Suicide prevention is an umbrella term for the collective efforts of local citizen organizations, mental health practitioners and related professionals to reduce the incidence of suicide. Beyond just direct interventions to stop an impending suicide, methods also involve a) treating the psychological and psychophysiological symptoms of depression, b) improving the coping strategies of persons who would otherwise seriously consider suicide, c) reducing the prevalence of conditions believed to constitute risk factors for suicide, and d) 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 connectedness, as well as environmental risk factors such as access to lethal means, appear to play significant roles in the prevention of suicide, suicide should not be viewed solely as a medical or mental health issue.
In the U.S., suicide prevention efforts are guided by the U.S. National Strategy for Suicide Prevention, published by the Department of Health and Human Services in 2001. 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. The purpose of the Best Practices Registry (BPR) is to identify, review, and disseminate information about best practices to address specific objectives of the National Strategy.
In recognition of the need for comprehensive approaches to suicide prevention, various strategies have been put forth in the last decade.
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 behavior throughout a group or population (as opposed to exploring the history and health conditions that could lead to suicide in a single individual). The document also outlines 11 specific objectives, listed below :
- Promote awareness that suicide is a public health problem that is preventable
- Develop broad-based support for suicide prevention
- Develop and implement strategies to reduce the stigma associated with being a consumer of mental health, substance abuse and suicide prevention services
- Develop and implement community-based suicide prevention programs
- Promote efforts to reduce access to lethal means and methods of self-harm
- Implement training for recognition of at-risk behavior and delivery of effective treatment
- Develop and promote effective clinical and professional practices
- Increase access to and community linkages with mental health and substance abuse services
- Improve reporting and portrayals of suicidal behavior, mental illness and substance abuse in the entertainment and news media
- Promote and support research on suicide and suicide prevention
- Improve and expand surveillance systems
Various specific suicide prevention strategies have been used:
- Selection and training of volunteer citizen groups offering confidential referral services.
- Promoting mental resilience through optimism and connectedness.
- Education about suicide, including risk factors, warning signs and the availability of help.
- Increasing the proficiency of health and welfare services at responding to people in need. This includes better training for health professionals and employing crisis counseling organizations.
- Reducing domestic violence and substance abuse are long-term strategies to reduce many mental health problems.
- Reducing access to convenient means of suicide (e.g. toxic substances, handguns).
- Reducing the quantity of dosages supplied in packages of non-prescription medicines e.g. aspirin.
- Interventions targeted at high-risk groups.
- Research. (see below)
It has also been suggested that news media can help prevent suicide by linking suicide with negative outcomes such as pain for the suicide and his 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.
Many methods of intervention have been developed to intercede before suicide is attempted. The general methods include: direct talks, screening for risks, and lethal means reduction. Each is explained in more detail below.
The World Health Organization has noted a very effective way to assess suicidal thoughts is to talk with a person directly, to ask about depression, and assess suicide plans as to how and when it might be attempted. Contrary to popular misconceptions, talking with people about suicide does not plant the idea in their heads. However, such discussions and questions should be asked with care, concern and compassion. 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. However, some people who have talked about suicide have later attempted it, so the discussions should be gradual and specifically when the person is comfortable about discussing his or her feelings.
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. 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. 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. 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. Asking about or screening for suicide does not appear to increase the risk.
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.
Lethal means reduction
Means reduction, reducing the odds that a suicide attempter will use highly lethal means, is an important component of suicide prevention.
For years, researchers and health policy planners have theorized and demonstrated that restricting lethal means can help reduce suicide rates, as delaying action until depression passes. There is 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. 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.
In the United States, numerous studies have concluded that firearm access is associated with increased suicide risk. Because guns are quick and more lethal than other suicide means (about 85% of attempts with a firearm are fatal, a much higher case fatality rate than for other methods), they are often a major driver of suicide rates.
There are various treatment modalities to reduce the risk of suicide by addressing the underlying conditions causing suicidal ideation, including, depending on case history, medical, pharmacological, psychotherapeutic talk therapies. and telemedicine approaches.
The conservative estimate is that 10% of individuals with psychiatric disorders may have an undiagnosed medical condition causing their symptoms, upwards of 50% may have an undiagnosed medical condition which if not causing is exacerbating their psychiatric symptoms. Illegal drugs and prescribed medications may also produce psychiatric symptoms. Effective diagnosis and if necessary medical testing which may include neuroimaging 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.
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. Lithium has also proven effective in lowering the suicide risk in those with unipolar depression as well.
There are multiple evidence-based psychotherapeutic talk therapies available to reduce suicidal ideation such as dialectical behaviour 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. Cognitive Behavior Therapy for Suicide Prevention (CBT-SP) is a form of DBT adapted for adolescents at high risk for repeated suicide attempts.
An emerging field, telepsychatry, is becoming a promising alternative in suicide prevention. A RCT trial conducted in Sri Lanka, a Brief Mobile Treatment (BMT), which included training in problem solving therapy, meditation, a brief intervention to increase social support as well as advice on alcohol and other drugs followed up with mobile phone, has shown effectiveness over the Usual Care.
Respect and self-esteem
The World Health Organization states that "worldwide, suicide is among the top five causes of mortality in the 15- to 19-year age group and in many countries it ranks first or second as a cause of death among both boys and girls in this age group" and recommends "destigmatiz[ing] mental illness" and "strengthening students' self-esteem" to protect "children and adolescents against mental distress and dependency" and enable "them to cope adequately with difficult and stressful life situations." It also says that "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".
Many non-profit organizations exist, such as the American Foundation for Suicide Prevention in the United States, which serve as crisis hotlines. In addition, some groups such as To Write Love on Her Arms have been promoted using social media to reach more people.
Best Practices Registry
The Best Practices Registry (BPR) For Suicide Prevention 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.
Suicide prevention organizations
- Samaritans (charity)
- American Foundation for Suicide Prevention
- Suicide Prevention Action Network USA
- Campaign Against Living Miserably
- National Suicide Prevention Lifeline
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- "National Strategy for Suicide Prevention" (PDF). Retrieved 2012-01-15.
- "Suicide Prevention: at what level does it work?", Bertolote, Jose. World Psychiatry. 2004 October; 3(3): 147-151.
- R. F. W. Diekstra. Preventive strategies on suicide.
- "Preventing Suicide - A Resource for Primary Health Care Workers" (PDF), World Health Organization, Geneva, 2000, p. 13.
- Office of the Surgeon General:The Surgeon General's Call To Action To Prevent Suicide 1999 
- Rory C. O'Connor, Stephen Platt, Jacki Gordon: International Handbook of Suicide Prevention: Research, Policy and Practice, p. 510 
- Rory C. O'Connor, Stephen Platt, Jacki Gordon, International Handbook of Suicide Prevention: Research, Policy and Practice, p.361; Wiley-Blackwell (2011), ISBN 0-470-68384-8
- Alan F. Schatzberg: The American Psychiatric Publishing textbook of mood disorders, p. 503: American Psychiatric Publishing; (2005) ISBN 1-58562-151-X
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- Lee HC, Lin HC, Liu TC, Lin SY (June 2008). "Contact of mental and nonmental health care providers prior to suicide in Taiwan: a population-based study.". Canadian Journal of Psychiatry 53 (6): 377–83. PMID 18616858.
- Pirkis J, Burgess P (December 1998). "Suicide and recency of health care contacts. A systematic review". The British journal of psychiatry : the journal of mental science 173 (6): 462–74. doi:10.1192/bjp.173.6.462. PMID 9926074.
- "Means Matter Campaign". Hsph.harvard.edu. Retrieved 2012-01-15.
- Suicide Prevention Resource Center - Lethal Means[dead link]
- Cox, GR, Robinson, J, Nicholas, A et al. (March 2013). "Interventions to reduce suicides at suicide hotspots: a systematic review.". BMC Public Health 9. doi:10.1186/1471-2458-13-214.
- "Means Matter Campaign - Coal Gas Case". Hsph.harvard.edu. Retrieved 2012-01-15.
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- "Means Matter - Risk". Hsph.harvard.edu. Retrieved 2012-01-15.
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- Randolph B. Schiffer, Stephen M. Rao, Barry S. Fogel, Neuropsychiatry: Neuropsychiatry of suicide, pp. 706-713, (2003)ISBN 0781726557
- Cipriani A, Pretty H, Hawton K, Geddes JR (October 2005). "Lithium in the prevention of suicidal behavior and all-cause mortality in patients with mood disorders: a systematic review of randomized trials". Am J Psychiatry 162 (10): 1805–19. doi:10.1176/appi.ajp.162.10.1805. PMID 16199826.
- Linehan MM, Comtois KA, Murray AM, et al. (July 2006). "Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder". Arch. Gen. Psychiatry 63 (7): 757–66. doi:10.1001/archpsyc.63.7.757. PMID 16818865.
- Marasinghe RB, Edirippulige S, Kavanagh D, Smith A, Jiffry MT. Telehealth approaches to suicide prevention: a review of evidences. eHealth Sri Lanka 2010 2010,1(suppl.1):S8
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- Chuang L., Mental Disorders Secondary to General Medical Conditions; Medscape;2011 
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- Andreas P. Otte, Kurt Audenaert, Kathelijne Peremans, Nuclear medicine in psychiatry: Functional imaging of Suicidal Behavior, pp.475-483, Springer (2004);ISBN 3-540-00683-4
- Patricia D. Barry, Suzette Farmer; Mental health & mental illness,p.282, Lippincott Williams & Wilkins;(2002) ISBN 0-7817-3138-0
- Baldessarini RJ, Tondo L, Hennen J (2003). "Lithium treatment and suicide risk in major affective disorders: update and new findings". J Clin Psychiatry. 64 Suppl 5: 44–52. PMID 12720484.
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- Canadian Agency for Drugs nd technology in Health: Dialectical Behaviour Therapy in Adolescents for Suicide Prevention: Systematic Review of Clinical-Effectiveness, CADTH Technology Overviews, Volume 1, Issue 1, March 2010 
- National Institute of Mental Health: Suicide in the U.S.: Statistics and Prevention 
- Stanley B, Brown G, Brent DA, et al. (October 2009). "Cognitive-behavioral therapy for suicide prevention (CBT-SP): treatment model, feasibility, and acceptability". J Am Acad Child Adolesc Psychiatry 48 (10): 1005–13. doi:10.1097/CHI.0b013e3181b5dbfe. PMC 2888910. PMID 19730273.
- Marasinghe RB, Edirippulige S, Kavanagh D, Smith A, Jiffry MT.Effect of mobile phone-based psychotherapy in suicide prevention: a randomized controlled trial in Sri Lanka.J Telemed Telecare. 2012 Apr;18(3):151-5. doi: 10.1258/jtt.2012.SFT107. Epub 2012 Feb 23.
- "Preventing Suicide, a resource for teachers and other school staff, World Health Organization, Geneva 2000" (PDF). Retrieved 2012-01-15.
- Best Practices Registry (BPR) For Suicide Prevention
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Agencies and organizations
- CDC website on Suicide Prevention
- The Suicide Prevention Resource Center (SPRC) provides prevention support, training, and resources to assist organizations and individuals to develop suicide prevention programs, interventions and policies, and to advance the National Strategy for Suicide Prevention.
- Stamp Out Suicide!
- The JED Foundation is the leading nonprofit organization working to reduce the rate of suicide and the prevalence of emotional distress among college students.
- Suicide Prevention:Effectiveness and Evaluation A 32-page guide from SPAN USA, the National Center for Injury Prevention and Control, and Education Development Center, Inc.
- American Association of Suicidology is a membership organization for all those involved in suicide prevention and intervention, or touched by suicide.
- American Foundation for Suicide Prevention is the leading not-for-profit dedicated to preventing suicide through research, education and advocacy.
- Suicide Prevention Action Network USA
- International Association for Suicide Prevention Organization co-sponsors World Suicide Prevention Day on September 10 every year with the World Health Organization (WHO).
- U.S. Surgeon General - Suicide Prevention
- Samaritans of Singapore is a non-profit and non-religious organisation which aims to provide 24-hour confidential emotional support to people in crisis, thinking of suicide or affected by suicide.
Journals of suicide prevention research
- Suicide and Life Threatening Behavior
- Archives of Suicide Research
- Crisis: The Journal of Crisis Intervention and Suicide Prevention