A month for reflecting on suicide prevention

This month’s issue presents a special focus on prevention of suicide. Readers will be well aware that suicide is a major cause of death, with around 2500 deaths annually in Australia, 500 in New Zealand and 800,000 globally. Suicide attempts are harder to quantify, but are many times greater in number.

In Australia, the suicide rate has declined from the late 1990s when the National Suicide Prevention Strategy was introduced, but has remained stable over the last decade. There have been strong calls for further action on suicide, with the National Mental Health Commission calling for a target of 50% reduction in suicide deaths over a decade. This target was supported by organizations attending a Suicide Prevention Summit at Australia’s Parliament House on the 2015 World Suicide Prevention Day. While the Australian Government has not adopted this target as recommended by the National Mental Health Commission, it has been adopted as policy by the Australian Labor Party, which is currently in Opposition.

Given that suicide prevention is already a major priority for the mental health sector, what more can be done and how realistic is a target of 50% reduction in suicide deaths? Krysinska and colleagues (this issue) argue that we should take a multilevel systems approach to suicide prevention, with multiple strategies implemented simultaneously in a region. They propose 9 strategies that could be implemented, and they use available data to give estimates of how many lives could be saved. Taking just the most promising of these interventions, Krysinska and colleagues estimate that 160 lives could be saved annually, and up to 5370 hospitalizations due to intentional self-harm could be prevented. If achieved, these reductions would be important health gains, but they do fall far short of the 50% reduction (around 1250 lives annually) that has been proposed as a target by the National Mental Health Commission.

Commentaries in this month’s issue on the proposal for a multilevel systems approach are generally positive, but a number of cautions are noted. Leeder (this issue) notes the difficulties of sustaining such a coordinated approach over time. Hegerl & Kohls (this issue) suggest that greater emphasis is needed on treatment of depression as a strategy for reducing suicide, while Schaffer & Sinyor (this issue) similarly argue the need to also include enhanced mental health care and greater use of anti-suicide treatments. Pirkis (this issue) questions the basis of the calculated reductions, particularly in a country like Australia where many of the strategies are already being implemented to some extent.

Other articles in this issue report research on suicide or self-harm that has practical implications for clinicians. A number of these articles are concerned with assessment of people at risk. Hu and colleagues (this issue) report that the 7 days following an incident of deliberate self-harm carries a very high risk of further self-harm: 6% in adolescents and 8% in young adults. The risk was particular high in young people with borderline personality, impulse-control and substance use disorders, followed by depressive and anxiety disorders. The authors recommend more thorough assessment of patients who have self-harmed before discharge from an emergency department or hospital inpatient unit.

Johnstone and colleagues (this issue) report data that low parental care is a risk factor for suicide attempts and non-suicidal self-injury. They advise clinicians to ask specifically about history of suicide attempts and non-suicidal self-injury, as well as about levels of parental care in childhood. Swannell et al. add to the literature showing that sexual orientation affects risk, with bisexual females having a particularly strong risk of suicidality and self-injury. They conclude that Australian society must continue to work towards destigmatization of sexual minorities.

Wilhelm and colleagues (this issue) argue that hospitals and mental health services should routinely assess lifestyle factors in people presenting with suicidal behaviours. They believe that assessing these factors will ‘enable people at a low point in their lives to make changes in their health-related behaviours with the potential to substantially improve their physical and mental health into the future’.

Finally, Inder and colleagues (this issue) report data that clinical intervention can make a major difference to people with bipolar disorder, who are another high risk group for suicide. They report the outcomes of a trial of psychotherapy over 18 months that found markedly reduced risk of suicide and self-harm following treatment. This study shows the benefits of sustained high-quality services for people at high risk.

Whether or not the government responds to calls for greater action on suicide prevention, it is to be hoped that this month’s issue of Australian and New Zealand Journal of Psychiatry (ANZJP) leads readers to reflect on what greater efforts they can make in their own work.