Suicide prevention

With Help Comes Hope - In the U.S., call 1-800-273-8255 to reach the National Suicide Prevention Lifeline

Suicide prevention is an umbrella term for the collective efforts of local citizen organizations, mental health practitioners and related professionals to reduce the incidence of suicide.

Such efforts include preventive and proactive measures within the realms of medicine and mental health, as well as public health and other fields – since protective factors such as social support and connectedness, as well as environmental risk factors such as access to lethal means, appear to play significant roles in the prevention of suicide, suicide should not be viewed solely as a medical or mental health issue.

In the U.S., suicide prevention efforts are guided by the 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.

Comprehensive Strategies
In recognition of the need for comprehensive approaches to suicide prevention, various strategies have been put forth in the last decade.

In 2001, the U.S. Department of Health and Human Services, under the direction of the Surgeon General, published the National Strategy for Suicide Prevention, establishing a framework for suicide prevention in the U.S. The document calls for a public health approach to suicide prevention, focusing on identifying patterns of suicide and suicidal behavior throughout a group or population (as opposed to exploring the history and health conditions that could lead to suicide in a single individual). The document also outlines 11 specific objectives, listed below :


 * 1) Promote awareness that suicide is a public health problem that is preventable
 * 2) Develop broad-based support for suicide prevention
 * 3) Develop and implement strategies to reduce the stigma associated with being a consumer of mental health, substance abuse and suicide prevention services
 * 4) Develop and implement community-based suicide prevention programs
 * 5) Promote efforts to reduce access to lethal means and methods of self-harm
 * 6) Implement training for recognition of at-risk behavior and delivery of effective treatment
 * 7) Develop and promote effective clinical and professional practices
 * 8) Increase access to and community linkages with mental health and substance abuse services
 * 9) Improve reporting and portrayals of suicidal behavior, mental illness and substance abuse in the entertainment and news media
 * 10) Promote and support research on suicide and suicide prevention
 * 11) Improve and expand surveillance systems

The JED Foundation, a nonprofit organization working to reduce the rate of suicide and the prevalence of emotional distress among college students, working in collaboration with the Suicide Prevention Resource Center, developed a Model for Comprehensive Mental Health Promotion and Suicide Prevention for Colleges and Universities, a research based model that is useful in conceptualizing suicide prevention broadly (i.e., not just for colleges and universities). This model pinpoints the following strategies:


 * Identify Students at Risk
 * Increase Help-Seeking Behavior
 * Provide Mental Health Services
 * Follow Crisis Management Procedures
 * Restrict Access to Potentially Lethal Means
 * Develop Life Skills
 * Promote Social Networks

Specific Strategies
Various specific suicide prevention strategies have been used:

It has also been suggested that news media can help prevent suicide by linking suicide with negative outcomes such as pain for the suicide and his survivors, conveying that the majority of people choose something other than suicide in order to solve their problems, avoiding mentioning suicide epidemics, and avoiding presenting authorities or sympathetic, ordinary people as spokespersons for the reasonableness of suicide.
 * Selection and training of volunteer citizen groups offering confidential referral services.
 * Promoting mental resilience through optimism and connectedness.
 * Education about suicide, including risk factors, warning signs and the availability of help.
 * Increasing the proficiency of health and welfare services at responding to people in need. This includes better training for health professionals and employing crisis counseling organizations.
 * Reducing domestic violence and substance abuse are long-term strategies to reduce many mental health problems.
 * Reducing access to convenient means of suicide (e.g. toxic substances, handguns).
 * Reducing the quantity of dosages supplied in packages of non-prescription medicines e.g. aspirin.
 * Interventions targeted at high-risk groups.
 * Research. (see below)

Theory
Under the theory of four humors, Hippocrates attributed melancholia to an excess of black bile, a view still propagated by Robert Burton to explain suicide in his 1621 Anatomy of Melancholy. Sociologist Emile Durkheim's 1897 book On Suicide identified four different motives for suicide, asserting that anomie or the "normlessness" of social connection strongly correlated with suicide. Psychoanalysts such as Harry Stack Sullivan saw suicide as "hostility turned inward" while Karl Menninger's 1936 Man Against Himself connected suicide with masturbation. Edwin Shneidman followed Henry Murray in attributing suicide to the emotional pain of unmet needs, asserting that "lethality" was what separated suicides from other frustrated individuals. Aaron T. Beck emphasized the importance of hopelessness as contributing factor. Roy Baumeister posits an "escape theory" of suicidal ideation where a numbed state of "cognitive deconstruction" precedes suicidal acts, wherein they are falsely perceived as the only logical action. Marsha Linehan identifies a number of factors that contribute to suicidal behavior, including certain biological deficits, exposure to trauma and a lack of adaptive coping skills.

In his 2005 book Why People Die by Suicide, Thomas Joiner posits a three-part explanation of suicide which focuses on ability and desire. The desire to commit suicide comes from a sense of disconnection from others and lack of belonging, combined with a belief that one is a burden on others. The ability to commit suicide comes from a gradual desensitization to violence and a decreased fear of pain, combined with technical competence in one or more suicide methods. This combination of desire and ability will precede the most serious suicide attempts under Joiner's model.

Lethal means reduction
Means reduction, reducing the odds that a suicide attempter will use highly lethal means, is an important component of suicide prevention.

For years, researchers and health policy planners have theorized and demonstrated that restricting lethal means helps reduce suicide rates. One of the most famous historical examples of this 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, composed over 50% of gas used. As carbon monoxide in gas decreased, suicides also decreased. The decrease was driven entirely by dramatic decreases in the number of suicides by carbon monoxide poisoning.

In the United States, numerous studies have concluded that firearm access is associated with increased suicide risk. Because guns are quick and more lethal than other suicide means (about 85% of attempts with a firearm are fatal, a much higher case fatality rate than for other methods), they are often a major driver of suicide rates.

Risk assessment
In the prevention of suicide it is important to develop an understanding of the likelihood of suicidal intent expressed by an individual. A suicide risk assessment is therefore a key component in the avoidance of a person committing suicide. Suicide risk assessment is an essential clinical tool which is used to demonstrate and identify the probable risk of suicide and to assess the likelihood, treatable risk and possible prognosis of suicide based on professional judgment. It assess the patient's history of suicidal intent, or vocalising of any suicidal thoughts as a determining factor in the level of suicidal intent.

Group psychotherapy strategy
A psychosocial-psychoeducational group therapeutic intervention for recurrent suicide attempters is being developed which involves a combination of open discussion of the daily lived experience of individuals who have made repeated suicide attempts, and teaching new skills that can be used to "stay safe". The goal outcome of skill use, staying "safe", means avoiding making an attempt or engaging in behaviour that is harmful to the person. Participants in this program are taught skills which they can reasonably apply in their everyday lives, from "basic personal rights" to self-soothing, setting boundaries in interpersonal relationships, distraction tactics, problem-solving strategies, and the idea that distress felt in the moment, no matter how seemingly unendurable, is not permanent but an experience that will pass. The goal of the program is to provide a supportive environment in which skill use is discussed each week, and successful skill use is consistently met with praise from other participants and the facilitators.

Basic personal rights
Many individuals who make recurrent suicide attempts come from backgrounds that were abusive or otherwise detrimental. Often individuals with such backgrounds have been given the message that they have no rights. Teaching basic personal rights, such as "I have the right to say no to a request" and "I have the right to make choices that take care of ME." helps to promote a sense of self-efficacy among participants. This can help set the stage for teaching skills that require participants actively to choose to care for themselves. Though a flaw may arise, when they think that they have the right to choose the personal course of the life they want, including whether or not they should die; this approach is known as the right to die.

Self-soothing
Self-soothing, a skill that is taught in suicide prevention groups and also in Dialectical Behavior Therapy, involves using one of the five senses to provide some sort of stimulation that is calming to the individual. For example, many find a hot beverage such as tea or coffee to be comforting. Other self-soothing activities might include a warm or cool bath or shower, putting on favourite comfortable clothes, stroking a pet, burning incense, or listening to music. The goal of self-soothing is to lessen the person's current level of distress by providing stimulation that feels positive.

Interpersonal boundaries
Individuals who make recurrent suicide attempts often feel that they have very little control over their lives, or that their lives are controlled by other people rather than themselves. The goal of teaching boundary-setting skills is to make the participants aware that it is okay for them to have needs and wants and to go about getting these needs and wants met. Boundary-setting also encourages participants to be aware of when other people in their lives are asking for things the participant would rather not give/share, or acting in a way that makes the participant feel unsafe. Boundary-setting means choosing actively which things will be shared and which will not, when someone is welcome to visit and when not, and so on.

Distraction tactics
Another skill that this particular therapeutic intervention and DBT have in common is the use of distraction tactics. The goal of using a distraction is to survive the period of distress by doing things that take one's mind off it. Distraction tactics may range anything from a quiet task like reading a favorite book, to an active task like going for a run. Distraction does not act to lessen the emotional pain, but it can take the mind off it long enough for it to recede, which may prevent a suicide attempt that is made to escape seemingly unendurable pain.

Problem-solving strategies
Crisis intervention, a technique used at Parkland Hospital Psychiatric Emergency Department in Dallas, asks: Is this patient suicidal? Is he or she at high risk? What is the problem—and what can be done about it? What would it take to help this patient become non-suicidal? Examples of how crisis intervention works are given by Doug Puryear, MD, in his March 18, 2010, article in Psychiatric Times.

Support groups
Many non-profit organizations exist, such as the American Foundation for Suicide Prevention in the United States, which serve as crisis hotlines. In addition, some groups like To Write Love on Her Arms have been promoted using social media to reach more people.

Agencies and Organizations
- SPRC Best Practices Registry - SPRC Resources and Research for Colleges - SPRC The Public Health Approach - SPRC National Strategy Summary - SPRC Online Library
 * CDC website on Suicide Prevention
 * The Suicide Prevention Resource Center (SPRC)provides prevention support, training, and resources to assist organizations and individuals to develop suicide prevention programs, interventions and policies, and to advance the National Strategy for Suicide Prevention.
 * Stamp Out Suicide!
 * The JED Foundationis the leading nonprofit organization working to reduce the rate of suicide and the prevalence of emotional distress among college students.
 * Suicide Prevention:Effectiveness and EvaluationA 32-page guide from SPAN USA, the National Center for Injury Prevention and Control, and Education Development Center, Inc.
 * American Association of Suicidologyis 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
 * Suicide.org

Journals of suicide prevention research

 * Suicide and Life Threatening Behavior
 * Archives of Suicide Research
 * Crisis: The Journal of Crisis Intervention and Suicide Prevention