A Reduction of Economic Warfare and Bombing Might Help 

My colleagues at Lancet have provided me with the information given below. Elaboration on all statistics can be provided, upon request.

Suicide is a worldwide public health problem, with 800 000 recorded suicides per year, and an estimated 16 million episodes of self-harm per year. Suicide is the second leading cause of death in 15–29 year olds, and the leading cause of death in young women. The burden of suicide is particularly high in Japan, India, China, and Russia, but comparisons between countries are limited by variations in the reliability of reporting and mortality records. In England, rates in men are three times higher than in women; the highest rates are in men aged between 40 and 54 years.

Two reports published recently focus on suicide prevention. In the UK, the annual report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness reviews lessons learned over the past 20 years. In the USA, a panel convened by the National Institutes of Health has developed a 10-year roadmap to advance research into suicide prevention in young people.

Key findings of the UK report include a large rise in England in the number of suicides among mental health patients. Between 2004 and 2014, 28% of suicides in the UK were in people in contact with mental health care within 12 months of their death. In-patient suicides have fallen, in part due to removal of ligature points on wards, but suicides under crisis resolution teams treating in the community have risen substantially, with a third having been discharged from hospital in the previous 2 weeks and 43% living alone. The commonest method used by patients is hanging, with self-poisoning, particularly by opiates, in second place. Jumping from a height or in front of a train is the third most common method. Over half of patients who died by suicide had a history of alcohol or drug misuse. Isolation, economic adversity, and recent self-harm have become other common risk factors over the past 20 years.

Key clinical messages are that crisis teams are unlikely to be a safe management option for patients at high risk or who live alone; patients should be followed up within 2–3 days of hospital discharge and care plans put in place; specialist alcohol and drug services need to be available; opiate analgesics need to be restricted to reduced use and short-term supplies; and additional help for men with mental ill health might require innovative delivery, for example online or in non-clinical settings.

Areas of uncertainty remain in suicide prevention and need further research. In terms of pharmacological treatment options, there is substantial evidence that antidepressants decrease the risk of suicide in depressed patients, including in young people, although the risk of suicidal ideation is also present. Clozapine, lithium, and more recently ketamine might also be helpful in certain populations, although the latter requires more research. Further evidence is also needed to add to psychological strategies such as cognitive behavioural therapy—for example, school-based or internet and helpline-based approaches to suicide prevention.

Recommendations from the US report include developing methods to improve surveillance by linking data from multiple sources, to gather data from diverse populations, to help practitioners to identify effective suicide prevention strategies, and to focus on removing stigma associated with suicide.

In young people in the UK, suicide rates are increasing, with 160 suicides per year over the past 20 years, perhaps linked to educational stress. In east and southeast Asia, there are links between suicide and academic pressure, and some evidence is emerging in England of this link. Online or face-to-face bullying might also be a risk factor, and bereavement and chronic illness are known risk factors in children and young people, as well as in adults. Genetic factors, past history, and current stressors are all important, but while decisions should be made on the basis of an individual’s risk profile, tick-box approaches are unlikely to be helpful.

Public health measures focused on restriction of means of suicide are also helpful. For example, at so-called suicide hotspots (such as suspension bridges, cliffs), putting up barriers, installing helplines, patrols, and local media warnings can all help to prevent suicides.

Preventing suicide is not a hopeless task. It is achievable both within mental health services and at the general population level. Targeted approaches for high-risk individuals can reduce risk, while creating a safe culture in hospitals and in the community is key. It is also important to remember those bereaved by suicide. While increasingly sophisticated epidemiology can help suicide prevention in the future, there is also a timeless need for empathy and kindness.

Oh yes, a reduction of economic warfare and bombing might help too.

Don Qaswa can be reached at rocinantenews@gmail.com


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