Lack of impact of past efforts to prevent suicide in Australia: A proposed explanation

In a recent issue of the journal, I presented a graph of the suicide rate in Australia from 1991 to 2016 on which I marked the introduction of various interventions which might have been expected to reduce the suicide rate (Jorm, 2019). These interventions included various new plans, strategies, reforms, organizations and treatments. The graph appeared to indicate that these interventions had not had any sustained impact. Readers of the journal were invited to explain this apparent lack of effect.

Since then, the journal has published two contributions proposing an explanation. Bastiampillai et al. (2020) argued that the interventions were ineffective because they did not influence the underlying sociological determinants of suicide. They drew on the perspective of Durkheim to argue that Australia has had a relatively stable suicide rate over the past century, but with periods when the trend deviated due to major social upheavals. They pointed out that the male suicide rate had increased during the Great Depression and decreased during World War II. They also identified another increase in both male and female suicide during the 1960s, which they attributed to availability of barbiturates. In a response to Bastiampillai et al. (2020), Pridmore (2020) agreed with them about the importance of sociological factors. However, he disputed their interpretation of the rise during the 1960s, attributing it to the considerable social change that occurred during this period, rather than availability of barbiturates.

Based on these responses and other discussions I have had with suicide experts, I now want to propose an explanation for the lack of impact of interventions. My explanation has three components.

Suicide is influenced by social factors that are outside the domain of mental health services

I agree with Bastiampillai et al. (2020) and Pridmore (2020) that there are major social factors affecting the suicide rate. These include loss of employment, financial crisis, relationship breakdown and trouble with the law. The availability of alcohol and other substances is also important. Mental health interventions are not likely to have a major impact on these social factors.

Treatments may have limited impact on suicide deaths

There is abundant evidence that mental disorder treatments can reduce symptoms and improve functioning. However, there is much less evidence on their effects on suicide deaths, and what evidence there is indicates limited impact. A recent review (D’Anci et al., 2019) found moderate-strength evidence for a beneficial effect of lithium, low-strength evidence for the benefits of the WHO Brief Intervention and Contact method, and low-strength evidence that cognitive-behaviour therapy does not reduce suicides. However, as suicide is uncommon, it is difficult to demonstrate improvements in this outcome. Taking the more common outcome of suicide attempts, there is in addition moderate-strength evidence for the benefits of cognitive-behaviour therapy and low-strength evidence for crisis response planning.

These limited benefits on suicide deaths and attempts are for treatments given under ideal trial conditions. In real-life circumstances, where treatment is often not minimally adequate, the impact is likely to be even weaker.

Mental health professionals may not be present when suicide risk is highest

Sometimes suicidal feelings arise over a short period of time in response to overwhelming events. Furthermore, suicidal actions can be impulsive. This may be particularly the case for males. In these circumstances, if a mental health professional was present, they may be able to intervene to reduce suicide risk. However, in practice, there is unlikely to be one present, limiting the capacity of services to have an impact.

Implications

Given the limited capacity of mental health services to reduce suicide deaths, what should we be doing differently from past efforts? There are no easy solutions, but I have a few suggestions. First, national policy needs to recognize the role of broader social factors in suicide and not expect mental health services to be the solution. Reducing suicide will require action outside the health sector.

Second, we should not assume that treatments aimed at mental disorders will necessarily reduce suicide. We have limited treatments which specifically target suicide reduction and need more attention to developing and evaluating these.

Finally, in order to reduce risk where suicidal feelings arise suddenly and actions may be impulsive, there is a need for interventions that operate on the spot and do not rely on health professionals. One possibility is mass training of the population in basic suicide intervention skills, so that people in the suicidal person’s social network have the capacity to intervene. Another is to develop technological solutions, such as mobile phone apps, which are continuously available to the person at risk. These show some initial promise of reducing suicidal risk (Melia et al., 2020).

Given the major impact of suicide mortality, both in Australia and globally, these issues merit ongoing discussion and debate in the ANZJP.