Population strategies

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Reducing availability of means for suicide

This is the most widely discussed population strategy.(25) It is based on evidence that if the availability and/or danger of a popular method for suicide changes then this tends to have an impact on suicide rates. The general principles of prevention through reducing availability of means are, first, that many suicidal acts occur impulsively and therefore if a dangerous means is available this is more likely to result in death and, secondly, that the eventual suicide rate in survivors of serious attempts is remarkably low.(26) Also the common adage that if people are intent on committing suicide they will find a means is not entirely correct (see below).

The most cited evidence for the effectiveness of this approach is the reduction in suicides in the United Kingdom which occurred in the 1960s and early 1970s when toxic coal gas supplies were gradually replaced with non-toxic North Sea gas. (27) Prior to this time coal gas poisoning through people placing their head in a gas oven was the most common method of suicide in the United Kingdom. As North Sea gas was gradually introduced the suicide rate dropped steadily, eventually being reduced by approximately a third. It is estimated that as many as 6000 deaths may have been prevented by this change. The effect also illustrates the point that when one method of suicide is no longer available people do not automatically immediately turn to another method, or if they do it may be to one that is less likely to cause death. Thus, it was some years before the suicide rate rose again, this being related to an increase in deaths from poisoning with carbon monoxide from car exhausts. Another factor that may well have been relevant to the decline in suicides during the 1960s and early 1970s was the reduction in prescribing of barbiturates, these being replaced by far less toxic benzodiazepines.

Reversal of the recent increase seen in many countries in deaths from carbon monoxide poisoning is likely to occur as more car exhausts are produced with catalytic converters. Indeed there is already evidence in the United Kingdom that a reversal in this trend has started to occur, with a consequent decline in suicide rates, particularly in young males.(28)

The widespread availability of guns in certain countries, particularly the United States, has been proposed as an important reason for their relatively high suicide rates. Guns are used in more than half of all suicides in the United States and their use for suicide correlates with the holding of gun licences in households. (29) Some controversy surrounds the question of whether restricting availability of guns leads to a reduction in suicide rates, but the weight of evidence seems to indicate that it does.(?0)

Given the very strong link between suicide and depression, and the risk of death from overdose of some of the older antidepressants, there has been much debate about whether more extensive use of less toxic newer antidepressants would prevent suicides. This is not a simple question, since some patients respond better to the older tricyclic antidepressants. Another consideration concerns the cost of the newer antidepressants compared with the older varieties. Also it is very important to remember that most people who are taking antidepressants do not kill themselves with their antidepressants but use other methods. This and the probable selective prescribing of SSRIs to people judged to be at risk probably accounts for the finding that suicide rates were higher in patients taking fluoxetine than patients taking other and in some cases more toxic antidepressants.(31) Nevertheless, common sense dictates that patients known to be at risk, and especially those with a history of suicidal behaviour, should be prescribed the less toxic preparations.

In the United Kingdom and some other countries there has been particular concern about deaths from paracetamol self-poisoning. A clear relationship between both fatal and non-fatal overdoses of paracetamol and availability has been shown for the United Kingdom and France. (32) Countries which have fewer tablets per pack seem to have a lower rate of mortality from paracetamol self-poisoning. This has resulted in legislation in the United Kingdom to reduce in the number of tablets of paracetamol (and aspirin) available per pack. It is too early to say whether or not this has been effective.

Much attention has also been paid to improving safety at popular sites for suicide. This includes erecting suicide barriers on bridges, multistorey car parks, and other sites. If environmental changes are made such that a popular suicide site becomes safer this does not mean that people at risk automatically move to using another site.

Clinicians involved in the development of suicide prevention strategies should look very carefully for local patterns which might provide clues about potentially effective measures for reducing access to methods. This could include, for example, ensuring that psychiatric inpatient units are free of hooks, pipes, and other objects or structures from which patients could hang themselves, secure fencing of railway lines or waterways close to psychiatric hospitals, and making local popular sites for suicide safer (e.g. suicide barriers on bridges). In addition attention should be paid to common dangerous methods of self-poisoning. Specific strategies may be required depending on local patterns. For example, ready availability of organophosphates and other toxic pesticides in some Asian countries, especially Sri Lanka,(33) appears to be a major factor in many suicides.

Education of primary care physicians

Much of the attention regarding improved detection of individuals at risk has concerned the management of depression in general practice. This was stimulated by findings that showed that many people who died by suicide or who attempted suicide had seen their general practitioners shortly before these acts. Thus, Barraclough et al.(34) found that 63 per cent of suicides had seen their general practitioners in the month before death and 36 per cent in the week before death. Changes in the profile of suicides in recent years have resulted in somewhat fewer patients having seen their general practitioners shortly before death (although this could of course reflect improved detection and treatment of other patients at risk). Thus, Vassilas and Morgan (3.5) found that 48 per cent of individuals aged 35 years and over who died by suicide and 20 per cent of those aged less than 35 years had seen their general practitioners in the month before death.

The main evidence that an educational programme for general practitioners might be effective in influencing suicide rates comes from a study conducted on the Swedish island of Gotland.(36) The 18 general practitioners on the island, which has a population of approximately 54 000, were offered an intensive educational programme consisting of lectures on depression in adults, children, adolescents, and the elderly, examination of local treatment practices, discussion of long-term treatment strategies, consideration of various aspects of suicide and suicide risk, and group discussions of case reports. In the year following this programme the suicide rate dropped significantly, prescribing of antidepressants by general practitioners increased, referrals to psychiatry, especially for depression, decreased, the amount of time lost from work for depression decreased, as did psychiatric admissions. Unfortunately this effect was fairly short-lived in that suicide rates rose again in subsequent years, which the authors attributed to some of the general practitioners having left the island. They also suggested that such programmes need to be repeated.(3Z) It is also important to note that the suicide rate only declined in females. The evidence in this study was based on relatively small numbers, at least with reference to suicide, although the effects on the management and outcome of depression are perhaps more impressive.

While the Gotland study has generated a lot of debate about suicide prevention in primary care, detection of people most at risk in general practice is extremely difficult because a large number of patients share risk factors, and because suicide is a rare event. The most pragmatic view is that effective detection and treatment of depression (and other psychiatric disorders) in primary care are extremely important aims in their own right and that they might also have benefits in terms of preventing some suicides.

Psychiatrists involved in designing suicide prevention strategies might ensure that there are effective local educational programmes for clinicians in primary care and other settings regarding detection and treatment of people with mental disorders.

Influencing media portrayal of suicidal behaviour

Dramatic reporting and portrayal of suicidal behaviour by the media can facilitate suicidal acts in other people. (38) This has been shown in the United States for both newspaper and television reporting of suicides. (39,40) The most dramatic demonstration of the potential power of the media in this regard is probably the effect found for a six-part fictional television series in Germany in which the railway suicide of a 19-year-old student was shown (in all six episodes). (41> In the weeks following this series there was a dramatic increase in railway suicides, particularly in young males, with no compensatory decrease in suicides by other methods. When the television series was shown again a similar but less marked effect was found, which appeared to be in keeping with the somewhat smaller audience viewing figures compared to the first occasion.

The possible influence of the media on attempted suicide has been less studied. There is, however, evidence that portrayal of suicide in films on television resulted in an increase in attempted suicide referrals to general hospitals in the New York area. (42> Recently, portrayal of a paracetamol overdose in a very popular television drama in the United Kingdom appeared to result in a marked short-term increase in general hospital referrals for self-poisoning, especially overdoses of paracetamol, with clear evidence that the impact on paracetamol overdoses was in viewers of the episode. (43,>

Therefore it is not surprising that there is much support for changing the way suicidal behaviour is presented in the media. For example, it has been suggested that reports of actual suicides should be straightforward, non-dramatic, and not include details of the method used (since the main media impact seems to be on actual methods for suicidal behaviour). In particular, dramatizing suicidal behaviour in popular television series should be avoided. Producers of programmes should be encouraged to seek advice from experts when contemplating including a suicidal act in a programme. Advertisements for helplines and other means of obtaining help should be shown following any programmes which include detailed discussion of suicidal behaviour.

In each country, consideration should be paid to the development of consensus statements about media policies, which could be produced by joint working parties including representatives of the press, clinical and voluntary agencies, and experts in the field of suicidal behaviour. More difficult is the potentially valuable task of encouraging a policy whereby the media can be used to portray effective coping strategies for people in distress. Such a strategy will need to encompass local cultural factors. Psychiatrists developing suicide prevention strategies might examine the practices of their local media with regard to reporting of suicides and, if necessary, hold meetings with media producers to explain the dangers of dramatic and extensive reporting, and also to explore how the media might help in prevention.

Education of the public about mental illness and its treatment

In view of the very strong link between suicide and mental illness, effective treatment of psychiatric disorder must be a central theme in suicide prevention. However, detection of people with disorder will depend on the awareness that they and those around them have regarding the signs and symptoms of disorder, and their willingness to seek appropriate help. These important stages in receiving effective help will depend on attitudes towards mental illness and knowledge of its nature and the feasibility of treatment. In the United Kingdom, the Defeat Depression Campaign (44,> and the Changing Minds 'Stigma Campaign'(45) represent major efforts to tackle the public's attitude and knowledge about depression and other mental disorders. At this stage, evidence is lacking as to whether or not they have been successful. Psychiatrists and their colleagues in other countries might consider similar campaigns where these are not already in place, although the method of delivery of messages will clearly depend on local factors. Potential strategies include leaflets in hospital and doctors' waiting rooms, workshops for the public, and articles in the local press or other media.

Educational approaches in schools

There have been three broad approaches to trying to prevent suicide through school-based programmes. The first of these includes teaching about the facts of suicide. Worrying evidence from the United States that such a programme appeared to lead to a small increase in pupils' ratings of the acceptability of suicide as an option compared with the ratings of pupils who did not receive the programme(46) suggests that this is not a wise approach.

Because suicidal behaviour in young people and others often appears to be related to poor problem-solving skills, a second school-based strategy has been the development of educational programmes in schools about life skills and problem-solving. (47) Given the early age at which suicidal behaviour begins, such programmes probably have to be targeted at extremely young school children, possibly with booster sessions later on. It is likely that the requirements of females from such programmes may differ those of males.(48)

A third approach is to train teachers, possibly with the assistance of screening questionnaires, in the detection of children and adolescents at risk of psychiatric disorder and possible suicidal behaviour. Pupils that are so detected will then need referral to an appropriate agency for further assessment nd possible treatment. Such an approach is currently under investigation.(46) (Suicide in children and adolescents is considered further in Ch§PͧL9;,2J„.0..)

For psychiatrists and others involved in developing local prevention strategies it is important to recognize that this is a highly sensitive area and one where the most effective (and least risky) approach is at present unclear.

Befriending agencies and telephone helplines

A very important component of suicide prevention policy in many countries is the support provided by largely volunteer staffed befriending agencies and especially telephone helplines. The best known of these is the Samaritans, which was founded in London in 1953 by Chad Varah. (49> Befrienders International is the main international organization which facilitates the development of such services. A key principle on which such services are based is that people in distress and at risk of suicide will benefit from being able to discuss their problems with someone entirely confidentially. Recently, more assertive outreach programmes, in which volunteers meet up with distressed individuals such as in prisons and in remote areas, have been added to the traditional telephone service. In the United Kingdom and elsewhere the use of e-mail counselling is gaining momentum.

One example of how such befriending has developed in a fashion to take account of local needs is the outreach programme by the Sumithrayo in Sri Lanka. (14> In some senses this service overlaps that of mental health services in that people admitted to hospital because of suicidal behaviour are followed up back in their own villages, where efforts are made to generate community support through engaging families and friends in providing help.

The effectiveness of these approaches is largely unknown. Clearly, conducting controlled trials to examine their efficacy is very difficult. Naturalistic studies have produced conflicting evidence about the effectiveness of the Samaritans in the United Kingdom. ^¿I.) An examination of changes in suicide rates in areas with and without crisis intervention services in the United States suggested that suicide rates in young white females may have been reduced in areas where such services were developed/52) Given the large numbers of contacts made with the Samaritans in the United Kingdom (4.5 million in 1998), it is clear that the service is valued by people in distress whether or not it has a major preventive impact on suicide.

Volunteer-run telephone helpline and similar services benefit greatly from the support and advice of local clinicians, who should regard them as a potentially valuable element in a local suicide prevention strategy.

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