Improving access to treatment for mental health problems as a major component of suicide prevention strategy

With an estimated 800,000 deaths caused by suicide each year, a focus on methods to effectively prevent suicide is of the utmost importance. The factors that contribute to suicidal behaviour are numerous and complex, and thus a multilevel, multifactorial approach to suicide prevention has been recommended (Hawton, 2014). In this issue of the journal, Krysinska and colleagues (2016) present an estimate of the effect of implementing a simultaneous combination of various strategies to suicide prevention in Australia. This is an interesting article, which deals with an important clinical issue; however, due to a lack of research evidence in Australian populations, a number of the interventions discussed in Krysinska’s article have little or no evidence of efficacy in local populations. Insufficient research evidence to explore and understand suicide is not only a problem in Australian contexts but also a well-documented issue worldwide (Hawton, 2014). Multiple methodological and ethical issues associated with studying suicide have led to challenges in collecting and interpreting data in this field. This presents a challenge to policy makers who require a strong evidence base to guide decisions. More research to evaluate the efficacy of suicide preventative interventions has been called for.

What we do know is that suicide risk is increased in particular sub-groups within any population – for example, in people aged 15–29 years, suicide is the second leading cause of death worldwide. Understanding the at-risk groups within a population may therefore be of merit when choosing preventative interventions for a national strategy, as one intervention may be more successful than another for specific target groups. Gaining an understanding of other at-risk sub-groups within the Australian population and highlighting effective interventions for these groups may be beneficial. By allowing the generalisation of evidence for prevention strategies targeted at these groups, this could also help overcome challenges arising from a lack of evidence for Australian populations as a whole.

One population at high risk of suicide is people with mental health problems. Individuals with psychiatric conditions have been estimated to make up 90% of those who make suicide attempts; however, many of these individuals remain untreated at the time of their deaths. Improving access to treatment for mental health problems should therefore be a major component of suicide prevention strategy, and suicide prevention should be a core component of health-care service provision. Improving general practitioner (GP) training, as indicated by Krysinska, is one step towards achieving this goal. Building GP awareness of mental health diagnoses and treatments may lead to early detection of illness and more effective implementation of treatments, which may in turn lead to individuals with mental health problems accessing the support they need before a time that they contemplate suicide. Additionally, considering that a previous attempt at suicide is the highest predictors of future death by suicide, supporting health-care professionals to identify and treat individuals who have previously made attempts on their lives is key to suicide prevention (Beautrais, 2014).

In terms of preventative interventions, for people with mental health problems, there is quite robust data to indicate that some pharmacological treatments may significantly help to reduce suicidality and could be efficacious in preventing or reducing self-harm (Hawton et al., 2015). Lithium, for example, has been shown to have a significant anti-suicidal effect in patients with unipolar and bipolar disorder, a population with a significantly high suicide rate (Cipriani et al., 2013), and clozapine is another drug with some evidence of anti-suicidal effect in patients with schizophrenia. Assessing the impact of improved access to pharmacological treatments in suicide prevention strategies is therefore of interest when exploring interventions to reduce suicide rates, particularly in populations with known psychiatric conditions.

Restricting access to lethal means is another intervention reported to be a successful method of reducing suicide. One example of this has been evidenced in studies exploring access to suicide hotspots, where reducing access to sites has been demonstrated to successfully reduce suicide deaths at these destinations (Pirkis et al., 2015). Such interventions have evidence to support their efficacy in Australia populations. For example, at Gap Park in Sydney, introducing a fence along a cliff edge, together with a number of other preventative interventions (access to a telephone helpline, signs to encourage help seeking and closed-circuit television [CCTV] installation), was shown to reduce suicide rates at the site. Conversely, reinstating access to a means via the removal of barriers at another Australian site was reportedly linked to increased suicide deaths.

More evidence to quantify the success of suicide prevention interventions both independently or in combination is required both globally and locally in order to strengthen suggestions of any potential synergic effects (Pirkis et al., 2015). This research could then inform us of all of the potentially effective strategies to reduce suicide. At a national level, policy makers can then consider which combination of these strategies should be implemented locally, as different strategies may be more effective in one area than another. Concentrating efforts to improve the implementation of suicide prevention interventions that are known to be successful is of high importance. At the same time, it is clear that such interventions require regular and ongoing evaluation in order to build upon the current literature to support and develop such work.

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