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Crucial elements in suicide prevention strategies
Progress in Neuro-Psychopharmacology & Biological Psychiatry 35 (2011) 848–853
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Progress in Neuro-Psychopharmacology & Biological Psychiatry j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p n p
Crucial elements in suicide prevention strategies Merete Nordentoft ⁎ Psychiatric Centre Copenhagen, Copenhagen University, Faculty of Health Sciences, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
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Article history: Received 1 July 2010 Received in revised form 28 October 2010 Accepted 25 November 2010 Available online 2 December 2010 Keywords: Percent attributable risk Prevention Risk factors Suicide Suicide attempt
a b s t r a c t Ways of conceptualizing suicide prevention are reviewed briefly, and the preventive model: Universal, Selected, and Indicated prevention (USI) is chosen as the structure for the literature review, and the discussion. Universal preventive interventions are directed toward entire population; selective interventions are directed toward individuals who are at greater risk for suicidal behaviour; and indicated preventions are targeted at individuals who have already begun self-destructive behaviour. On the universal prevention level, an overview of the literature is presented with focus on restrictions in firearms and carbon monoxide gas. At the selective prevention level, a review of risk of suicide in homelessness and schizophrenia and risk factors for suicide in schizophrenia is conducted and possible interventions are mentioned together with the evidence for their effect. Suicide rate and preventive measures in affective disorder are also touched upon. At the indicated prevention level, studies of fatal and non-fatal suicide acts after suicide attempt are mentioned. The evidence of preventive measures to reduce repetition rates is presented. Finally, the state of the art is discussed with regard to prevention at the universal, the selected and the indicated level and clinical and research implications are outlined. © 2010 Published by Elsevier Inc.
1. Introduction Suicide is one of the leading health problems in the world. Each year almost one million people die from suicide. Thus, suicide is among the top ten causes of death worldwide and the second most common cause of non-illness death worldwide. For at least twenty years, there have been activities in WHO to increase awareness of suicide prevention and to put suicide prevention on the national agenda in all countries. In 1988, WHO EURO issued the “Health for All Strategy”. Target 12 concerned suicide prevention (World Health Organization, 1985). Since then, an expert meeting in Szeged, Hungary in 1989 agreed on “Consultation on Strategies for Reducing Suicidal Behaviour in the European Region” and recommended establishment of national suicide prevention strategies in all the WHO member states of the region. WHO recommended nations to develop and implement suicide prevention strategies: “Each government needs to adapt or modify specific components of the National Strategy Guidelines to fit their own cultural, economic, demographic, political and social needs” (UN/WHO Guidelines for the Development of National Strategies for the Prevention of Suicidal Behaviours, 1993). In 1996, “Global Trends in Suicide Prevention: Toward the Development of
Abbreviations: SUPRE, an acronym for the project SUicide PREvention; USI, Universal, selective and indicated prevention; WHO, World Health Organization; WHO EURO, World Health Organisation, Regional Office for Europe. ⁎ Corresponding author. E-mail address: [email protected]. 0278-5846/$ – see front matter © 2010 Published by Elsevier Inc. doi:10.1016/j.pnpbp.2010.11.038
National Strategies for Suicide Prevention” was issued in collaboration with WHO and United Nations Secretariat, (Ramsay and Tanney, 1996). In 2000, WHO launched the SUPRE campaign (SUicide PREvention) which included recommendations about awareness campaigns and reliable statistics, and finally, in 2005, The European Ministerial Conference in Helsinki endorsed “Mental Health Declaration for Europe: Facing the Challenges, Building Solutions”, target v: to develop and implement measures to reduce the preventable causes of mental health problems, comorbidity and suicide (http://www.euro.who.int/document/mnh/edoc06.pdf) and the “Mental Health Action Plan for Europe: Facing the Challenges, Building Solutions”, chapter 5: Prevent mental health problems and suicide (http://www.euro.who.int/document/ mnh/edoc07.pdf). Thus, through the consistent effort of recent decades, international focus on the problem of suicide has led to the development of suicide prevention strategies in a range of countries for instance Finland (1992), Norway (1994),Sweden (1995),Greenland (1997),Denmark (1998), Australia (1999),USA (2001), England (2002), Scotland (2002), Germany (2002), Malaysia (2007), New Zealand (2008), and Ireland (2005). A national strategy can be defined as (Mehlum, personal communication): “A comprehensive and nationwide approach to reduce suicidal behaviours across the life span through coordinated and culture sensitive response from multiple public or private sectors of society.” In a landmark paper, John Mann and a large number of international experts (Mann et al., 2005) concluded that more studies were needed to establish the evidence basis for the elements in suicide prevention strategies, and that there was an evidence basis for physician education in depression
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recognition and treatment and restricting access to lethal methods reduce suicide rates. 2. Understanding suicide Striving to live is fundamental for all living creatures, also among human beings. Suicidal impulses and suicidal behaviour must be considered as disturbances of this fundamental condition. When suicidal behaviour occurs, it must be considered as a sign of strain on the individual that exceeds his or her capability to cope with the situation. The diathesis-stress model can be used as a framework for understanding suicidal impulses and suicidal behaviour. To develop preventive interventions requires theoretical considerations and empirical knowledge about aetiology and pathogenesis and empirical data concerning risk factors, predisposing factors, protective and precipitating factors, and effectiveness of preventive measures. Suicide cannot be understood as a disease or an accident, but suicidal acts can be considered severe and preventable complications to a range of diseases and conditions in which social aspects play an important role. Therefore, it can be difficult to fit prevention of suicide into models for disease or accident prevention, but elements of disease and accident prevention can be compiled. 3. Universal, selective, and indicated prevention The Universal, Selected and Indicated preventive model (USI model) was suggested by Gordon (Gordon, 1983) and later accepted by the Institute of Medicine in 1994 (Mrazek and Haggerty, 1994). This model is relevant for use in suicide prevention, but can also be used in other fields. The model is used in the publication from the Institute of Medicine of the National Academies, Committee on Pathophysiology and Prevention of Adolescent and Adult Suicide: Reducing suicide a national imperative (Institute of Medicine, 2002): “The prevailing prevention model in the interdisciplinary field of prevention science is the Universal, Selective, and Indicated (USI) prevention model. This USI model focuses attention on defined populations — from everyone in the population, to specific at-risk groups, to specific high-risk individuals — i.e., three population groups for whom the designed interventions are deemed optimal for achieving the unique goals of each prevention type.” “Universal strategies or initiatives address an entire population (the nation, state, the local county or community, school or neighbourhood). These prevention programs are designed to influence everyone, reducing suicide risk by removing barriers to care, enhancing knowledge of what to do and say to help suicidal individuals, increasing access to help, and strengthening protective processes like social support and coping skills. Universal interventions include programs such as public education campaigns, school-based ‘suicide awareness’ programs, means restriction, education programs for the media on reporting practices related to suicide, and schoolbased crisis response plans and teams.” “Selective strategies address subsets of the total population, focusing on at-risk groups that have a greater probability of becoming suicidal. Selective prevention strategies aim to prevent the onset of suicidal behaviours among specific subpopulations. This level of prevention includes screening programs, gatekeeper training for ‘frontline’ adult caregivers and peer ‘natural helpers’, support and skill-building groups for at-risk groups in the population, and enhanced accessible crisis services and referral sources.” “Indicated strategies address specific high-risk individuals within the population — those evidencing early signs of suicide potential. Programs are designed and delivered in groups or individually to reduce risk factors and increase protective factors. At this level, programs include skill-building support groups in high schools and colleges, parent support training programs, case management for
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individual high-risk youth at school, and referral sources for crisis intervention and treatment” This model is much easier to use in suicide prevention than the traditional primary, secondary, tertiary model. In the following, the USI model will be used as a framework for describing some of the most important suicide preventive measures in different areas.
4. Methodological problems in research of suicide prevention Even though suicide is a large public health problem, and even though high-risk groups for suicide can be identified, the base rate of suicide is low, also in high-risk groups. It is widely accepted that suicide attempts are estimated to be much more common — hospitaltreated cases are often found to be 10 times more common — than suicides, and population surveys ((Scoliers et al., 2009)) indicate that much higher figures for suicide attempts can be found in the community. The population of persons who attempt suicide and those who die by suicide overlap, but the age and gender distribution in the two groups demonstrate that this overlap is only partial. Also other risk factors only overlap to some extent. To evaluate an intervention, the best method is a large randomised clinical trial that includes a representative sample of the target group. However, due to the low base rate, the trials should include several thousand participants in order to reduce the risk of type II error (Pocock, 1996). Randomised clinical trials large enough to provide evidence of effectiveness of suicide preventive measures in risk groups are difficult to organize, and practical, political and ethical considerations may make such trials impossible. It is seldom possible to carry out such large trials; they would necessitate multicentre trials, which again are associated with methodological difficulties in ensuring that the same interventions are carried out at different sites. Meta-analyses of randomised clinical trials can compensate to some extent for the trials being underpowered, but often the trials included in meta-analyses are different with regard to population group included, duration and intensity of treatment. Reluctance to carry out randomised clinical trials in suicide prevention presents an additional problem. As suicide attempts are much more common than suicides, many investigators have chosen to use suicide attempt as a proxy variable for suicide. If suicide attempt is chosen as outcome measure, it is possible to establish randomised studies with sufficient power to examine a potential effect of preventive measures. Even though risk factors for suicide and suicide attempt are not completely the same, it is likely that preventive efforts effective in reducing frequency of suicide attempts are also effective in preventing suicide. In many cases, it is not possible to carry out a randomised clinical trial of factors likely to play a role in increasing or decreasing suicide rates in the general population or in specific risk groups. In such cases, it is necessary to carry out naturalistic, individually based, observational studies or ecological studies to identify risk factors. Nested casecontrol studies have an advantage over case-control studies, since selecting controls from a large database implies possibilities for matching on several relevant factors and for adjusting estates of risk for possible confounders. However, naturalistic studies of any kind carry a risk of interchanging cause and effect. Randomised clinical trials cannot be carried out to evaluate health care reforms, changes in culture or religion, media coverage, unemployment, immigration policy, restrictions in means for suicide, and changed legislation or pattern of use for alcohol and drugs. In these cases, ecological studies or individually based naturalistic studies must be carried out. However, the interpretation of such studies is associated with difficulties, as it can be impossible to disentangle what is the effect of the change that is the subject of the study and what are the effects of confounding factors. Observational studies cannot provide the same strong evidence as randomized
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clinical trials; nevertheless, there are numerous areas where recommendations for practice will have to rely on weaker evidence. 5. Universal suicide prevention It is evident from the fluctuating suicide rates in different countries that a range of factors play a role, such as changes in social, cultural and political climate, changes in health status and access to alcohol and drugs, access to lethal methods for suicide, and access to health care. There are several examples of interventions that could be classified as universal preventive mechanism. However some of these interventions have not been initiated because of their direct effect on suicide, but because of other factors such as for instance mandatory implementation of catalytic converters, and reduction of carbon monoxide in household gas due to environmental concerns, and school-based programmes aiming at reducing bullying. Introduction of school programmes has been proposed aimed at reducing suicidal behaviour, but based on two recent reviews it seems sound to conclude that there is insufficient evidence to either support or refute any benefits from curriculum-based programmes in schools. More broadly based comprehensive school health should be evaluated for their effectiveness in addressing the determinants of adolescent risk behaviour (Ploeg et al., 1996;Guo and Harstall, 2002). It is well established that media attention regarding suicide can also influence suicide rates (Hawton and Williams, 2002;Simkin et al., 1995;Zahl and Hawton, 2004), and influencing media coverage of suicidal events can be considered to be an element in a universal approach. Recently, awards for sober mentioning of suicide in the media has been launched in Denmark, Belgium and Australia as means to improve and encourage media coverage in accordance with the WHO guidelines (http://www.who.int/mental_health/prevention/suicide/resource_media.pdf) Among the possible interventions in universal suicide prevention, restricting access to means for suicide is the best documented. This intervention is recommended as an active ingredient in suicide prevention strategies (Mann et al., 2005). However, in some cases, restrictions in means for suicide have been decided directly with the aim of influencing suicide rates, whereas in other cases, for example environmental considerations or risk of accidents have been the main reason for restricting availability of means for suicide. This was for instance the case with removing carbon monoxide from household gas and car exhaust through catalytic converters. There is huge variation in the use of methods for suicide all over the world. In USA, 60% of all suicides are committed with firearms, while in Southeast Asia, a similar figure accounts for pesticide suicides (Eddleston et al., 1998;Gunnell and Eddleston, 2003). It has long been hypothesized that restrictions of means for suicide can positively influence suicide rates (Marzuk et al., 1992;Farmer and Rohde, 1980), and many studies have been carried out to elucidate the effect of restricting means for suicide. Three reviews have been carried out to study the possible effect of restrictions in access to firearms (Miller and Hemenway, 1999;Lester, 1998;Haw et al., 2004). All three reviews concluded that there was a strong association between gun ownership and gunshot suicide. All the studies reviewed indicate the same conclusion, namely that the availability of firearms increases the risk of firearm suicide in all age groups, including children. All studies of the effect of gun legislation indicate that strict gun legislation reduces firearms suicide rate. The availability of carbon monoxide and its relation to suicide rates has been investigated in studies of detoxification of coal gas and in the introduction of mandatory catalytic converters. Kreitman (1976) studied the effect of detoxification of domestic gas in UK from 1955 to 1971 and found that there was a marked decline in carbon monoxide suicides in both genders concomitantly with reduced availability of toxic domestic gas. The same conclusion was found by other authors,
investigating the problem in a range of other countries. The effect of mandatory catalytic converters in all petrol cars sold since 1993 was studied from 1991 to 1996 in the UK by Kendell (1998), who concluded that the introduction of catalytic converters decreased the number of suicides without substitution of other methods. The same conclusion was reached by researcher in United States (Amos et al., 2001;Mott et al., 2002) and Denmark (Nordentoft et al., 2007). When examining suicide rates in different countries at different points in time, it is obvious that methods for suicide are different in different countries during different time periods. It is beyond doubt that not only the availability but also the awareness and cultural acceptance of a method determine whether it is a frequently used method or not. It is obvious that suicide with car exhaust was introduced as a method for suicide after it had been available for decades. One can even speak of a method for suicide being marketed, as for instance asphyxia-suicide with plastic bags (Humphry, 1992). As stated by Gunnell, accessibility to and the lethality of a particular method may have profound effect on the overall suicide rate. Such effects appear to depend on the popularity of the method, and the extent to which alternative methods that are acceptable to the individual are available (Gunnell et al., 2000). Therefore, when recommending restrictions in access to dangerous methods for suicide, it must also be considered how to avoid marketing of lethal methods for suicide. Lester (1998) published a review, primarily of his own research papers, that concluded by recommending a range of ways to limit access to lethal methods for suicide. These included strict gun laws, car emission control of carbon monoxide content, natural domestic gas, restricting access to tops of buildings, fencing bridges, limiting packet size of medication frequently used for suicidal acts, enclosing pills in plastic blisters, removing lethal agents before releasing suicide attempters to their homes. On the basis of the above-mentioned studies, it must be recommended to adopt strict laws concerning firearms, to make available domestic gas without content of carbon monoxide, to make catalytic converters mandatory and control carbon monoxide emission from cars and other vehicles, to secure controlled environments such as hospitals and prisons with regard to possibilities for hanging, to prescribe less toxic medication and small amounts of toxic drugs, to limit packet size of over-the-counter sale of medication often used for attempted suicide. 6. Selective prevention in risk groups The most important risk groups are the mentally ill, alcohol and drugs abusers, those with a newly diagnosed severe somatic disease, prisoners, and homeless persons. It is well documented that mental illness in all diagnostic groups is a risk factor for suicide (Mortensen et al., 2000;Qin and Nordentoft, 2005), and most disorders multiplies the suicide risk at least tenfold. In their estimation of lifetime risk of suicide in various disorders, Inskip et al. (1998) estimated the lifetime risk in schizophrenia to be 4%. Palmer et al. (2005), in their recent meta-analysis, estimated the lifetime risk to be 5.6%. In 2005, Hawton et al. published a systematic review of risk factors and identified 29 eligible studies. They found robust evidence of increased risk of suicide in schizophrenia for depressive disorders, previous suicide attempts, drug abuse, agitation and motor restlessness, fear of mental disintegration, poor adherence to treatment and recent loss (Hawton et al., 2005). Among patients with schizophrenia, there were no large studies investigating the effect on suicide of psychosocial interventions. The analyses of data from the OPUS trial indicates that the study did not have sufficient power to detect any effect on suicide, and that there was no indication of a positive effect on deliberate self-harm (Nordentoft et al., 2002;Petersen et al., 2005;Bertelsen et al., 2007). In schizophrenia, no randomised controlled trial of specific
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antipsychotic drugs has proven an effect on suicide (Meltzer, 2002); however, a study indicates that Clozapin is superior to Olanzapin with regard to reducing the risk of deliberate self-harm (Meltzer et al., 2003). Also affective disorder and alcoholism have been considered to have high lifetime risk of suicide. Miles (1977) estimated that the lifetime risk of suicide in alcoholism would be 15%, opiate addiction 5%, and depression 15%, but these figures are most likely too high. Inskip et al. (1998) estimated the lifetime risk in alcohol dependence to be 7% and 6% in affective disorder. Bostwick and Pankratz (2000) divided the suicide risk in affective disorder in several different risk groups with different estimation of lifetime risk for suicide. Their estimate of lifetime risk for patients with affective disorder hospitalized for suicidality was 8.6%, while for patients with affective disorder with no specific history of suicidality, the lifetime risk estimation was 4.0% and for outpatients with affective disorder 2.2%. Depression and other psychiatric disorders are reported to be under-recognized and under-treated in primary care setting (MunkJorgensen et al., 1997). Studies examining suicidal behaviour in relation to primary care physician education programmes, mostly targeting depression recognition and treatment, have all reported increased prescription rates for antidepressants and often substantial declines in suicide rates (Rutz et al., 1989;Rutz, 2001;Rihmer et al., 2001;Rutz, 1992). However, these studies were small and considerable variation might be due to change. There is a current debate about the effect of Selective Serotonin Reuptake Inhibitors (SSRI) on suicidal behaviour. Several metaanalysis of published and unpublished randomised clinical trials have been conducted comparing SSRI and placebo among adults (Hammad et al., 2006b;Fergusson et al., 2005;Gunnell et al., 2005) and children and adolescents (Whittington et al., 2004;Hammad et al., 2006a). The randomised clinical trials of SSRI compared to placebo do not have enough power to detect differences in completed suicide; concerning suicidal ideation and behaviour, there is no evidence of a protective effect. In affective disorders, many studies of the effect of Lithium have been conducted, the majority being naturalistic studies. However, a meta-analysis (Cipriani et al., 2005) summarizes the evidence from randomised controlled trials of the effect of long-term Lithium therapy for affective disorders and concluded that Lithium is effective in the prevention of suicide, deliberate self-harm, and death from all causes in patients with mood disorders. Moreover it has been hypothesized that anti-aggressive effects of Lithium might play a role in suicide prevention in patients with non-affective disorders (Muller-Oerlinghausen and Lewitzka, 2010). A range of studies demonstrate that recent diagnosis of severe somatic illness is associated with increased risk of suicide. This evidence is most clear from studies of neurological diseases and cancer, and forms the basis for recommendation of careful crisis management in these patients and evaluation of suicide risk (Stenager et al., 1998;Yousaf et al., 2005). Studies of homeless persons found increased risk of suicide compared to the general population, and the excess suicide mortality was most dominant in younger age groups (Babidge et al., 2001; Hwang et al., 1997;Hwang, 2000;Roy et al., 2004;Nordentoft and Wandall-Holm, 2003). Prisoners and newly released comprise another important and often overlooked and untreated risk group.(Fazel et al., 2010;Fazel et al., 2008;Pratt et al., 2006;Pratt et al., 2010). On the basis of the above-mentioned studies about selected prevention, it must be concluded that mental illness, including substance abuse, is the most important risk factor for suicide, as the mentally ill form a large risk group with a very high risk of suicide. Persons with severe and newly diagnosed somatic disorders also form an important risk group, and even though the hazard ratio for suicide is smaller than in mental illness, it is an important risk group because
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somatic illness is very common especially among elderly. Socially excluded persons such as homeless and prisoners are also at increased risk, but smaller in number. In many of the above-mentioned groups there is poor evidence for effectiveness of interventions directed versus the risk of suicide. Therefore the best guideline will be to provide the best possible support and treatment to persons in the risk groups, and to provide skill-building programs for staff involved in order to increase awareness of suicide risk. 7. Indicated prevention Indicated prevention is focused on the high-risk group of persons who have attempted suicide or have presented themselves to health services because of suicidal ideation. Help lines, psychiatric emergency rooms, psychiatric emergency outreach and other crisis interventions can play a role in preventing suicide attempts among persons in a suicidal crisis, and there are different interventions aiming to reduce risk of suicidal acts after suicide attempt. Many studies have been conducted with the aim of elucidating risk of repetition of fatal and non-fatal suicidal acts. Owens et al. (2002) conducted a systematic review of fatal and non-fatal repetition of selfharm and found that the median one-year repetition rate was 16% non-fatal and 2% fatal. After more than nine years, around 7% of patients had died by suicide. Since Kreitman and Foster in 1991 reported risk factors for repeated suicide attempt, many other authors have investigated this matter. The most frequently reported risk factor for repetition is previous suicide attempt, thus confirming the notion that there are substantial differences in the risk of repetition among ‘first evers’ and repeaters. Other frequently reported risk factors are alcohol and drug abuse, depression, previous inpatient treatment, sociopathy, unemployment, frequent change of address, hostility, hopelessness, and living alone (Nordentoft, 2007). The predictors of suicide identified in more than one study were male gender, increasing age, previous suicide attempt, substance abuse, somatic disease, high suicidal intent score, violent suicide attempt or suicide attempt with severe lethality, and ongoing or previous psychiatric treatment (Nordentoft, 2007). Thus the literature reviews confirm that suicide attempt is associated with market increased risk of repeated non-fatal and fatal suicidal acts, and that those in highest risk are those who are often considered difficult to treat. A systematic review of randomised clinical trials of psychosocial and pharmacological interventions for persons who have attempted suicide revealed that until now, apart from dialectic behavioural therapy (Linehan et al., 1991), no intervention has proven effective in reducing suicide rate or repetition rate (Hawton et al., 1999). The authors identified non-significant trends toward reduced repetition of deliberate self-harm for problem-solving therapy compared with standard aftercare, for provision of an emergency contact card in addition to standard care compared with standard aftercare alone, and for intensive aftercare plus outreach compared with standard aftercare. In one relatively large study in this group, which evaluated community follow-up of patients who did not attend outpatient appointments, there was a near significant difference in repetition of deliberate self-harm of 10.7% compared with 17.4% (0.57; 0.32 to 1.02) (Van Heeringen et al., 1995). Hawton et al. concluded that the results of the systematic review indicate that there is currently insufficient evidence on which to base firm recommendations about the most effective forms of treatment for patients who have recently deliberately harmed themselves. Given the size of the problem, they consider this situation serious. The main problem with nearly all trials in the meta-analysis was that they included far too few subjects to have the statistical power to detect clinically meaningful differences in rates of repetition of deliberate self-harm between experimental and control treatments, if such differences existed. Even when the results from similar trials were synthesized with meta-analytical
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techniques, there were insufficient numbers of patients to detect such differences. Even though some studies have been published after the Cochrane review, (Tyrer et al., 2003;Brown et al., 2005;Vaiva et al., 2006;Guthrie et al., 2001) and the odds ratios in all trials point in the same direction, namely toward a protective effect of the experimental conditions, there is still insufficient evidence to form basis for firm recommendations. As pointed out by Hawton, it might be necessary for such interventions to be combined with case management programmes for high-risk individuals e.g.: assertive outreach. Other less intensive interventions were tested in randomized clinical trials. Among patients who refused aftercare after suicide attempt, Motto (Motto and Bostrom, 2001;Motto, 1976) found that regularly sending letters four times a year in five years significantly reduced the suicide rate in contact group compared to no contact group for many years. In Australia, a similar trial was carried out with regularly postcards eight times during first twelve month after suicide attempt and a significant reduction in the number of repeated suicidal acts were identified during the first two years in the contact group compared to no contact group (Carter et al., 2005;Carter et al., 2007). An uncontrolled study of telephone services for elderly in Italy revealed lower suicide rates than expected in the population who had this service (De Leo et al., 1995), and later Vaiva et al. in a randomized clinical trial confirmed that telephone contact one month after suicide attempt reduced number of reattempts over one year (Vaiva et al., 2006). Other interventions are skill-building support groups in high schools and colleges, and parent support training programs, which may be relevant for adolescents at risk for suicidal behaviour. In conclusion, the results of indicated preventive studies indicates that it is possible to reduce the risk of reattempt after suicide attempt through a range of different specific interventions, but yet no studies compare these interventions. Even low intensity interventions can be effective. Large randomized clinical trials are needed in order to establish stronger evidence basis in this important field.
associated with the risk factor. Such figures can of course be discussed, and most likely studies in different countries will result in different estimates. However, it is beyond doubt that the risk groups mentioned in the table are among the most important, and that they together comprise the majority of high-risk group. 9. Conclusion The crucial elements in national suicide prevention strategies can be summarized at the universal, selective and indicated level of prevention. Among universal preventive interventions, restriction of access to methods for suicide seems to be the best documented, especially for methods with high case fatality. Media guidelines and provision of information about where to seek help in critical situations are also important measures. Regarding selective prevention, the most important risk groups both in terms of magnitude of the increased risk and size of the risk group are the mentally ill, including those with alcohol and substance abuse, and those who have attempted suicide. Preventive interventions are educational programs for staff-members in mental health settings and in somatic departments dealing with diagnosis and treatment of serious somatic disorders. It is important to have an overview risk of suicide in different risk groups and to consider and recommend interventions to reduce risk of suicide. Among indicated preventive measures, it is important to provide possibilities for crisis management and treatment for those at immediate risk for suicidal acts. Help lines, cognitive behavioural therapy dialectic behavioural therapy and an assertive approach are among the most promising interventions. At the national level a governing body should be established with the task of monitoring time changes in suicide rates in different risk groups and initiating and promoting research, quality development and interventions.
8. The crucial elements References To guide the prevention strategy, it can be helpful to evaluate the population attributable risk associated with different risk factors. The population attributable risk is an estimate of the proportion of the problem that could be avoided if the increased risk in a specific risk group could be reduced to the level of the general population. It is calculated by using the formula: Proportion at risk in the general population ðRR−1Þ 100 Proportion at risk in the general population ðRR−1Þ + 1 In Table 1, the population attributable risk for some of the largest risk groups are estimated. The percentages add up to more than 100% as the groups are not mutually exclusive. The figures are based on estimates of the size of the risk groups and the relative risk (RR) Table 1 Population attributable risk.§ Admitted or recently discharged, psychiatric ward# Recent suicide attempt¤ Elderly men++ Alcohol abuse** Criminal history## §
25% 16% 13% 23% 12%
Based on estimates of proportion in the general population with the risk factor and estimates of relative risk associates with the risk factor. #Based on Danish register-based study carried out by Qin and Nordentoft (2005). ## Based on Danish statistics and Danish register-based study carried out by Qin and Nordentoft (2005). ¤Based on reviews carried out by Owens et al. (2002) and Nordentoft (2007). ++ Based on Danish suicide statistics, similar findings in other countries. ** Based on data from Danish registers and paper published by Fazel et al. (2010).
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Contents lists available at ScienceDirect
Progress in Neuro-Psychopharmacology & Biological Psychiatry j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p n p
Crucial elements in suicide prevention strategies Merete Nordentoft ⁎ Psychiatric Centre Copenhagen, Copenhagen University, Faculty of Health Sciences, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
a r t i c l e
i n f o
Article history: Received 1 July 2010 Received in revised form 28 October 2010 Accepted 25 November 2010 Available online 2 December 2010 Keywords: Percent attributable risk Prevention Risk factors Suicide Suicide attempt
a b s t r a c t Ways of conceptualizing suicide prevention are reviewed briefly, and the preventive model: Universal, Selected, and Indicated prevention (USI) is chosen as the structure for the literature review, and the discussion. Universal preventive interventions are directed toward entire population; selective interventions are directed toward individuals who are at greater risk for suicidal behaviour; and indicated preventions are targeted at individuals who have already begun self-destructive behaviour. On the universal prevention level, an overview of the literature is presented with focus on restrictions in firearms and carbon monoxide gas. At the selective prevention level, a review of risk of suicide in homelessness and schizophrenia and risk factors for suicide in schizophrenia is conducted and possible interventions are mentioned together with the evidence for their effect. Suicide rate and preventive measures in affective disorder are also touched upon. At the indicated prevention level, studies of fatal and non-fatal suicide acts after suicide attempt are mentioned. The evidence of preventive measures to reduce repetition rates is presented. Finally, the state of the art is discussed with regard to prevention at the universal, the selected and the indicated level and clinical and research implications are outlined. © 2010 Published by Elsevier Inc.
1. Introduction Suicide is one of the leading health problems in the world. Each year almost one million people die from suicide. Thus, suicide is among the top ten causes of death worldwide and the second most common cause of non-illness death worldwide. For at least twenty years, there have been activities in WHO to increase awareness of suicide prevention and to put suicide prevention on the national agenda in all countries. In 1988, WHO EURO issued the “Health for All Strategy”. Target 12 concerned suicide prevention (World Health Organization, 1985). Since then, an expert meeting in Szeged, Hungary in 1989 agreed on “Consultation on Strategies for Reducing Suicidal Behaviour in the European Region” and recommended establishment of national suicide prevention strategies in all the WHO member states of the region. WHO recommended nations to develop and implement suicide prevention strategies: “Each government needs to adapt or modify specific components of the National Strategy Guidelines to fit their own cultural, economic, demographic, political and social needs” (UN/WHO Guidelines for the Development of National Strategies for the Prevention of Suicidal Behaviours, 1993). In 1996, “Global Trends in Suicide Prevention: Toward the Development of
Abbreviations: SUPRE, an acronym for the project SUicide PREvention; USI, Universal, selective and indicated prevention; WHO, World Health Organization; WHO EURO, World Health Organisation, Regional Office for Europe. ⁎ Corresponding author. E-mail address: [email protected]. 0278-5846/$ – see front matter © 2010 Published by Elsevier Inc. doi:10.1016/j.pnpbp.2010.11.038
National Strategies for Suicide Prevention” was issued in collaboration with WHO and United Nations Secretariat, (Ramsay and Tanney, 1996). In 2000, WHO launched the SUPRE campaign (SUicide PREvention) which included recommendations about awareness campaigns and reliable statistics, and finally, in 2005, The European Ministerial Conference in Helsinki endorsed “Mental Health Declaration for Europe: Facing the Challenges, Building Solutions”, target v: to develop and implement measures to reduce the preventable causes of mental health problems, comorbidity and suicide (http://www.euro.who.int/document/mnh/edoc06.pdf) and the “Mental Health Action Plan for Europe: Facing the Challenges, Building Solutions”, chapter 5: Prevent mental health problems and suicide (http://www.euro.who.int/document/ mnh/edoc07.pdf). Thus, through the consistent effort of recent decades, international focus on the problem of suicide has led to the development of suicide prevention strategies in a range of countries for instance Finland (1992), Norway (1994),Sweden (1995),Greenland (1997),Denmark (1998), Australia (1999),USA (2001), England (2002), Scotland (2002), Germany (2002), Malaysia (2007), New Zealand (2008), and Ireland (2005). A national strategy can be defined as (Mehlum, personal communication): “A comprehensive and nationwide approach to reduce suicidal behaviours across the life span through coordinated and culture sensitive response from multiple public or private sectors of society.” In a landmark paper, John Mann and a large number of international experts (Mann et al., 2005) concluded that more studies were needed to establish the evidence basis for the elements in suicide prevention strategies, and that there was an evidence basis for physician education in depression
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recognition and treatment and restricting access to lethal methods reduce suicide rates. 2. Understanding suicide Striving to live is fundamental for all living creatures, also among human beings. Suicidal impulses and suicidal behaviour must be considered as disturbances of this fundamental condition. When suicidal behaviour occurs, it must be considered as a sign of strain on the individual that exceeds his or her capability to cope with the situation. The diathesis-stress model can be used as a framework for understanding suicidal impulses and suicidal behaviour. To develop preventive interventions requires theoretical considerations and empirical knowledge about aetiology and pathogenesis and empirical data concerning risk factors, predisposing factors, protective and precipitating factors, and effectiveness of preventive measures. Suicide cannot be understood as a disease or an accident, but suicidal acts can be considered severe and preventable complications to a range of diseases and conditions in which social aspects play an important role. Therefore, it can be difficult to fit prevention of suicide into models for disease or accident prevention, but elements of disease and accident prevention can be compiled. 3. Universal, selective, and indicated prevention The Universal, Selected and Indicated preventive model (USI model) was suggested by Gordon (Gordon, 1983) and later accepted by the Institute of Medicine in 1994 (Mrazek and Haggerty, 1994). This model is relevant for use in suicide prevention, but can also be used in other fields. The model is used in the publication from the Institute of Medicine of the National Academies, Committee on Pathophysiology and Prevention of Adolescent and Adult Suicide: Reducing suicide a national imperative (Institute of Medicine, 2002): “The prevailing prevention model in the interdisciplinary field of prevention science is the Universal, Selective, and Indicated (USI) prevention model. This USI model focuses attention on defined populations — from everyone in the population, to specific at-risk groups, to specific high-risk individuals — i.e., three population groups for whom the designed interventions are deemed optimal for achieving the unique goals of each prevention type.” “Universal strategies or initiatives address an entire population (the nation, state, the local county or community, school or neighbourhood). These prevention programs are designed to influence everyone, reducing suicide risk by removing barriers to care, enhancing knowledge of what to do and say to help suicidal individuals, increasing access to help, and strengthening protective processes like social support and coping skills. Universal interventions include programs such as public education campaigns, school-based ‘suicide awareness’ programs, means restriction, education programs for the media on reporting practices related to suicide, and schoolbased crisis response plans and teams.” “Selective strategies address subsets of the total population, focusing on at-risk groups that have a greater probability of becoming suicidal. Selective prevention strategies aim to prevent the onset of suicidal behaviours among specific subpopulations. This level of prevention includes screening programs, gatekeeper training for ‘frontline’ adult caregivers and peer ‘natural helpers’, support and skill-building groups for at-risk groups in the population, and enhanced accessible crisis services and referral sources.” “Indicated strategies address specific high-risk individuals within the population — those evidencing early signs of suicide potential. Programs are designed and delivered in groups or individually to reduce risk factors and increase protective factors. At this level, programs include skill-building support groups in high schools and colleges, parent support training programs, case management for
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individual high-risk youth at school, and referral sources for crisis intervention and treatment” This model is much easier to use in suicide prevention than the traditional primary, secondary, tertiary model. In the following, the USI model will be used as a framework for describing some of the most important suicide preventive measures in different areas.
4. Methodological problems in research of suicide prevention Even though suicide is a large public health problem, and even though high-risk groups for suicide can be identified, the base rate of suicide is low, also in high-risk groups. It is widely accepted that suicide attempts are estimated to be much more common — hospitaltreated cases are often found to be 10 times more common — than suicides, and population surveys ((Scoliers et al., 2009)) indicate that much higher figures for suicide attempts can be found in the community. The population of persons who attempt suicide and those who die by suicide overlap, but the age and gender distribution in the two groups demonstrate that this overlap is only partial. Also other risk factors only overlap to some extent. To evaluate an intervention, the best method is a large randomised clinical trial that includes a representative sample of the target group. However, due to the low base rate, the trials should include several thousand participants in order to reduce the risk of type II error (Pocock, 1996). Randomised clinical trials large enough to provide evidence of effectiveness of suicide preventive measures in risk groups are difficult to organize, and practical, political and ethical considerations may make such trials impossible. It is seldom possible to carry out such large trials; they would necessitate multicentre trials, which again are associated with methodological difficulties in ensuring that the same interventions are carried out at different sites. Meta-analyses of randomised clinical trials can compensate to some extent for the trials being underpowered, but often the trials included in meta-analyses are different with regard to population group included, duration and intensity of treatment. Reluctance to carry out randomised clinical trials in suicide prevention presents an additional problem. As suicide attempts are much more common than suicides, many investigators have chosen to use suicide attempt as a proxy variable for suicide. If suicide attempt is chosen as outcome measure, it is possible to establish randomised studies with sufficient power to examine a potential effect of preventive measures. Even though risk factors for suicide and suicide attempt are not completely the same, it is likely that preventive efforts effective in reducing frequency of suicide attempts are also effective in preventing suicide. In many cases, it is not possible to carry out a randomised clinical trial of factors likely to play a role in increasing or decreasing suicide rates in the general population or in specific risk groups. In such cases, it is necessary to carry out naturalistic, individually based, observational studies or ecological studies to identify risk factors. Nested casecontrol studies have an advantage over case-control studies, since selecting controls from a large database implies possibilities for matching on several relevant factors and for adjusting estates of risk for possible confounders. However, naturalistic studies of any kind carry a risk of interchanging cause and effect. Randomised clinical trials cannot be carried out to evaluate health care reforms, changes in culture or religion, media coverage, unemployment, immigration policy, restrictions in means for suicide, and changed legislation or pattern of use for alcohol and drugs. In these cases, ecological studies or individually based naturalistic studies must be carried out. However, the interpretation of such studies is associated with difficulties, as it can be impossible to disentangle what is the effect of the change that is the subject of the study and what are the effects of confounding factors. Observational studies cannot provide the same strong evidence as randomized
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clinical trials; nevertheless, there are numerous areas where recommendations for practice will have to rely on weaker evidence. 5. Universal suicide prevention It is evident from the fluctuating suicide rates in different countries that a range of factors play a role, such as changes in social, cultural and political climate, changes in health status and access to alcohol and drugs, access to lethal methods for suicide, and access to health care. There are several examples of interventions that could be classified as universal preventive mechanism. However some of these interventions have not been initiated because of their direct effect on suicide, but because of other factors such as for instance mandatory implementation of catalytic converters, and reduction of carbon monoxide in household gas due to environmental concerns, and school-based programmes aiming at reducing bullying. Introduction of school programmes has been proposed aimed at reducing suicidal behaviour, but based on two recent reviews it seems sound to conclude that there is insufficient evidence to either support or refute any benefits from curriculum-based programmes in schools. More broadly based comprehensive school health should be evaluated for their effectiveness in addressing the determinants of adolescent risk behaviour (Ploeg et al., 1996;Guo and Harstall, 2002). It is well established that media attention regarding suicide can also influence suicide rates (Hawton and Williams, 2002;Simkin et al., 1995;Zahl and Hawton, 2004), and influencing media coverage of suicidal events can be considered to be an element in a universal approach. Recently, awards for sober mentioning of suicide in the media has been launched in Denmark, Belgium and Australia as means to improve and encourage media coverage in accordance with the WHO guidelines (http://www.who.int/mental_health/prevention/suicide/resource_media.pdf) Among the possible interventions in universal suicide prevention, restricting access to means for suicide is the best documented. This intervention is recommended as an active ingredient in suicide prevention strategies (Mann et al., 2005). However, in some cases, restrictions in means for suicide have been decided directly with the aim of influencing suicide rates, whereas in other cases, for example environmental considerations or risk of accidents have been the main reason for restricting availability of means for suicide. This was for instance the case with removing carbon monoxide from household gas and car exhaust through catalytic converters. There is huge variation in the use of methods for suicide all over the world. In USA, 60% of all suicides are committed with firearms, while in Southeast Asia, a similar figure accounts for pesticide suicides (Eddleston et al., 1998;Gunnell and Eddleston, 2003). It has long been hypothesized that restrictions of means for suicide can positively influence suicide rates (Marzuk et al., 1992;Farmer and Rohde, 1980), and many studies have been carried out to elucidate the effect of restricting means for suicide. Three reviews have been carried out to study the possible effect of restrictions in access to firearms (Miller and Hemenway, 1999;Lester, 1998;Haw et al., 2004). All three reviews concluded that there was a strong association between gun ownership and gunshot suicide. All the studies reviewed indicate the same conclusion, namely that the availability of firearms increases the risk of firearm suicide in all age groups, including children. All studies of the effect of gun legislation indicate that strict gun legislation reduces firearms suicide rate. The availability of carbon monoxide and its relation to suicide rates has been investigated in studies of detoxification of coal gas and in the introduction of mandatory catalytic converters. Kreitman (1976) studied the effect of detoxification of domestic gas in UK from 1955 to 1971 and found that there was a marked decline in carbon monoxide suicides in both genders concomitantly with reduced availability of toxic domestic gas. The same conclusion was found by other authors,
investigating the problem in a range of other countries. The effect of mandatory catalytic converters in all petrol cars sold since 1993 was studied from 1991 to 1996 in the UK by Kendell (1998), who concluded that the introduction of catalytic converters decreased the number of suicides without substitution of other methods. The same conclusion was reached by researcher in United States (Amos et al., 2001;Mott et al., 2002) and Denmark (Nordentoft et al., 2007). When examining suicide rates in different countries at different points in time, it is obvious that methods for suicide are different in different countries during different time periods. It is beyond doubt that not only the availability but also the awareness and cultural acceptance of a method determine whether it is a frequently used method or not. It is obvious that suicide with car exhaust was introduced as a method for suicide after it had been available for decades. One can even speak of a method for suicide being marketed, as for instance asphyxia-suicide with plastic bags (Humphry, 1992). As stated by Gunnell, accessibility to and the lethality of a particular method may have profound effect on the overall suicide rate. Such effects appear to depend on the popularity of the method, and the extent to which alternative methods that are acceptable to the individual are available (Gunnell et al., 2000). Therefore, when recommending restrictions in access to dangerous methods for suicide, it must also be considered how to avoid marketing of lethal methods for suicide. Lester (1998) published a review, primarily of his own research papers, that concluded by recommending a range of ways to limit access to lethal methods for suicide. These included strict gun laws, car emission control of carbon monoxide content, natural domestic gas, restricting access to tops of buildings, fencing bridges, limiting packet size of medication frequently used for suicidal acts, enclosing pills in plastic blisters, removing lethal agents before releasing suicide attempters to their homes. On the basis of the above-mentioned studies, it must be recommended to adopt strict laws concerning firearms, to make available domestic gas without content of carbon monoxide, to make catalytic converters mandatory and control carbon monoxide emission from cars and other vehicles, to secure controlled environments such as hospitals and prisons with regard to possibilities for hanging, to prescribe less toxic medication and small amounts of toxic drugs, to limit packet size of over-the-counter sale of medication often used for attempted suicide. 6. Selective prevention in risk groups The most important risk groups are the mentally ill, alcohol and drugs abusers, those with a newly diagnosed severe somatic disease, prisoners, and homeless persons. It is well documented that mental illness in all diagnostic groups is a risk factor for suicide (Mortensen et al., 2000;Qin and Nordentoft, 2005), and most disorders multiplies the suicide risk at least tenfold. In their estimation of lifetime risk of suicide in various disorders, Inskip et al. (1998) estimated the lifetime risk in schizophrenia to be 4%. Palmer et al. (2005), in their recent meta-analysis, estimated the lifetime risk to be 5.6%. In 2005, Hawton et al. published a systematic review of risk factors and identified 29 eligible studies. They found robust evidence of increased risk of suicide in schizophrenia for depressive disorders, previous suicide attempts, drug abuse, agitation and motor restlessness, fear of mental disintegration, poor adherence to treatment and recent loss (Hawton et al., 2005). Among patients with schizophrenia, there were no large studies investigating the effect on suicide of psychosocial interventions. The analyses of data from the OPUS trial indicates that the study did not have sufficient power to detect any effect on suicide, and that there was no indication of a positive effect on deliberate self-harm (Nordentoft et al., 2002;Petersen et al., 2005;Bertelsen et al., 2007). In schizophrenia, no randomised controlled trial of specific
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antipsychotic drugs has proven an effect on suicide (Meltzer, 2002); however, a study indicates that Clozapin is superior to Olanzapin with regard to reducing the risk of deliberate self-harm (Meltzer et al., 2003). Also affective disorder and alcoholism have been considered to have high lifetime risk of suicide. Miles (1977) estimated that the lifetime risk of suicide in alcoholism would be 15%, opiate addiction 5%, and depression 15%, but these figures are most likely too high. Inskip et al. (1998) estimated the lifetime risk in alcohol dependence to be 7% and 6% in affective disorder. Bostwick and Pankratz (2000) divided the suicide risk in affective disorder in several different risk groups with different estimation of lifetime risk for suicide. Their estimate of lifetime risk for patients with affective disorder hospitalized for suicidality was 8.6%, while for patients with affective disorder with no specific history of suicidality, the lifetime risk estimation was 4.0% and for outpatients with affective disorder 2.2%. Depression and other psychiatric disorders are reported to be under-recognized and under-treated in primary care setting (MunkJorgensen et al., 1997). Studies examining suicidal behaviour in relation to primary care physician education programmes, mostly targeting depression recognition and treatment, have all reported increased prescription rates for antidepressants and often substantial declines in suicide rates (Rutz et al., 1989;Rutz, 2001;Rihmer et al., 2001;Rutz, 1992). However, these studies were small and considerable variation might be due to change. There is a current debate about the effect of Selective Serotonin Reuptake Inhibitors (SSRI) on suicidal behaviour. Several metaanalysis of published and unpublished randomised clinical trials have been conducted comparing SSRI and placebo among adults (Hammad et al., 2006b;Fergusson et al., 2005;Gunnell et al., 2005) and children and adolescents (Whittington et al., 2004;Hammad et al., 2006a). The randomised clinical trials of SSRI compared to placebo do not have enough power to detect differences in completed suicide; concerning suicidal ideation and behaviour, there is no evidence of a protective effect. In affective disorders, many studies of the effect of Lithium have been conducted, the majority being naturalistic studies. However, a meta-analysis (Cipriani et al., 2005) summarizes the evidence from randomised controlled trials of the effect of long-term Lithium therapy for affective disorders and concluded that Lithium is effective in the prevention of suicide, deliberate self-harm, and death from all causes in patients with mood disorders. Moreover it has been hypothesized that anti-aggressive effects of Lithium might play a role in suicide prevention in patients with non-affective disorders (Muller-Oerlinghausen and Lewitzka, 2010). A range of studies demonstrate that recent diagnosis of severe somatic illness is associated with increased risk of suicide. This evidence is most clear from studies of neurological diseases and cancer, and forms the basis for recommendation of careful crisis management in these patients and evaluation of suicide risk (Stenager et al., 1998;Yousaf et al., 2005). Studies of homeless persons found increased risk of suicide compared to the general population, and the excess suicide mortality was most dominant in younger age groups (Babidge et al., 2001; Hwang et al., 1997;Hwang, 2000;Roy et al., 2004;Nordentoft and Wandall-Holm, 2003). Prisoners and newly released comprise another important and often overlooked and untreated risk group.(Fazel et al., 2010;Fazel et al., 2008;Pratt et al., 2006;Pratt et al., 2010). On the basis of the above-mentioned studies about selected prevention, it must be concluded that mental illness, including substance abuse, is the most important risk factor for suicide, as the mentally ill form a large risk group with a very high risk of suicide. Persons with severe and newly diagnosed somatic disorders also form an important risk group, and even though the hazard ratio for suicide is smaller than in mental illness, it is an important risk group because
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somatic illness is very common especially among elderly. Socially excluded persons such as homeless and prisoners are also at increased risk, but smaller in number. In many of the above-mentioned groups there is poor evidence for effectiveness of interventions directed versus the risk of suicide. Therefore the best guideline will be to provide the best possible support and treatment to persons in the risk groups, and to provide skill-building programs for staff involved in order to increase awareness of suicide risk. 7. Indicated prevention Indicated prevention is focused on the high-risk group of persons who have attempted suicide or have presented themselves to health services because of suicidal ideation. Help lines, psychiatric emergency rooms, psychiatric emergency outreach and other crisis interventions can play a role in preventing suicide attempts among persons in a suicidal crisis, and there are different interventions aiming to reduce risk of suicidal acts after suicide attempt. Many studies have been conducted with the aim of elucidating risk of repetition of fatal and non-fatal suicidal acts. Owens et al. (2002) conducted a systematic review of fatal and non-fatal repetition of selfharm and found that the median one-year repetition rate was 16% non-fatal and 2% fatal. After more than nine years, around 7% of patients had died by suicide. Since Kreitman and Foster in 1991 reported risk factors for repeated suicide attempt, many other authors have investigated this matter. The most frequently reported risk factor for repetition is previous suicide attempt, thus confirming the notion that there are substantial differences in the risk of repetition among ‘first evers’ and repeaters. Other frequently reported risk factors are alcohol and drug abuse, depression, previous inpatient treatment, sociopathy, unemployment, frequent change of address, hostility, hopelessness, and living alone (Nordentoft, 2007). The predictors of suicide identified in more than one study were male gender, increasing age, previous suicide attempt, substance abuse, somatic disease, high suicidal intent score, violent suicide attempt or suicide attempt with severe lethality, and ongoing or previous psychiatric treatment (Nordentoft, 2007). Thus the literature reviews confirm that suicide attempt is associated with market increased risk of repeated non-fatal and fatal suicidal acts, and that those in highest risk are those who are often considered difficult to treat. A systematic review of randomised clinical trials of psychosocial and pharmacological interventions for persons who have attempted suicide revealed that until now, apart from dialectic behavioural therapy (Linehan et al., 1991), no intervention has proven effective in reducing suicide rate or repetition rate (Hawton et al., 1999). The authors identified non-significant trends toward reduced repetition of deliberate self-harm for problem-solving therapy compared with standard aftercare, for provision of an emergency contact card in addition to standard care compared with standard aftercare alone, and for intensive aftercare plus outreach compared with standard aftercare. In one relatively large study in this group, which evaluated community follow-up of patients who did not attend outpatient appointments, there was a near significant difference in repetition of deliberate self-harm of 10.7% compared with 17.4% (0.57; 0.32 to 1.02) (Van Heeringen et al., 1995). Hawton et al. concluded that the results of the systematic review indicate that there is currently insufficient evidence on which to base firm recommendations about the most effective forms of treatment for patients who have recently deliberately harmed themselves. Given the size of the problem, they consider this situation serious. The main problem with nearly all trials in the meta-analysis was that they included far too few subjects to have the statistical power to detect clinically meaningful differences in rates of repetition of deliberate self-harm between experimental and control treatments, if such differences existed. Even when the results from similar trials were synthesized with meta-analytical
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techniques, there were insufficient numbers of patients to detect such differences. Even though some studies have been published after the Cochrane review, (Tyrer et al., 2003;Brown et al., 2005;Vaiva et al., 2006;Guthrie et al., 2001) and the odds ratios in all trials point in the same direction, namely toward a protective effect of the experimental conditions, there is still insufficient evidence to form basis for firm recommendations. As pointed out by Hawton, it might be necessary for such interventions to be combined with case management programmes for high-risk individuals e.g.: assertive outreach. Other less intensive interventions were tested in randomized clinical trials. Among patients who refused aftercare after suicide attempt, Motto (Motto and Bostrom, 2001;Motto, 1976) found that regularly sending letters four times a year in five years significantly reduced the suicide rate in contact group compared to no contact group for many years. In Australia, a similar trial was carried out with regularly postcards eight times during first twelve month after suicide attempt and a significant reduction in the number of repeated suicidal acts were identified during the first two years in the contact group compared to no contact group (Carter et al., 2005;Carter et al., 2007). An uncontrolled study of telephone services for elderly in Italy revealed lower suicide rates than expected in the population who had this service (De Leo et al., 1995), and later Vaiva et al. in a randomized clinical trial confirmed that telephone contact one month after suicide attempt reduced number of reattempts over one year (Vaiva et al., 2006). Other interventions are skill-building support groups in high schools and colleges, and parent support training programs, which may be relevant for adolescents at risk for suicidal behaviour. In conclusion, the results of indicated preventive studies indicates that it is possible to reduce the risk of reattempt after suicide attempt through a range of different specific interventions, but yet no studies compare these interventions. Even low intensity interventions can be effective. Large randomized clinical trials are needed in order to establish stronger evidence basis in this important field.
associated with the risk factor. Such figures can of course be discussed, and most likely studies in different countries will result in different estimates. However, it is beyond doubt that the risk groups mentioned in the table are among the most important, and that they together comprise the majority of high-risk group. 9. Conclusion The crucial elements in national suicide prevention strategies can be summarized at the universal, selective and indicated level of prevention. Among universal preventive interventions, restriction of access to methods for suicide seems to be the best documented, especially for methods with high case fatality. Media guidelines and provision of information about where to seek help in critical situations are also important measures. Regarding selective prevention, the most important risk groups both in terms of magnitude of the increased risk and size of the risk group are the mentally ill, including those with alcohol and substance abuse, and those who have attempted suicide. Preventive interventions are educational programs for staff-members in mental health settings and in somatic departments dealing with diagnosis and treatment of serious somatic disorders. It is important to have an overview risk of suicide in different risk groups and to consider and recommend interventions to reduce risk of suicide. Among indicated preventive measures, it is important to provide possibilities for crisis management and treatment for those at immediate risk for suicidal acts. Help lines, cognitive behavioural therapy dialectic behavioural therapy and an assertive approach are among the most promising interventions. At the national level a governing body should be established with the task of monitoring time changes in suicide rates in different risk groups and initiating and promoting research, quality development and interventions.
8. The crucial elements References To guide the prevention strategy, it can be helpful to evaluate the population attributable risk associated with different risk factors. The population attributable risk is an estimate of the proportion of the problem that could be avoided if the increased risk in a specific risk group could be reduced to the level of the general population. It is calculated by using the formula: Proportion at risk in the general population ðRR−1Þ 100 Proportion at risk in the general population ðRR−1Þ + 1 In Table 1, the population attributable risk for some of the largest risk groups are estimated. The percentages add up to more than 100% as the groups are not mutually exclusive. The figures are based on estimates of the size of the risk groups and the relative risk (RR) Table 1 Population attributable risk.§ Admitted or recently discharged, psychiatric ward# Recent suicide attempt¤ Elderly men++ Alcohol abuse** Criminal history## §
25% 16% 13% 23% 12%
Based on estimates of proportion in the general population with the risk factor and estimates of relative risk associates with the risk factor. #Based on Danish register-based study carried out by Qin and Nordentoft (2005). ## Based on Danish statistics and Danish register-based study carried out by Qin and Nordentoft (2005). ¤Based on reviews carried out by Owens et al. (2002) and Nordentoft (2007). ++ Based on Danish suicide statistics, similar findings in other countries. ** Based on data from Danish registers and paper published by Fazel et al. (2010).
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