Preventing suicide

B. Ravi Shankar

Department of Psychiatry, Christian Medical College, Vellore 632002, India

I read De Leo's (2002) editorial on preventing suicide with interest. However, I would like to raise a few concerns. In spite of much development and understanding in both biological and psychological causes for suicide, the prevention of suicide remains an imperfect art. However, the comparison of suicide prevention with that of ischaemic heart disease seems inappropriate. The risk factors for ischaemic heart disease are well known, stable and quantifiable. Ideally, risk factors used for predictive purpose should be stable, whereas in suicide, clearly, most are not (Hawton, 1987). Therefore, when risk factors are not stable it will be difficult to apply the same analogy to suicide prevention.

The risk factors for suicide are different for community- and hospital-based populations. We have made progress in pharmacological interventions in hospital-based populations with lithium in bipolar disorders (Kallner et al, 2000) and clozapine in schizophrenia (Meltzer & Okayli, 1995), which have been shown to reduce suicide rates. However, the risk factors in community-based populations are different and a number of psychosocial risk factors have been reported to be significantly associated with the risk of suicide. We need to understand local perspectives and regional factors that influence suicide rates. There is a need for qualitative studies to examine these issues; the factors thus identified should then be explored in epidemiological studies.

EDITED BY KHALIDA ISMAIL

REFERENCES

De Leo, D. (2002) Why are we not getting any closer to preventing suicide? British Journal of Psychiatry, 181, 372-374.[Free Full Text]

Hawton, K. (1987) Assessment of suicide risk. British Journal of Psychiatry, 150, 145-153.[Medline]

Kallner, G., Lindelius, R., Petterson, U., et al (2000) Mortality in 497 patients with affective disorders attending a lithium clinic or after having left it. Pharmacopsychiatry, 33, 8-13[Medline]

Meltzer, H. Y. & Okayli, G. O. (1995) Reduction of suicidality during clozapine treatment of neuroleptic-resistant schizophrenia: impact on risk—benefit assessment. American Journal of Psychiatry, 152, 183-190.[Abstract]


 

Author's reply

D. De Leo

Griffith University, Australian Institute for Suicide Research and Prevention, Mt Gravatt Campus, 4111 Queensland, Australia

EDITED BY KHALIDA ISMAIL

While the ability to prevent suicide is far less advanced than the prevention of heart disease, in my editorial the analogy highlighted the need for a multifaceted approach to anti-suicide strategies. I made the point that a single preventive measure would not be effective in reducing suicide mortality, as evidenced through the prevention of other types of death such as ischaemic heart disease. In the case of suicide, for example, the worldwide optimal treatment of depression would bring only a minimal reduction in suicide rates (further details available from the author upon request). None the less, fighting depression is generally perceived as the K constant of suicide prevention in existing national strategies. This happens despite growing evidence substantiating a much reduced life-span risk for suicide in depression than that reported in earlier investigations (Bostwick & Pankratz, 2000). Given the complexity of its pathways, the prevention of suicide, like the prevention of many types of death, requires a combination of approaches, such as public and medical education, promoting community connectedness, controlling access to means, early identification and intervention, etc.

It is certainly true that risk factors for suicide are unstable and may change over time (De Leo, 2002), but probably more important is the (mostly unexplored) interaction between risk and protective factors. This is the really crucial issue in suicide prevention (by the way, protective conditions of course counteract also the risk of ischaemic heart disease: the Mediterranean diet and omega-3-fatty acids have already convincingly underlined the role of local differences in mortality rates). And this recalls another important point raised by Dr Ravi Shankar, which refers to the local (cultural/traditional) specificity of suicidal behaviour. In countries such as China, risk factors for suicide are not dissimilar from those of Western countries — what varies is their ranking in terms of importance and expressivity (Phillips et al, 2002). Furthermore, it is well-known that within the same country there may be contiguous areas with largely differing suicide rates and that the same risk factors may operate differently in different social contexts.

To identify the exact components of a multifaceted prevention programme, tailored to local characteristics, greater knowledge of risk and protective factors is needed for both the psychiatric and general populations. Prevention of suicide is currently based on scant evidence. Therefore, I fully agree with Dr Ravi Shankar's view that more sound research is required. Prevention must be grounded in evidence if it is likely to have an effect on suicide mortality.

REFERENCES

Bostwick, J. M. & Pankratz, V. S. (2000) Affective disorders and suicide risk: a re-examination. American Journal of Psychiatry, 157, 1925-1932.[Abstract/Free Full Text]

De Leo, D. (2002) Struggling against suicide: the need for an integrative approach. Crisis, 23, 22-31.

Phillips, M. R., Yang, G., Zhang, Y., et al (2002) Risk factors for suicide in China: a national case—control psychological autopsy study. Lancet, 360, 138-146.[CrossRef][Medline]





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