Preventing suicide by a systems approach

While body counts in the Vietnam War made us cringe when used to judge success or failure, suicide and death are by definition inseparable, so knowing how many people die from suicide – the body count – is an important start in addressing it. And we don’t know for most of the world.

We guess there are about 1 million deaths a year (World Health Organization [WHO], 2014). We have no comprehensive information about how many people in Africa commit suicide, or in Indonesia or in Papua New Guinea (WHO, 2014). For the Middle East, India, China and South America, we have estimates based on samples with many deaths coded as ‘indeterminate’. This is all the more surprising when we know that the burden attributable to mental illness more generally even when reduced to dollars is immense:

The direct economic effects (such as spending on care) and the indirect effects (such as lost productivity) already cost the global economy $2.5 trillion a year. By 2030, this is projected to increase to around $6 trillion, in constant dollars – more than heart disease and more than cancer, diabetes, and respiratory diseases combined. (Insel et al., 2015)

The peak age for suicide in low- and middle-income countries is thought to be about 20, whereas for high-income countries, it is around 50, and in the 70s in Australia. The loss of productive life in the low-income countries is appalling (WHO, 2014).

In Australia, as Krysinska et al. (2016) remind us, where deaths by suicide are comparatively accurately registered, 2500 Australians die this way each year and 25 times that number attempt suicide. The figures, although distressing, convey little of the immensity of associated suffering. ‘I think of him every morning when I wake’, a colleague told me recalling her brother who committed suicide 30 years ago – an indelible, ineradicable scar of loss and anger.

Preventing suicide has an immediate element and a long-term component. A patient saved from death from a massive heart attack thereafter will need lifetime care and support. So it is with the management of patients saved from death who might otherwise suicide. The implication is that a management plan, spanning years, is needed for success.

How preventable is suicide and what are our best strategies? Similar questions confront us about obesity where increasingly we recognise the importance of environmental factors in the determination of individual eating behaviour. High-calorie super serves, if readily available, provoke self-destructive over-eating, and override individual intention. Cassius falsely claimed that ‘The fault, dear Brutus, is not in our stars//But in ourselves, that we are underlings’. We may be the ‘underlings’ but the ‘stars’ of multinational commerce and industry have us firmly under their control. Individual resolution and intention will not save us.

But upstream prevention of suicide is largely beyond us except for advocating for the removal of guns and other instruments of death from our communities and for improved education about mental health. Changing the social circumstances of alienation and disempowerment that underpin suicide is a social, political and educationalchallenge of serious political complexity. Much as we may wish for population-based strategies that reduce suicide, generally we need to look elsewhere.

As clinicians we must ask, as Krysinska and colleagues do, whether we can identify strategies that might mitigate suicide that can use established clinical interventions to address the needs of individual patients. They encourage us to search out ways of achieving marginal benefits – drops in suicide rates of say 10% a year. While these achievements may seem small, clinical trials of new cancer drugs are considered positive when changes of this magnitude follow the exhibition of a new therapeutic agent.

Krysinska and colleagues pose a further question and ask whether we can use multiple interventions at once and achieve additional benefits, perhaps even greater than the simple sum of the two or more therapies? They offer a theoretical analysis based on published results of individual interventions and conclude that a trial of a system of combined interventions is worthwhile.

A problem with multiple simultaneous interventions is that they stretch resources across campaigns, and in mental health, resources are already woefully inadequate. This must be assessed: programmes to assist general practitioners, e.g., are resource-intensive and the health system has lots to do, so we should be cautious how many fronts we open at once. The place for coordinated care in the management of patients with mental illness has received serious attention (Rosenberg and Hickie, 2013). Headspace, a national programme of mental health services, has offered multidisciplinary care and support to Australians aged 12–25 years since 2005 and depends on care coordination (McGorry et al., 2007). We need to know more about its results.

Krysinska and colleagues propose a combination of psychosocial treatment at the time of an event such as threatened or failed suicide and structured aftercare. The long-term consequences need to be examined. Dealing with the problems leading to attempted suicide is a short-term task, but a long-term view is also needed for the support and management of patients at risk of suicide. Most trials of coordinated care for people with multiple complex problems unravel doing the hard-slog years. Enthusiasm wanes. Staff changes and programmes often fall to pieces.

The contribution of Krysinska and colleagues to our approach to suicide prevention is to remind us that with a phenomenon so grounded in individual and social complexity, we should be prepared to try different strategies shown to be effective, perhaps in combination, the whole while assessing what they achieve. We have an encouraging precedent: the steady improvement in the management of childhood leukaemia using combinations of chemotherapeutic agents, supplemented by exciting new technologies, has revolutionised survival.

Perhaps a system for the prevention of suicide that similarly combines strategies offers our best hope. The trials should be regional, realising that regional experiments do not easily scale up to state or national level. We should try it out and see.

See Viewpoint by Krysinska et al., 50(2): 115–118.