IASP Guidelines for Suicide Prevention
THEORIES OF SUICIDE
APPROACHES TO PREVENTION
OTHER RISK FACTORS
AN INDIVIDUAL APPROACH
Suicidal behaviour is a major public health issue in all countries, and the World Health Organisation has estimated that in the year 2000 approximately one million people will die by suicide (WHO, 1999), making it a more common cause of death than motor vehicle accidents.
But this is only the tip of the iceberg. At least ten times that number each year engage in suicidal behaviour which comes to the attention of health professionals; and, on the basis of community surveys, it is probable that a similar number also risk their lives in some way, but do not seek attention.
In addition to this obvious mortality and morbidity, it has also been estimated that for every person who suicides, at least six people are directly affected.
Suicide has been present since recorded history, but it is only in the last 100 years that intensive studies from a number of different perspectives have evolved. These have followed from the 1897 work, "Le Suicide" of Emile Durkheim, a French sociologist. At times such sociological theories have predominated; at other times theological; psycho-analytical; educational; behavioural; and more recently biological perspectives have been in the forefront.
Clinical studies have demonstrated that in most countries suicide predominates in males, although there are important exceptions such as China; it increases with age; marriage and strong religious faith appear to be protective; and there are marked differences between some ethnic groups and individual countries, and also within different areas of the one country. For example, African Americans have a lower rate of 7.0 per 100,000 compared to white Americans, 13.1 per 100,000; in Europe suicide rates vary from as low as 3.5 per 100,000 in Greece to as high as 39.9 per 100,000 in Hungary; and in the U.S.A. there is up to a three-fold variation between States, with New Jersey and Nevada having rates of 7.1 and 23.4 per 100,000 respectively.
The quality of suicide statistics collected varies from country to country, and it is difficult to compare figures. Nevertheless, the most recently available suicide statistics for a number of different countries demonstrate high rates in the Baltic States and countries of the Russian Federation, as well as in Sri Lanka (figure 1). Low rates are evident in some Mediterranean countries, and elsewhere in the world, but the reliability of some of these statistics is questionable.
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There are also marked differences in method of suicide between countries. For example, the four most common methods in Sweden are poisoning, hanging, firearms and drowning; in Hungary they are hanging, poisoning, jumping and drowning; in the U.S.A. they are firearms, hanging, poisons and cutting or piercing; in Australia they are hanging, poisoning by drugs, poisoning by other methods including by alcohol and motor vehicle exhaust, and firearms; in India they are poisons, hanging, self immolation by fire and drowning; and in China they are hanging, drowning, poisoning and jumping.
THEORIES OF SUICIDE
Despite this intense study, there is no universally accepted "theory of suicide". Indeed, there may never be, as suicidal behaviour, by its very nature, challenges our ability to provide a cohesive conceptual hypothesis within which to work.
One model which has some face validity is the threshold and trigger model, which is really synonymous with what is sometimes called a stress-diathesis model: the diathesis of longitudinal issues which may lower or raise the threshold to engage in suicidal behaviour is impinged upon by stressors or a trigger, which precipitates the behaviour.
Factors related to the threshold include genetic predisposition, biochemical factors in a person's metabolism, personality traits, the emotional state of hopelessness, and the presence of ongoing support systems.
Triggers can include mental disorders or physical illnesses, alcohol and/or other substance abuse, and interpersonal loss or rejection.
Clearly these issues are not independent and mutually exclusive. For example, even the biological marker serotonin is influenced by other factors such as diet (in particular it is affected by cholesterol levels); drugs, including alcohol; gender; and age.
APPROACHES TO PREVENTION
Despite the lack of a definitive theory of suicidal behaviour, models such as the above allow hypothesis testing, both of the causes of suicidal behaviour and its prevention. This has allowed the World Health Organisation to present six broad approaches to the prevention of suicidal behaviour (W.H.O. 1993).
These are the treatment of those with mental disorders; guns possession control; detoxification of domestic gas; detoxification of car emissions; control of toxic substances availability; and a toning down of reports in the press.
Although the W.H.O. has delineated the treatment of mental disorders as the first of the six basic steps for the prevention of suicide, the other steps are referred to in the first instance as they, probably more so than the treatment of mental disorders, can vary from country to country.
For example, those countries where suicide by firearms predominates, such as in the United States of America, should naturally focus more on that issue, just as in some other countries in which suicide by firearms is not a major issue there is a less pressing need to address that. That is also so for several of the other steps in suicide prevention. Thus detoxification of domestic gas in some countries such as the U.K., Japan and Switzerland has been correlated with a decrease in the suicide rate, but quite clearly this is not an issue in some other countries. This is also so for the detoxification of car emissions, as in some developing countries the availability of motor vehicles as a method of suicide is not an issue. However, in those countries other toxic substances such as pesticides may predominate as a cause of suicide, for example in Sri Lanka, India, and some of the Pacific nations such as Western Samoa. In other countries such as Australia, where the use of prescribed drugs as a means of suicide is the most important cause of death, stricter legislation in regard to the prescribing of such medication and education of physicians to prescribe the least toxic medication should be encouraged.
The role of the media is important in a small proportion of those who commit suicide and again the relative importance of this will vary between different countries. However, studies carried out in Austria, Canada, the Netherlands, the U.K. and the U.S.A. have given support to the view that if the media behave responsibly by minimising sensational depictions about suicide, there is probably less subsequent suicide done by imitation.
The implementation of these issues requires firm advocacy on the part of professionals, volunteers, and also by those who are afflicted with suicidal impulses. Indeed, although suicidal persons are often in situations which lack autonomy and influence, by enhancing their coping skills through environmental change it is probable that suicidal behaviour will be diminished. This may involve advocacy at the legislative level, for example in decriminalising suicidal behaviour in those countries where this has not yet been achieved.
There is no doubt that mental disorders are an important factor in suicide. The W.H.O. (1993) has reviewed studies from a number of different countries including Sweden, Hungary, Denmark, Western Samoa, the U.K., the U.S.A. and Australia. As a result of pooling their results concerning 5588 persons who committed suicide, it is evident that only 2 per cent had no indication of a mental disorder at the time of death. The disorders delineated included 24 per cent affective disorders, 22 per cent neurotic and personality disorders, 18 per cent alcohol and other drug abuse, 10 per cent schizophrenia, 5 per cent organic brain syndromes and 21 per cent other mental disorders.
Lesser degrees of mental disorder are present in those who attempt suicide, but it is quite clear from its prevalence in those who engage in suicidal behaviour that there is a "window of opportunity" for preventing suicide. This is particularly so as many who attempt and commit suicide have had recent contact with the helping professions. However, even when there has been contact, that has not always resulted in adequate management. In fact, there are studies which demonstrate that only a relatively small percentage of those who have committed suicide have had the potential benefit of standard treatments. For example, in an American report only 16 per cent of 1635 persons who had committed suicide had evidence of psychotropic drug use at autopsy (Marzuk et al, 1995). Similar results have been reported from other countries including Switzerland and Sweden.
That careful assessment, diagnosis and management of mental disorders can reduce suicidal behaviour has been demonstrated in the management of depression and schizophrenia (Rutz et al, 1992; Isacsson, 1996; Meltzer and Okayli, 1995, Tondo et al, 1997), conditiions in which up to 12% die by suicide.
There are also challenging new findings with the more recently available anti-depressants. Thus there has been a demonstrated reduction in suicidal behavior in patients with repeated suicide attempts but without major depression or another axis one diagnosis when treated with an anti-depressant with central serotonergic functioning (Verkes et al, 1998). There has also been a reported decrease in negative affect and an increase in affiliative behavior in volunteers given similar serotonergic drugs (Knutson et al, 1998).
These new findings and the more well established results emphasise the importance of the treatment of mental disorders in the prevention of suicide. This does not necessarily mean that all those afflicted require psychiatric treatment, as a number of interventions, including the support of volunteers, can alleviate much of the distress associated with emotional illness.
OTHER RISK FACTORS
In the individual person, in addition to the presence of mental disorders there are certain signs which should particularly alert others to the possibility of suicide. The expression of suicidal intent with agitation, guilt, hopelessness and constriction of interests with self-absorption are particularly ominous indicators. So too is "malignant alienation", a term described by Morgan (1979) for the syndrome seen in those who have exhausted their therapist's patience and resources and who are sometimes subjected to disparaging comments from others, including the helping professions.
There are also certain groups of persons who are particularly at risk for suicidal behaviour. These include those with a past history of attempted suicide, alcohol and other substance dependent persons, young males, the elderly, the bereaved, indigenous groups, those with sexual identity conflicts, migrants, those living in rural areas, those in prison custody, and those with debilitating physical illness.
a. Those with a past history of attempted suicide
There have been many studies indicating that those who attempt suicide are far more likely to commit suicide in the future than other groups. Indeed, probably about 1 per cent per year of those who attempt suicide go on to commit suicide, and the risk is particularly high in the first year after an attempt. Quite clearly this is a high risk group and considerable attention has been paid to these persons. Full assessment with attention to socio-cultural factors as well as the optimum management of mental disorders is required, as is the promotion of more appropriate problem solving methods.
b. Alcohol and other substance dependent persons
It has long been recognised that alcohol and other substance dependence is associated with an increased risk of suicide. Some have considered that such abuse is related to the individual attempting to "treat" him or herself with that substance, with there being an underlying depressive or other mental disorder present. That is not always the case, and it is important to note that until the person is abstinent one is not in a good position to assess any underlying emotional condition.
The relative importance of alcohol and other substance dependence varies greatly from country to country. For example, alcohol abuse is not considered to be a problem in Islamic countries, whereas in other countries, such as the Eastern European block, alcohol is a potent contributing factor to suicidal behaviour.
c. Young males
In the majority of countries there has been an increase in suicide in young males, although that is not reflected in some societies such as Japan. Varying factors have been considered to have contributed to this, including a break down in family relationships, unemployment, and a change in social roles in young men. A number of studies have emphasised the importance of mental disorders even in the younger age groups, although this is less so in those few children under the age of 15 who commit suicide.
It is also evident that the seeking of treatment for emotional illness is not undertaken easily by young men, and a changed community attitude towards the management of mental disorders is necessary. Similarly, the fact that there are treatments which are effective needs to be readily acknowledged by the community, in order that groups such as young men, who have traditionally rejected treatment for emotional conditions, feel free to pursue assessment and management.
d. The elderly
There is generally an increased rate of suicide in the elderly in all countries. Depression is often understated, and cognitive functioning can deteriorate with associated diminution in social functioning. Sometimes mental deterioration in the elderly is accepted as an inevitable part of aging, but this attitude should be challenged. There is no reason why emotional illness in the elderly should not be treated vigorously and sometimes the apparent memory disturbance in disturbed elderly persons can be seen in retrospect to have been "pseudo dementia", with the presenting picture having been clouded by their mental disorder.
It is important that requests for euthanasia in the elderly should not be taken at face value, and a careful search for treatable mental disorders should be undertaken. Alcohol and other substance abuse is also prevalent in the elderly, and may be a pointer towards an underlying disorder. Physical illness is also more common in the elderly, and there is a risk at times for clinicians to explain away associated emotional symptoms as being a readily understandable concomitant of physical illness, when in fact those emotional symptoms may need vigorous treatment in their own right. It is also important to recognise that many drugs which are used in general physical medicine can produce unwanted emotional side effects.
In treating the elderly one must be cautious about doses of psychotropic medication, as impaired renal and hepatic function may lead to elevated serum levels of anti-depressants and other psychotropics.
e. The bereaved
Those who have experienced the death of others, particularly if that death has been by suicide, appear to be more vulnerable to experiencing suicidal impulses. This is particularly so at the anniversary of the deaths, and an expression of a wish to join somebody who has died should be interpreted as of grave significance in terms of suicidal intent.
Careful judgement is required in order to decide when a bereavement process can more reasonably be considered part of a depressive disorder. Grief is usually focussed on the lost object, whereas clinical depression has symptoms which are more self-centred, with feelings of guilt. However, it can be challenging to distinguish these in clinical practice. Guidelines vary from country to country, but it is generally considered that if depressive symptomatology persists for longer than six months after bereavement, then that depression should be treated in its own right rather than simply being considered part of a grief and mourning process which will resolve spontaneously.
f. Indigenous groups
Indigenous groups in many parts of the world have been reported as having increased rates of suicide. This is so in the Inuit in Canada, in the American Indians, in the New Zealand Maori, and in Australian Aborigines. The reason for the increased rate of suicide is complex and involves socio-cultural factors in addition to associated mental disorders. Indeed, in such groups the socio-cultural factors probably predominate, as those groups have often suffered quite extreme social, environmental and emotional deprivation, with disruption of their traditional values. Often this leads to alcohol and substance abuse.
The main aim in influencing the overall suicide rate of such communities involves political action rather than specific individual treatment, but it should not be forgotten that the prevention of individual suicide is essentially a personal matter and emotional suffering must be addressed along the usual lines.
g. Sexual identity conflicts
There is now evidence that those with conflicts about their sexual identity are more at risk for suicidal behaviour. Although sensitivity to these issues is required in establishing any suicide prevention programme, it is important not to miss the presence of any associated mental disorder, as well as addressing the more obvious issues of the varying degrees of societal acceptance, depending on the cultural views of individual countries.
Migration occurs for many reasons and can be not only between countries, but within a country, for example with migration from rural areas to the city. Persons who migrate are by their very definition deprived of stable social supports, and the provision of such social networks can be of great value in reducing overall suicide potential. However, again the very fact of migration should not be used in order to minimise the importance of mental disorders when they are present.
i. Those living in rural areas
In some countries there is a particular problem in regard to suicide in rural areas. This appears to be associated with social changes in the amalgamation of small farms into larger holdings, with the resultant increase in unemployment in the rural sector. This leads to a break down in family relationships and, with the ready availability of firearms and agricultural poisons in rural areas, there is a potent amalgam of factors leading to suicide. The problem is compounded by the paucity of social and health services in rural areas and obviously the overall management is by no means simple. However, in addition to social and political action, individual therapists still have the responsibility of assessing, detecting and managing the mental disorders which result from the diverse factors affecting those living in rural areas.
j. Those in prison and police custody
There is a considerable literature attesting to the fact that those in custody have a higher rate of suicide. That is particularly so during the initial phases of custody, and for those who have committed more serious offences such as murder. This is not unexpected in view of the fact that sometimes anti-social or impulsive behaviour is associated with mental disorders, and also with alcohol and substance abuse. The loss of social supports and rejection from others which imprisonment entails is also a potent stressor.
Every community has a considerable responsibility to those who are in custody, and this involves the provision of readily available assessment and treatment services.
k. Those with a debilitating physical illness
The presence of severe physical illness is associated with an increased rate of suicide, particularly when that illness involves chronic pain. Adequate control of pain and care of the dependency needs of those with physical illness needs to be provided. A sensitive understanding of the emotional effects of the threat of physical illness, a threat which can be anxiety provoking, in addition to the loss and potential loss which leads to depression, needs to be recognised.
It is the individual patient's perception of his or her condition that is important, and caution is urged in the treatment of those who focus intently with hypochondriacal delusions on their illness.
Again there is sometimes a tendency to consider emotional distress associated with debilitating illness to be readily understandable and therefore not in need of specific treatment. Careful clinical judgement needs to be exercised in assessing this issue and the judicious use of non-pharmacological support and encouragement of coping procedures, as well as the occasional use of psychotropic medication needs to be considered.
AN INDIVIDUAL APPROACH
Although mental disorders are common in those who engage in suicidal behaviour, it is emphasised that a broad biopsychosocial approach is essential. It is only by a careful and comprehensive assessment of a person's needs that an overall management programme can be formulated for any individual.
The following guidelines for the assessment and management of suicidal individuals have been found to be useful by members of the International Association for Suicide Prevention.
i. First contact
Persons with suicidal thoughts and actions evoke mixed feelings in all persons, including those in the helping professions. Therefore volunteer workers as well as health professionals such as social workers, psychologists and psychiatrists are not immune to having thoughts and feelings which could be anti-therapeutic. It is important to realise that not everybody has to take on the responsibility of treating those with suicidal thoughts and actions, but at the very least those who are in the situation where such persons may present should have the basic skills to make a general assessment of suicidal persons, even though they should not feel obliged to continue management. Indeed, any potential therapist should be aware of his or her limitations, and be willing to seek the assistance of colleagues with appropriate referral.
The initial contact with suicidal persons is particularly important, but often it occurs in less than ideal circumstances such as in a busy emergency room, in the person's home, or on the telephone. In some countries this will mean that it is difficult to speak with the person in private and confidentiality can be an issue.
It is important to recall that often suicidal persons have recently perceived rejection and a considerable degree of expertise and patience may be required in order to establish rapport. This can be achieved by indicating that one wishes to try and understand what is happening to that person and that a certain amount of time has been set aside in order to do so.
Having established a reasonable environment in which to assess the person, that person should be allowed to present his or her history in as full a manner as possible. Depending on whether the assessing person is a volunteer or a health professional, differing questions will be asked. However, for all those who are attempting to elicit information from suicidal persons it should be remembered that challenging or direct questions which could be interpreted as critical will rarely help. Rather, comments such as "things seem to have got on top of you" or "you must have been pretty upset about that" are often sufficient to allow persons to talk about their difficulties, and the open ended comment "can you tell me more about it" is often useful.
Some persons may remain resistant, but by stressing that it is important to try and understand what is happening and by the use of silence, which further indicates a willingness to listen, most will respond and rapport will be achieved.
ii. Degree of suicidal intent
More direct questions may be necessary in order to elucidate the degree of suicidal intent. Suicidal thoughts and behaviour usually revolve around interpersonal phenomena and the role of people of significance to the person should be sought. This may necessitate a systematic enquiry about the person's relationship with family members and friends. More specifically, suicidal intent can be determined on the basis of the degree of planning, knowledge of the lethality of the intended suicidal act, the degree of isolation of the person, and also by asking open ended questions such as "what are your feelings about living and dying". Such a question permits those with suicidal thoughts to express their feelings in a way that is not provided for by direct questions such as "do you really want to kill yourself", which does not allow for the ambivalent feelings which are almost invariably present in suicidal persons.
The most important initial decision is based on one's assessment of the safety of the suicidal person. It may be that the opportunity of ventilating thoughts and feelings to a concerned person has been sufficient for some suicidal persons. In the absence of a mental disorder, or if suicidal thoughts and actions have resulted in positive changes in personal relationships, further contact may be unnecessary, although the opportunity for further follow up should be left open, particularly if there are inadequate social supports.
For those who are profoundly suicidal with a severe mental disorder, hospitalisation may be necessary. Indeed, sometimes compulsory hospitalisation in order to reduce the likelihood of danger to the person or to others may be required. If that is the case, it must be emphasised to the suicidal person and his or her relatives and friends that it has been done in order to protect the person, rather than to punish them for their suicidality. The majority of people benefit from some ongoing contact. This should be structured to meet individual needs, and clearly delineated follow-up appointments, preferably with the same therapist, should be scheduled.
iv. Subsequent management
Few persons require support for longer than two or three months, and this can involve three to six sessions, each of sufficient duration to allow the person to deal with his or her current interpersonal difficulties. It is usually beneficial to involve significant other people such as the person's partner, as the presence of a neutral therapist allows the expression of mixed feelings in a controlled manner. This is important as such feelings may have been expressed in the past by suicidal threats and actions.
Those who engage in the care of persons who are suicidal must be willing to listen to the demands which they may make. However, such demands cannot be met unconditionally, and tact is required in pointing out the person's responsibility for his or her actions. It is useful to insist that they clearly describe their options, other than suicidal behaviour, should they find themselves in a similar crisis in the future.
v. Encouraging independence and coping skills
There is a fine line between fostering independence and appearing to reject the suicidal. This can be overcome by making it quite clear that the therapist's involvement is time limited and that, although at the end of that time the person may not be completely at ease with him or herself, confidence can be expressed in their ability to cope in a more adaptive manner when future crises arise. Although the aim is to encourage living independently of the helping professions, some persons, such as young single parents with few family and social supports and patients with borderline personalities and chronic mental disorders, will require longer term supportive contact.
vi. Use of physical treatments
There is always concern about prescribing drugs when persons are suicidal, as there is inevitably some risk that the drugs themselves could be used in a suicide attempt. However, if there are sufficient signs and symptoms of a mental disorder to warrant the use of anti-depressant, anti-anxiety or anti-psychotic medication, there is no reason why the potential benefits of such medication should be denied to the suicidal. This is so for persons with a number of different conditions, although the most commonly prescribed medications will be the anti-depressants. These are particularly useful for patients with the classic biological features of depression, including agitation, insomnia, loss of weight, poor concentration and lowered libido.
Having decided to utilise anti-depressants, it is imperative to use an adequate dose. It is also imperative to be aware of the potential risk of suicide with such drugs because of the toxicity of the anti-depressant used. The newer anti-depressants are quite clearly less toxic in overdose and should be used if there is any concern about suicidal behaviour.
vii. Longer term care
Suicidal ideation and behaviour tend to recur, depending on the nature of ongoing interpersonal stressors and any associated mental disorder. Although the aim of all management should be to enhance the coping skills and independence of patients, fine clinical judgement is required in assessing the need for ongoing contact. Therapists and those who have been suicidal should be aware of the warning signs of relapse, and of the fact that some people need maintenance medication and psychotherapeutic support in the longer term. This is particularly so for those with recurrent depressive and schizophrenic disorders.
There are a number of ways in which suicide can be prevented. Broad social issues can be influenced by firm advocacy for change in appropriate areas in different countries, such as by restricting access to specific means of suicide and by enhancing health and social services in general.
At the individual level, after the establishment of rapport, there should be screening for the presence of specific mental disorders, which, if present, should be treated vigorously. If medication is indicated, the safest drug should be prescribed, although it is emphasised that even if drugs are utilised, non-drug treatment is important in every suicidal person. The focus of supportive therapy should be the provision of hope for the future, the enhancement of independence, and the learning of different ways of coping with the inevitable stressors of everyday life.
By following these guidelines there is every reason to believe that an impact can be made upon the worldwide problem of suicidal behaviour.