6] There are various screening tools in the form of self-report questionnaires to help identify those at risk such as the Beck Hopelessness Scale and Is Path Warm?. A number of these self-report questionnaires have been tested and found to be effective for use among adolescents and young adults.[7] There is however a high rate of false-positive identification and those deemed to be at risk should ideally have a follow-up clinical interview.[8] The predictive quality of these screening questionnaires has not been conclusively validated so it is not possible to determine if those identified at risk of suicide will actually commit suicide.[9] Asking about or screening for suicide does not create or increase the risk.[10]

In approximately 75 percent of completed suicides, the individuals had seen a physician within the year before their death, including 45 to 66 percent within the prior month. Approximately 33 to 41 percent of those who completed suicide had contact with mental health services in the prior year, including 20 percent within the prior month. These studies suggest an increased need for effective screening.[11][12][13][14][15] Many suicide risk assessment measures are not sufficiently validated, and do not include all three core suicidality attributes (i.e., suicidal affect, behavior, and cognition).[16]

Underlying condition

The conservative estimate is that 10% of individuals with psychiatric disorders may have an undiagnosed medical condition causing their symptoms,[17] upwards of 50% may have an undiagnosed medical condition which if not causing is exacerbating their psychiatric symptoms.[18][19] Illegal drugs and prescribed medications may also produce psychiatric symptoms.[20] Effective diagnosis and if necessary medical testing which may include neuroimaging[21] to diagnose and treat any such medical conditions or medication side effects may reduce the risk of suicidal ideation as a result of psychiatric symptoms, most often including depression, which are present in up to 90–95% of cases.[22]

Interventions

A photo illustration produced by the Defense Media Agency on suicide prevention

Many methods have been developed in an effort to prevent suicide. The general methods include: direct talks, screening for risks, lethal means reduction and social intervention. The medication lithium may be useful in certain situations to reduce the risk of suicide.[23][24] Talk therapies[25] including phone delivery of services may also help.[26]

Direct talks

National Suicide Prevention Lifeline, a nationwide crisis line in the United States also available in Canada

An effective way to assess suicidal thoughts is to talk with the person directly, to ask about depression, and assess suicide plans as to how and when it might be attempted.[27] Contrary to popular misconceptions, talking with people about suicide does not plant the idea in their heads.[27] However, such discussions and questions should be asked with care, concern and compassion.[27] The tactic is to reduce sadness and provide assurance that other people care. The WHO advises to not say everything will be all right nor make the problem seem trivial, nor give false assurances about serious issues.[27] The discussions should be gradual and specifically executed when the person is comfortable about discussing his or her feelings. ICARE (Identify the thought, Connect with it, Assess evidences for it, Restructure the thought in positive light, Express or provide room for expressing feelings from the restructured thought) is a model of approach used here.[27][28]

Lethal means reduction

Means reduction, reducing the odds that a suicide attempter will use highly lethal means, is an important component of suicide prevention.[29] This practice is also called "means restriction".

Researchers and health policy planners have theorized and demonstrated that restricting lethal means can help reduce suicide rates, as delaying action until depression passes.[30] In general, strong evidence supports the effectiveness of means restriction in preventing suicides.[31] There is also strong evidence that restricted access at so-called suicide hotspots, such as bridges and cliffs, reduces suicides, whereas other interventions such as placing signs or increasing surveillance at these sites appears less effective.[32] One of the most famous historical examples, of means reduction, is that of coal gas in the United Kingdom. Until the 1950s, the most common means of suicide in the UK was poisoning by gas inhalation. In 1958, natural gas (virtually free of carbon monoxide) was introduced, and over the next decade, comprised over 50% of gas used. As carbon monoxide in gas decreased, suicides also decreased. The decrease was driven entirely by dramatic decreases in the number of suicides by carbon monoxide poisoning.[33][34]

In the United States, numerous studies have concluded that firearm access is associated with increased suicide completion.[35] "About 85% of attempts with a firearm are fatal: that's a much higher case fatality rate than for nearly every other method. Many of the most widely used suicide attempt methods have case fatality rates below 5%."[36][37] Although restrictions on access to firearms have reduced firearm suicide rates in other countries, such restrictions were not feasible in the United States because the Second Amendment to the United States Constitution based on late 1600s English bill of rights limits the potential for regulation laws but broadly restricting firearms access to at-risk individuals is gaining stakeholder's attention as a preventive measure.[38]

Social intervention

A telephone connected to a crisis hotline at Niagara Falls State Park

National Strategy for Suicide Prevention promotes and sponsors various specific suicide prevention endeavors:

  • Developing groups led by professionally trained individuals for broad-based support for suicide prevention.
  • Promoting community-based suicide prevention programs.
  • Screening and reducing at-risk behavior through psychological resilience programs that promotes optimism and connectedness.
  • Education about suicide, including risk factors, warning signs, stigma related issues and the availability of help through social campaigns.
  • Increasing the proficiency of health and welfare services at responding to people in need. e.g., Sponsored training for helping professionals, Increased access to community linkages, employing crisis counseling organizations.
  • Reducing domestic violence and substance abuse through legal and empowerment means are long-term strategies.
  • Reducing access to convenient means of suicide and methods of self-harm. e.g., toxic substances, poisons, handguns.
  • Reducing the quantity of dosages supplied in packages of non-prescription medicines e.g., aspirin.
  • School-based competency promoting and skill enhancing programs.
  • Interventions and usage of ethical surveillance systems targeted at high-risk groups.
  • Improving reporting and portrayals of negative behavior, suicidal behavior, mental illness and substance abuse in the entertainment and news media.
  • Research on protective factors & development of effective clinical and professional practices.

It has also been suggested by NSSP that media should prevent romanticising of negative emotions and coping strategies which can lead to vicarious traumatization. The Centers for Disease Control and Prevention (from a 1994 workshop) and the American Foundation for Suicide Prevention (1999) have suggested that TV shows and news media can help prevent suicide by linking suicide with negative outcomes such as pain for the suicide and their survivors, conveying that the majority of people choose something other than suicide in order to solve their problems, avoiding mentioning suicide epidemics, and avoiding presenting authorities or sympathetic, ordinary people as spokespersons for the reasonableness of suicide.[39]

Postvention

Postvention is for people affected by an individual's suicide, this intervention facilitates grieving, guides to reduce guilt, anxiety, and depression and to decrease the effects of trauma. Bereavement is ruled out and promoted for catharsis and supporting their adaptive capacities before intervening depression and any psychiatric disorders. Postvention is also provided to intervene to minimize the risk of imitative or copycat suicides, but there is a lack of evidence based standard protocol. But the general goal of the mental health practitioner is to decrease the likelihood of others identifying with the suicidal behavior of the deceased as a coping strategy in dealing with adversity.[40]

Medication

Recent research has shown that lithium has been effective with lowering the risk of suicide in those with bipolar disorder to the same levels as the general population.[41] Lithium has also proven effective in lowering the suicide risk in those with unipolar depression as well.[42]

Counseling

There are multiple evidence-based psychotherapeutic talk therapies available to reduce suicidal ideation such as dialectical behavior therapy (DBT) for which multiple studies have reported varying degrees of clinical effectiveness in reducing suicidality. Benefits include a reduction in self-harm behaviours and suicidal ideations.[43][44] Cognitive Behavior Therapy for Suicide Prevention (CBT-SP) is a form of DBT adapted for adolescents at high risk for repeated suicide attempts.[45][46]

The World Health Organization recommends "specific skills should be available in the education system to prevent bullying and violence in and around the school premises in order to create a safe environment free of intolerance".[47]

Coping planning

Coping planning is an innovative strengths-based intervention that aims to meet the needs of people who ask for help, including those experiencing suicidal ideation.[48] By addressing why someone asks for help, the risk assessment and management stays on what the person needs, and the needs assessment focuses on the individual needs of each person.[49][50] The Coping Planning approach to suicide prevention draws on the health-focused theory of coping. Coping is normalized as a normal and universal human response to unpleasant emotions and interventions are considered a change continuum of low intensity (e.g. self-soothing) to high intensity support (e.g. professional help). By planning for coping, it supports people who are distressed and provides a sense of belongingness and resilience in treatment of illness.[51][52] The proactive coping planning approach overcomes implications of ironic process theory.[53]The biopsychosocial[54] strategy of training people in healthy coping improves emotional regulation and decreases memories of unpleasant emotions.[55] A good coping planning strategically reduces the inattentional blindness for a person while developing resilience and regulation strengths.[56]

Support groups

Many non-profit organizations exist, such as the American Foundation for Suicide Prevention in the United States, which serve as crisis hotlines; it has benefited from at least one crowd-sourced campaign.[57] The first documented program aimed at preventing suicide was initiated in 1906 in both New York, the National Save-A-Life League and in London, the Suicide Prevention Department of the Salvation Army.[58]

Suicide prevention interventions fall into two broad categories: prevention targeted at the level of the individual and prevention targeted at the level of the population.[59] To identify, review, and disseminate information about best practices to address specific objectives of the National Strategy Best Practices Registry (BPR) was initiated. The Best Practices Registry of Suicide Prevention Resource Center is a registry of various suicide intervention programs maintained by the American Association of Suicide Prevention. The programs are divided, with those in Section I listing evidence-based programs: interventions which have been subjected to indepth review and for which evidence has demonstrated positive outcomes. Section III programs have been subjected to review.[60][61]

Model of suicide

Van Orden et al. (2010) posited that there are two major factors involved in suicide attempts. The first major factor is a desire for death and the second acquired capability. Desire for death occurs through ideations of thwarted belongingness. It is described as feeling alienated from others emotionally and perceived burdensomeness which is described as feeling that one is incompetent and therefore a burden on others.[62] The acquired capability in this context is used because people naturally fear death and painful experiences. The capability to carry out the suicide attempt is usually formed from emotional and physical pain and disrupted cognitive status and is acquired through previous suicide attempts (self-directed violence), rehearsing suicide through behavior or imagery, and getting used to painful or dangerous experiences in other ways.

Individuals who are suicidal often have tunnel vision about the situation and consider permanence of suicide as an easy way out of a difficult situation.[63] Other significant risk factors for suicide include psychiatric disorders, substance abuse, etc.[64][65] Individuals who have good interpersonal social relationship and family support tend to have lower risk of suicide.[66] People who have greater self-control, greater self-efficacy, intact reality-testing, and more adaptive coping skills are at less risk. Those who are hopeful, have future plans or events to look forward to, and have satisfaction in life are considered to have protective factors against suicide.[67]

Strategies

A United States Army suicide prevention poster

Suicide is the act of deliberately killing oneself or, more specifically, an act deliberately initiated and performed by the person concerned in the full knowledge, or expectation, of its fatal outcome.[68]

In recognition of the need for comprehensive approaches to suicide prevention, various strategies have been developed with the support of evidence. The traditional approach has been to identify the risk factors that increase suicide or self-harm, though meta-analysis studies suggest that suicide risk assessment might not be useful and recommend immediate hospitalization of the person with suicidal feelings as the healthy choice.[69] In 2001, the U.S. Department of Health and Human Services, under the direction of the Surgeon General, published the National Strategy for Suicide Prevention, establishing a framework for suicide prevention in the U.S. The document calls for a public health approach to suicide prevention, focusing on identifying patterns of suicide and suicidal ideation throughout a group or population (as opposed to exploring the history and health conditions that could lead to suicide in a single individual).[70] The ability to recognize warning signs of suicide allows individuals who may be concerned about someone they know to direct them to help.[4]

Suicide gesture and suicidal desire (a vague wish for death without any actual intent to kill oneself) are potentially self-injurious behaviors that a person may use to attain some other ends, like to seek help, punish others, or to receive attention. This behavior has the potential to aid an individual’s capability for suicide and can be considered as a suicide warning, when the person shows intent through verbal and behavioral signs.[71]

Specific strategies

Suicide prevention strategies focus on reducing the risk factors and intervening strategically to reduce the level of risk. Risk and protective factors, unique to the individual can be assessed by a qualified mental health professional.

Some of the specific strategies used to address are:

  • Crisis intervention.
  • Structured counseling and psychotherapy.
  • Hospitalization for those with low adherence to collaboration for help and those who require monitoring & secondary symptom treatment.
  • Supportive therapy like substance abuse treatment, Psychotropic medication, Family psychoeducation and Access to emergency phone call care with emergency rooms, suicide prevention hotlines...etc.
  • Restricting access to lethality of suicide means through policies and laws.
  • Creating & using crisis cards, an uncluttered card formatted readably that describes list of activities one should follow in crisis still the positive behavior responses settles in the personality.
  • Person-centered life skills training. e.g., Problem solving.
  • Registering with support groups like Alcoholics Anonymous, Suicide Bereavement Support Group, a religious group with flow rituals, etc.
  • Therapeutic recreational therapy that improves mood.
  • Motivating self-care activities like physical exercise's and meditative relaxation.

Psychotherapies that have shown most successful or evidence based are Dialectical behavior therapy (DBT), it has shown to be helpful in reducing suicide attempts and reducing hospitalizations for suicidal ideation[72] and Cognitive therapy (CBT), it has shown to improve problem-solving and coping abilities.[73]

Preventative Factors

Individuals with access to proper mental health care, a sense of belonging, good problem solving skills, and a system of beliefs that discourages suicide are less likely to attempt suicide.[74]

Economics

In the United States it is estimated that an episode of suicide results in costs of about $1.3 million. Money spending on appropriated interventions is estimated to result in a decrease in economic loses that are 2.5 fold greater than the amount spent.[75]

See also

References

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  6. ↑ Office of the Surgeon General:The Surgeon General's Call To Action To Prevent Suicide 1999
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  72. ↑ Linehan et al., 2006
  73. ↑ Stellrecht et al., 2006
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Further reading

  • Suicide prevention and assessment handbook, Centre for Addiction and Mental Health, 2011.
  • Nancy Boyd-Franklin; Elizabeth N. Cleek; Matt Wofsy; Brian Mundy (2013). "Risk Assessment and Suicide Prevention". Therapy in the Real World: Effective Treatments for Challenging Problems. Guilford Press. p. 341. ISBN 978-1-4625-1034-4.
  • Van Orden K. A.; et al. (2010). "The interpersonal theory of suicide". Psychological Review. 117: 575–600. doi:10.1037/a0018697.
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