Is it time to employ Rose’s Theorem to prevent suicide?

Over 800,000 people die by suicide every year around the world. If every suicide affects at least six family members or friends, then every year in the world, there would be about 5 million new survivors. Suicide rates are high in many countries despite the fact that a lot of resources are spent on suicide research and prevention. Possibly, we need to rethink how resources available for suicide prevention efforts are allocated.

There are two main preventive strategies in public health: the high-risk approach and the population approach. In the field of suicide prevention, there is a tendency to concentrate resources on individuals who are regarded as high-risk suicide patients. A determination which individual is at a high suicide risk is frequently based on imprecise criteria. All psychiatric disorders are associated with an elevated suicide risk. The high-risk strategy excludes a lot of individuals with psychiatric disorders who are at moderate risk and does not appear to be effective in reducing the burden of suicide.

Geoffrey Rose (1926–1993), an eminent British scientist, proposed ‘that a large number of people at small risk may give rise to more cases of disease than a small number who are at high risk’ (‘Rose’s Theorem’) (Rose, 1985). According to Rose, a population-oriented approach is beneficial because it reduces the likelihood that more people will develop a large number of significant risk factors. In other words, Rose suggested that changing the population distribution of a risk factor is better than targeting people at high risk.

A mathematical model study suggests that the effect of reducing a relatively small suicidal risk for a large population is more effective than to reduce suicide risk among mentally ill individuals (Yip et al., 2014). The US Air Force suicide prevention program is probably an evidence of the applicability of Rose’s Theorem for preventing suicide: improving overall community mental health can reduce suicidal acts more effectively than vast efforts to identify an acutely suicidal person (Knox et al., 2004). This program includes consistent communication about suicide prevention, destigmatization of seeking help for psychiatric problems and the training of ‘everyday’ gatekeepers.

Possibly, shifting some suicide prevention resources from individuals who are regarded as high-risk suicide patients to all psychiatric patients and/or to the general population may reduce suicide rates. This issue should be examined and discussed by psychiatrists, epidemiologists, public health experts and policymakers.