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Suicide prevention is an umbrella term 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 a) treating the psychological and psycho-physiological 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 social engagement, 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. Suicide prevention is risky for health professionals in terms of practitioner emotional distress and risk for malpractice suits.
Interpersonal 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 it is described as feeling that one is incompetent and therefore a burden on others. 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 easy way out of a difficult situation. Other significant risk factors for suicide include psychiatric disorders, substance abuse...etc. Individuals who have good interpersonal social relationship and family support tend to have lower risk of suicide. 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, having future plans or events to look forward to, and having satisfaction in life has normalized protective factors against suicide.
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.
In recognition of the need for comprehensive approaches to suicide prevention, various strategies have been developed with the support of evidence. Any suicide prevention approach requires to identify the risk factors that increases suicide or self-harm. 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). Thus the American Association of Suicidology outlines 10 important suicide warning signs, listed below :
- Suicidal Ideation: thinking, talking, or writing about suicide, planning for suicide.
- Substance abuse.
- Anxiety, agitation and unable to sleep or sleeping all the time.
- Social Withdrawal from friends, family, or society.
- Anger, rage or seeking revenge.
- Recklessness or impulsiveness.
- Mood changes.
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.
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, 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 and Cognitive therapy (CBT), it has shown to improve problem-solving and coping abilities.
Many methods of intervention have been developed to intercede before suicide is attempted. The general methods include: direct talks, screening for risks, lethal means reduction and social intervention. Each is explained in more detail below.
The World Health Organization (WHO) 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. Research has shown that many suicide risk assessment measures were not sufficiently validated, and do not include all three core suicidality attributes (i.e., suicidal affect, behavior, and cognition).
Lethal means reduction
Means reduction, reducing the odds that a suicide attempter will use highly lethal means, is an important component of suicide prevention. 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. In general, strong evidence supports the effectiveness of means restriction in preventing suicides. 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. 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 completion. "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%."
National Strategy for Suicide Prevention promotes and sponsors various specific suicide prevention endeavors:
- Developing groups leaded 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 is also been further 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 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.
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.
There are drug and talk therapies to prevent suicide, including phone delivery of services. According to randomized, controlled trials, these treatments have improved secondary outcomes, such as depression and suicidal ideation. However, only lithium has improved the primary outcome, of suicide itself. Because suicide is a rare event, most trials will have few or no suicides in either the treatment or control group, so they can't demonstrate effects on suicide itself.
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.
In one randomized, controlled trial, a program that included mobile phone followup reduced suicidal ideation and depression, and increased social support, but did not reduce actual self-harm and most substance abuse.
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; it has benefited from at least one crowd-sourced campaign. 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. In United States, suicide is the 10th most common cause of death and 0.5 percent of adults made a suicide attempt in 2012 Centers for Disease Control and Prevention survey; Suicide prevention efforts that 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. 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 (BPR) 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.
- Advocacy of suicide
- List of suicide crisis lines
- Living Is For Everyone
- World Suicide Prevention Day
- Gatekeeping (education)
- Suicide prevention contract
- Social skills
Suicide prevention organizations
- "Maine Suicide Prevention Website". Maine.gov. Retrieved 2012-01-15.
- January 15, 2012 (2003-09-16). "Suicide prevention definition - Medical Dictionary definitions of popular medical terms easily defined on MedTerms". Medterms.com. Retrieved 2012-01-15.
- Packman, Pennuto, Bongar, & Orthwein, 2004
- Ribeiro & Joiner, 2009
- Kraft , Jobes, Lineberry, Conrad, & Kung, 2010
- Van Orden et al., 2010
- Schwartz-Lifshitz M, Zalsman G, Giner L, Oquendo MA (2012). "Can we really prevent suicide?". Curr Psychiatry Rep. 14: 624–33. doi:10.1007/s11920-012-0318-3. PMC . PMID 22996297.
- Rudd, 2006
- Goldsmith, Pellmar, Kleinman, & Bunney, 2002
- WHO, 1998
- "National Strategy for Suicide Prevention" (PDF). Retrieved 2012-01-15.
- Joiner, 2005; Wingate et al., 2004; Rudd, 2006
- Linehan et al., 2006
- Stellrecht et al., 2006
- "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
- Crawford, MJ; Thana, L; Methuen, C; Ghosh, P; Stanley, SV; Ross, J; Gordon, F; Blair, G; Bajaj, P (May 2011). "Impact of screening for risk of suicide: randomised controlled trial.". The British Journal of Psychiatry. 198 (5): 379–84. doi:10.1192/bjp.bp.110.083592. PMID 21525521.
- Depression and Suicide at eMedicine
- González HM, Vega WA, Williams DR, Tarraf W, West BT, Neighbors HW (January 2010). "Depression Care in the United States: Too Little for Too Few". Archives of General Psychiatry. 67 (1): 37–46. doi:10.1001/archgenpsychiatry.2009.168. PMC . PMID 20048221.
- Luoma JB, Martin CE, Pearson JL (June 2002). "Contact with mental health and primary care providers before suicide: a review of the evidence.". The American Journal of Psychiatry. 159 (6): 909–16. doi:10.1176/appi.ajp.159.6.909. PMID 12042175.
- 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. 173 (6): 462–74. doi:10.1192/bjp.173.6.462. PMID 9926074.
- Harris K. M.; Syu J.-J.; Lello O. D.; Chew Y. L. E.; Willcox C. H.; Ho R. C. M. (2015). "The ABC's of suicide risk assessment: Applying a tripartite approach to individual evaluations". PLoS ONE. 10 (6): e0127442. doi:10.1371/journal.pone.0127442.
- "Means Matter Campaign". Hsph.harvard.edu. Retrieved 2012-01-15.
- Suicide Prevention Resource Center - Lethal Means[dead link]
- Yip, PS; Caine, E; Yousuf, S; Chang, SS; Wu, KC; Chen, YY (23 June 2012). "Means restriction for suicide prevention.". Lancet (London, England). 379 (9834): 2393–9. doi:10.1016/S0140-6736(12)60521-2. PMID 22726520.
- Cox, GR, Robinson, J, Nicholas, A; et al. (March 2013). "Interventions to reduce suicides at suicide hotspots: a systematic review.". BMC Public Health. 9: 214. doi:10.1186/1471-2458-13-214. PMC . PMID 23496989.
- "Means Matter Campaign - Coal Gas Case". Hsph.harvard.edu. Retrieved 2012-01-15.
- Kreitman, N (Jun 1976). "The Coal Gas Story: United Kingdom suicide rates, 1960-1971". Br J Prev Soc Med. 30 (2): 86–93. doi:10.1136/jech.30.2.86. PMC . PMID 953381.
- "Means Matter - Risk". Hsph.harvard.edu. Retrieved 2012-01-15.
- "Firearm Access is a Risk Factor for Suicide - Means Matter Basics - Means Matter - Harvard School of Public Health". Hsph.harvard.edu. Retrieved 2012-01-15.
- "Cdc Mmwr". Cdc.gov. Retrieved 2012-01-15.
- R. F. W. Diekstra. Preventive strategies on suicide.
- 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
- Hall RC, Popkin MK, Devaul RA, Faillace LA, Stickney SK (November 1978). "Physical illness presenting as psychiatric disease". Arch. Gen. Psychiatry. 35 (11): 1315–20. doi:10.1001/archpsyc.1978.01770350041003. PMID 568461.
- Chuang L., Mental Disorders Secondary to General Medical Conditions; Medscape;2011  Archived October 19, 2011, at the Wayback Machine.
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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 . PMID 19730273.
- Marasinghe, RB; Edirippulige, S; Kavanagh, D; Smith, A; Jiffry, MT (Apr 2012). "Effect of mobile phone-based psychotherapy in suicide prevention: a randomized controlled trial in Sri Lanka". J Telemed Telecare. 18 (3): 151–5. doi:10.1258/jtt.2012.SFT107. PMID 22362830.
- "Preventing Suicide, a resource for teachers and other school staff, World Health Organization, Geneva 2000" (PDF). Retrieved 2012-01-15.
- Bertolote, 2004
- Heath N. L.; Baxter A. L.; Toste J. R.; McLouth R. (2010). "Adolescents' willingness to access school-based support for non-suicidal self-injury". Canadian Journal of School Psychology. 25 (3): 260–276. doi:10.1177/0829573510377979.
- Bertolote, Jose (October 2004). "Suicide Prevention: at what level does it work?". World Psychiatry. 3 (3): 147–151. PMC . PMID 16633479.
- Best Practices Registry (BPR) For Suicide Prevention
- Rodgers PL, Sudak HS, Silverman MM, Litts DA (April 2007). "Evidence-based practices project for suicide prevention". Suicide Life Threat Behav. 37 (2): 154–64. doi:10.1521/suli.2007.37.2.154. PMID 17521269.
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!
- Centre for Suicide Prevention (CSP), Canada
- 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 & suicide prevention resources
- Suicide and Life Threatening Behavior
- Archives of Suicide Research
- Crisis: The Journal of Crisis Intervention and Suicide Prevention
- Van Orden K. A.; et al. (2010). "The interpersonal theory of suicide". Psychological Review. 117: 575–600. doi:10.1037/a0018697.
- Rudd, M. D. (2006). The assessment and management of suicidality. Sarasota, FL : Professional Resource Press.
- Self-harm care management, NICE, UK
- Practice Guidelines for Suicide prevention, APA