There are a wide range of possible prevention strategies which can be targeted at high-risk groups. Here some of the more important examples of such groups and relevant strategies will be discussed.
One obvious approach to preventing suicide in people with known psychiatric disorders is to try and use recognized risk factors for suicide in each disorder to identify high-risk patients. The main psychiatric disorders in series of people who have died by suicide when examined using the psychological autopsy approach are depression (approximately two-thirds), severe alcohol abuse (approximately 15 per cent), and schizophrenia (5-10 per cent). The main risk suicide risk factors identified in these three disorders include, for example, previous attempts, family history of suicidal behaviour, and living alone. One difficulty in using a risk-identification approach, however, is that the risk factors identified from studies of groups of individuals who have died from suicide are often misleading when applied to individual patients. Also there is the issue that when applying such factors a relatively large number of individuals will appear to be at risk when they may not in fact be so.(5,54) In clinical practice it is important to be aware of patients who because of their individual characteristics are at long-term high risk and also the acute situations which may temporarily increase the risk in patients, be they ones at long-term risk or not. The most pragmatic approach, therefore, is to ensure that proven effective treatments for patients with these conditions are available and also to be particularly cautious at times of obvious high risk. There are particular periods of risk of suicide for patients with psychiatric disorders. One of these is during the first few weeks after discharge from psychiatric hospital. (55) This emphasizes the necessity for continuity of care at this critical time, and especially the clear identification of a key worker who gets to know the patient before discharge from hospital and provides him or her with early support after discharge. Other risk times may be following the break-up of a relationship or other significant loss, during periods of marked hopelessness, shortly after discharge from hospital, and following recent suicidal behaviour by another patient or someone else close to the individual.
Important strategies in preventing suicide in patients with affective disorders include very active treatment of individual episodes of illness, use of lithium and other mood stabilizers for patients with recurrent bipolar disorders, (56) and use of long-term antidepressants in patients with frequent relapses of depressive disorders. The risk factors in schizophrenia indicate that risk is greatest not so much during acute episodes but between episodes when patients may have insight and feel hopeless about their circumstances and prospects.(5Z) Continuity of care is likely to be a particularly important factor in preventing suicides in such patients at risk, with care being continued energetically during periods of remission. Community psychiatric nurses have a very important role with such patients. The use of the newer atypical neuroleptics might also be beneficial.(58)
Direct treatment of abuse is likely to be the best preventive strategy for patients with substance abuse disorders, with care taken to manage episodes of depression. The particularly high risk in the weeks following a break-up of a relationship for patients with severe alcohol abuse (5.9) again points to the need for continuity of support in the community.
Studies of suicides indicate that comorbidity is particularly common, especially the combination of depression with alcohol abuse and/or personality disorder. (69 Clearly the prevention of suicide in such patients is a challenging task, especially as compliance with treatment is often less good than in patients with single disorders. Effective prevention is likely to depend on close integration of care between different statutory care agencies.
Another important element in prevention in this population is education in suicide risk assessment and management procedures for clinical staff at all levels of seniority. These might be incorporated in educational programmes for risk assessment in general.
In planning suicide prevention in the elderly population, account must taken of the relative immobility of many older people. In a region of Italy, introduction of a telephone service to provide support and access to emergency help for elderly persons at risk has been associated with an encouraging decline in elderly suicides in the area/61 This might serve as a model for other countries.
In view of the clear association between non-fatal suicidal behaviour and subsequent suicide, establishment of adequate services for suicide attempters, including the provision of careful assessments of patients in the general hospital and offering treatments for which at least some indicators of benefit are available (see above), is an important element in any national suicide prevention strategy. There is good evidence that non-medical staff can carry out assessments and arrange aftercare as safely and effectively as psychiatrists. Models for ideal services exist, such as that published by the Royal College of Psychiatrists in the United Kingdom. Similar policies might be developed for general hospitals in other countries.
Certain occupational groups are known to be at relatively high risk of suicide. In the United Kingdom these include farmers, veterinary surgeons, dental practitioners, medical practitioners, pharmacists, and female nurses. ^.M4 It is interesting to note that all these groups have relatively easy access to dangerous methods for suicide. Prevention of suicide in such occupational groups is an important consideration, although each group makes a relatively small contribution to the overall national suicide rate and prevention through detection of those most at risk encounters the usual difficulties of prevention of relatively rare behaviour using rather crude risk factors. It is probably more important to have general strategies for improving care in individual groups. In doctors, for example, there are some particular difficulties about confidentiality and therefore providing easy means of doctors getting confidential help is important. In farmers, improving the knowledge and attitudes of farming communities towards psychiatric disorder, and removing access to firearms at times of risk, are likely to be important. (65)
There are relatively high suicide rates in prisoners, especially young males held on remand. (69 While one aspect of prevention is through ensuring that prisons and police cells are safe in terms of absence of structures from which inmates can hang themselves, there are a range of other potentially useful and humane strategies. These include careful assessments of new inmates using risk-assessment procedures, training of staff with regard to both assessment skills and attitudes towards mental health problems and suicide prevention, in-reach programmes by befriending organizations such as the Samaritans, and ready access to psychiatric and psychological services. Clinicians involved in local suicide prevention programmes should include prisons in their considerations. (Suicide in prison is considered further in Ch§pterJ1.8.)
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