Building an evidence base for national suicide prevention strategies

Suicide prevention is a critically important, yet daunting goal that like other large public health challenges (e.g. dementia care, newborn health) encompasses numerous important but distinct parts. In this issue, Krysinska and colleagues (2016) estimate the real-world impact of several simultaneously implemented suicide prevention strategies on suicide death and attempt rates in a region. The systems-based approach articulated in their article is a welcome attempt at integration of the diverse, yet limited literature to date on the impact of suicide prevention programs on suicide rates across a population.

Suicide is a complex behavioral endpoint reflecting the tragic synergy between failed coping mechanisms, proximate and historical life stressors and, in the overwhelming majority of cases, major mental illness including depressive and bipolar disorders, schizophrenia, borderline personality disorder and substance use disorders. In this context, Krysinska and colleagues (in press) underscore two basic, yet fundamental ideas about suicide prevention, namely that suicide attempts and deaths can be prevented and that no single intervention can be expected to carry the entire suicide prevention aspirations of a region or country. This is acknowledged in the recent World Health Organization (WHO) report (2014) Preventing suicide: a global imperative that articulated the goal of a 10% reduction in suicide deaths worldwide by 2020. It stressed the importance of national suicide prevention strategies that involve comprehensive, system-wide interventions in areas such as health care, education and social welfare, but ultimately called on the health sectors of government to take the leadership role.

Krysinska and colleagues have estimated the population effects of a number of well-studied interventions by combining the published risk reduction with the prevalence estimates of exposure to these interventions. This sophisticated approach identified seven interventions that would be estimated to reduce suicide from a low of 0.3% (suicide public awareness campaign) to a high of 6.3% (general practitioner [GP] training). Four interventions were also estimated to reduce suicide attempts from a low of 0.5% (reducing access to means) to a high of 19.8% (coordinated/assertive/brief aftercare).

The methodological requirement for large studies that estimate population-level effects is a strength of the paper. Seven of the nine interventions studied (all but psychosocial treatment and aftercare programs following an episode of self-harm/suicide attempt) are aimed at the population as a whole which is especially critical for the estimated 30–50% of people who do not have contact with the mental health care system during the year prior to suicide death. A fully comprehensive suicide prevention program would pair these strategies with enhanced mental health care across the healthcare system including evidence-based risk assessments (Sareen et al., 2014), identification of high-risk time periods and specific interventions for monitoring and treatment that are guided by a patient’s diagnosis, stressors, coping skills and support systems. It would also include improved access to putatively anti-suicide treatments such as dialectical behavioral therapy for borderline personality disorder (Linehan et al., 2006), clozapine for patients with schizophrenia (Meltzer et al., 2003) and post-hospitalization contact through postcards, text messages or other modalities that appear to help reduce risk of suicidal behavior (Luxton et al., 2013).

As Krysinska and colleagues note, rates of suicide death have remained relatively stable in Australia. This is similar to other countries, and is in stark contrast to the substantial reductions seen in recent decades in rates of death from other major causes such as heart disease, cancer and HIV/AIDS. Bold goals articulated by the WHO as well as numerous national bodies underscore a growing consensus among researchers and policy experts that a piecemeal approach to suicide prevention is unlikely to result in large changes in rates. While implementing multiple suicide prevention strategies over a short time span may make it harder to estimate the effects of individual interventions, it will enhance our ability to understand potentially synergistic effects of coinciding interventions. For example, our group has speculated that positive effects of placing a suicide prevention barrier at a suicide ‘hotspot’ bridge in Toronto, Canada, may have been attenuated by the presence of negative and pessimistic media reporting. New developments such as the emergence of social media are also having yet undetermined positive and/or negative effects on suicidal risk and behavior. This complex field will undoubtedly need to evolve to match changes in society and healthcare delivery, but the basic value of focusing on evidence-based strategies remain, and the authors are to be applauded for their efforts at contributing to the evidence base from which effective policy and interventions can emerge.

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