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World Suicide Prevention Day - 10th September 2003

Suicide can be Prevented

Celebrating the 1st World Suicide Prevention Day
10th September, 2003

An IASP initiative in collaboration with World Health Organization (WHO)

SUICIDE CAN BE PREVENTED!

The impact of suicide

In the year 2000 an estimated 815,000 people died from suicide around the world representing one death every 40 seconds. Suicide is the 13th leading cause of death worldwide. Among those aged 15-44, self-inflicted injuries are the fourth leading cause of death worldwide and the sixth leading cause of ill health and disability (WHO 1999).

But suicide deaths represent only a part of the problem. In addition to the number of suicide deaths, many more persons make non-fatal attempts to take their lives or harm themselves, often seriously enough to require medical attention. Furthermore, for every suicide death there are many survivors; their lives are profoundly affected emotionally, socially, and economically. Each year, the economic costs associated with self-inflicted injuries are estimated to be in the billions of dollars.

Among countries reporting suicide, the highest suicide rates are found in Eastern European countries and the lowest rates are found mostly in Latin America, in Muslim countries and in a few Asian countries. Unfortunately, there is little information on suicide from most African countries. Rates of suicide are not distributed equally throughout the general population. Globally, suicide rates tend to increase with age. Suicide rates are higher among men than women. However, the sex difference in suicide rates is smaller in Asian countries than elsewhere in the world.

Factors involved in suicidal behavior

Suicidal behaviour has a large number of underlying causes which are complex and interact with one another. Identifying these factors and understanding their role in both fatal and non-fatal suicidal behavior is central to preventing suicide. Factors such as living in poverty, unemployment, loss of loved ones, arguments with family or friends, a breakdown in relationships and legal or work-related problems are all acknowledged as risk factors when affecting those who are predisposed or otherwise especially vulnerable to self-harm. A family history of suicide is a recognised risk factor with both social and genetic correlates. Other predisposing factors include alcohol and drug abuse, a history of physical or sexual abuse in childhood, and social isolation. Psychiatric problems, such as depression and other mood disorders, schizophrenia and a general sense of hopelessness also play a central role. Physical illness, particular those that are painful or disabling, are also important factors. Having access to means to kill oneself (most typically guns, medicines, and agricultural poisons) is both an important risk factor in itself and an important determinant of whether an attempt will be successful or not. Having made a previous suicide attempt is a powerful predictor of subsequent fatal suicidal behaviour, particularly in the first 6 months after the first attempt.

A number of factors nevertheless appear to protect people against suicidal feelings or acts. They include high self-esteem and social 'connectedness', especially with family and friends, having social support, being in a stable and happy marriage, and commitment to a religion.

What can be done to prevent suicide?

Since a number of mental disorders are significantly associated with suicide, the early identification and appropriate treatment of these conditions is an important strategy for preventing suicide. There is also some evidence that educating primary health care personnel in the identification and treatment of people with mood disorders may effectively result in a reduction of suicide rates among those at risk. In addition, the new generation of drugs for the treatment of both mood and schizophrenic disorders, with have fewer side effects and a more specific therapeutic profile than those used previously, would appear to improve patients’ adherence to treatment and produce a better outcome, thus reducing the likelihood of suicidal behaviour in patients.

Interventions based on the principle of connectedness and easy access and availability of help such as the Tele-Check or the so-called "green card" (client receive a card that gives them immediate access to a range of options, including on-call psychiatrist or hospitalization) has provided encouraging results. Relationship approaches, psychosocial interventions, suicide prevention centers, and school-based interventions are strategies that have suggested some positive indications but require further investigation.

Restricting access to the means of suicide is particularly relevant when such access can readily be controlled such as control of the sale of pesticides and herbicides, potentially poisonous drugs and domestic gas detoxification. The association between possession of handguns in the home and suicide rates has been noted. In some countries (Australia, Canada and the United States) restrictions on the ownership of firearms have been associated with a decrease in their use for suicide.

The potential impact of the media on suicide rates has been known for a long time. Present-day evidence suggests that the effect of media reporting in encouraging imitation suicides depends largely on the way the event is reported - the tone and language used, how the reports are highlighted, and whether accompanying graphics or other inappropriate material is used. Responsible reporting by the media is seen as absolutely imperative.

The loss of a person by suicide can arouse different feelings of grief in the relatives and close friends of those who have committed suicide than the feelings they experience when death is from natural causes. In general, there is still a taboo attached to the discussion of suicide and those bereaved by suicide might have less opportunity to share their grief with others. Communicating one’s feelings is an important part of the healing process. For this reason, support groups serve an important role. Evidence has suggested that the self-help groups have positive outcomes for their participants. Policy Responses

In 1999 the World Health Organization launched a global initiative for the prevention of suicide, with the following objectives:

1. To bring about a lasting reduction in the frequency of suicidal behaviours, with emphasis on developing countries and countries in social and economic transitions.
2. To identify, assess and eliminate at early stages, as far as possible, factors that may result in young people taking their own lives.
3. To raise the general awareness about suicide and provide psychosocial support to people with suicidal thoughts or experiences of attempted suicide, and to thei relatives and close friends of those people who have attempted or completed suicide.

The main strategy for the implementation of this global initiative has two strands, along the lines of the WHO’s primary health care strategy:

1. The organisation of global, regional and national multi-sectoral activities to increase awareness about suicidal behaviours and how to effectively prevent them.
2. The strengthening of countries’ capabilities to develop and evaluate national policies and plans for suicide prevention.

Action is needed!

Although a lot of good work is currently being done, there is a strong need for intensified and coordinated action in order to prevent suicide in the many contexts which it occurs. We will particularly mention:

1. The need for improvement of treatment methods and facilities for those with a psychiatric disturbance through the development of newer and more effective medications for psychiatric disorders. The advent of the serotonin re-uptake inhibitors may have resulted in a decline in suicide rates in Scandinavia. Research funding should be directed towards devising more effective techniques of psychotherapy and counselling for suicidal individuals. In particular, there shouold be more specific techniques for those people whose personality disorders are more frequently associated with suicidal behaviour.
2. Many more people need to be aware of the signs and symptoms of suicidal behaviour and of where help, if needed, can be obtained - whether from family, friends, doctors, social workers, religious leaders, employers or teachers and other school staff. In particular, doctors and other health care providers should be educated and trained to recognize, refer and treat those with psychiatric disorders, especially affective disorders.
3. An urgent priority for governments and their health care planning departments is the early identification and treatment of individuals suffering not only from mental disorders, but also from drug and alcohol abuse and dependence.
4. A range of environmental changes are suggested for restricting access to methods of suicide, including obliging car manifacturers to change the shape of exhaust pipes of vehicles and to introduce a mechanism by which the engine automatically turns off after running idle for a specified time. Furthermore restricting access by people other than farmers to pesticides and the availability of insecticides and fertilizers. Where potentially lethal medications are concerned requiring strict monitoring of prescriptions by doctors and pharmacists, reducing the maximum size of prescriptions, packaging medications in plastic blisters and where possible, prescribing medication in the form of suppositories. To pass stricter gun control laws and to make gun owners more aware of how they keep guns from being used for illegal or suicidal purposes.

Action must be coordinated

Suicide prevention efforts will be less effective if they are not set within the framework of large-scale plans developed by multidisciplinary teams, comprising government officials, health care planners and health care workers, and researchers and practitioners from a variety of disciplines and sectors. Major investments in planning, resources and collaboration between these groups will go a long way towards reducing this important public health problem.

Research will guide future steps

Major investment is needed, both for research and for prevention efforts. While short-term efforts contribute to an understanding of why suicide occurs and what can be done to prevent it, longitudinal research studies are necessary to fully understand the role of biological, psychosocial and environmental factors in suicide. There is also a great need for rigorous and long-term evaluations of interventions. To date, most projects have been of short duration with little, if any, evaluation.

More research should be conducted to examine the relative contribution of psychosocial and biological factors in suicidal behaviours. A greater coupling of the two types of factors in research programmes would allow for major advances in the current knowledge of suicide. One particularly promising area is the rapidly expanding research in molecular genetics, where among other things, there is now greater knowledge relating to the control of serotonin metabolism.

More clinical research should be carried out on the causative role of co-morbid conditions, for example, the interaction between depression and alcohol abuse. There should be a greater focus on sub-groups of the population based on age (since suicide in the elderly has different characteristics from that in young people), personality and temperament. Brain imaging is another area that calls for more research effort. Finally, there should be more research on the role of hostility, aggression and impulsivity in suicidal behaviour. IASP and suicide prevention in a global perspective

The International Association for Suicide Prevention (IASP) was founded in Vienna in 1960 as a working fellowship of researchers, clinicians, practitioners, volunteers and organisations of many kinds. IASP wishes to contribute to suicide prevention through the resources of its members and in collaboration with other major organisations in the field of prevention. IASP recognises the particularly strong need to increase the focus on suicide prevention in developing countries and in the Eastern European states and Russia. Although suicide rates have correlates such as cultural and societal variables, there are a large number of commonalities shared by most countries and regions. Hence, IASP believes that suicide prevention should be put on the agenda for global and regional collaborative programmes. At the same time action must be taken locally - and this action starts with you and me. This is why the World Health Organization and IASP Sept 10th 2003 are celebrating the first World Suicide Prevention Day - to underline the responsibility for all of us to save lives that may be at stake.

It is possible - we can do it!

References

World Health Organization (1999). Injury: A leading Cause of the Global Burden of Disease. Document HSC/PVI/99.11. Geneva: WHO.

This document represents an adaption of the chapter on "Self-Directed Violence" from the "World Report on Violence and Health", World Health Organization, Geneva, 2002.


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