preventing the crisis, not just treating the crisis

This blog will be slightly different today as we wanted to highlight and share the key findings from The Lancet Public Health Series released in September of this year. The 6 paper series outlines a public health approach to suicide prevention exploring a wide range of opportunities for intervention and I will be highlighting the key points here.

As you can imagine we at The Mental Elf have covered a wide range of topics in relation to suicide; from ethnic disparities in suicide mortality, to at risk clinical groups e.g. bipolar disorder, depression in first time fathers, and doctors, to rising temperatures and suicidal behaviour and that has just been this year. In fact, we’ve published over 70 blogs over the last decade, summarising the latest reliable suicide prevention research.

The Comprehensive Mental Health Action Plan (WHO 2021a) set a target of a 30% reduction in the suicide rate (internation­ally) by 2030. Between 2013 and 2019 there has been a 10% decrease in the age-adjusted global suicide rate, however the trend appears to be plateauing and there is clear variation in the rates of reduction in different Countries around the world (WHO 2021b).

To build on the rates of reduction this Series views suicide through a public health lens for 2 reasons:

1. The greatest reductions in suicide are most likely to be achieved through public health measures that target the whole population, and
2. There will never be enough adequately trained mental health professionals to deliver one-on-one treatment to suicidal individuals

Methods

The Public Health approach to any key area has 5 steps:

1. Define and quantify the problem
2. Identify the factors that heighten risk for the problem;
3. Propose ways to prevent or ameliorate the problem, based on epidemiological evidence;
4. Implement effective strategies at scale; and
5. Evaluate the success of these strategies.

This series looks at points 2 and 3 which could then be implemented at scale, to reduce the likelihood of suicidal crises.

The public health model

Layering of vulnerabilities can lead to suicidal thoughts and behaviours. Combining social determinants, commercial determinants, sociodemographic risk factors and a range of individual risk factors can lead to suicide. As such, if interventions can be provided in each of these areas, then vulnerability should reduce. There are a range of interventions:

• Universal interventions: interventions to all individuals in the broader population
• Selective interventions: interventions to individuals who are not yet thinking about suicide or engaging in suicidal behaviours, but who may be predisposed to do so in the future (e.g. people in financial crisis, using substances, currently presenting with symptoms of mental illness)
• Indicated interventions: Interventions to individuals who are actively having suicidal thoughts or engaging in suicidal behaviours
• Postvention: Interventions to individuals affected by the suicide of someone within their family/work/locality.

The papers in the series are individually linked in the references section, however I have highlighted each paper below so you know where to look for more information:

• Paper 1: Pirkis et al introduce a public health model of suicide and suicide prevention and highlight the key changes of perspective and policy that are required.
• Paper 2: Hawton et al report on quantitative studies relating to reducing access to means used for suicide and the resulting impact on suicide rates.
• Paper 3: Sinyor et al outline a range of international government initiatives and the impact on rates of unemployment, financial position and the resulting impact on suicide rates.
• Paper 4: Pirkis et al highlight 5 different ways that transmission of suicide may occur with quantitative studies relating to these. They then propose preventative approaches that can be adopted.
• Paper 5: Pirkis et al look at specific societal risk factors and the associated increased risk of suicide. Preventative approaches are suggested alongside the challenges.
• Paper 6: Hawton & Pirkis pull together an overview of the series and create a call to action for policy makers to look beyond the clinical interventions and focus on universal and selective interventions that they can influence. Key recommendations are made across policy, practice, research and evaluation and advocacy.

The Lancet Public Health Series on Suicide Prevention was published in September 2024.

Results / key interventions

The key messages fall into 2 broad categories: public health interventions (mainly universal interventions) and reducing key risks and determinants of suicide (mainly selective interventions):

Public health interventions

Reducing access to means (or methods)

• National bans on highly hazardous pesticides: Particularly in low or middle income countries (LMICs) banning highly hazardous pesticides led to a significant reduction in suicide rates, without method substitution (increases in other methods). In Sri Lanka over a 20yr period there were nearly 93,000 fewer suicides than predicted following the ban.
• Reducing access to firearms: There is a strong link between firearm availability and suicide. There is emerging evidence that removing access to firearms has shown reduction in suicide without method substitution.
• Reducing access to medication: Withdrawal of coproxamol in the UK led to a 61% reduction in suicide by this drug. Reducing allowed purchase size of paracetamol has reduced deaths and liver toxicity from paracetamol overdose.
• Reducing risks in public places: Where bridges have become known as sites for suicide by jumping, installing barriers or nets has been shown to be effective; reducing suicides at these sites by an average of 91%. Interventions that involve restricting access to rail tracks have also been shown to reduce railway suicides.

Some of the most effective public health interventions for suicide prevention focus on restricting access to the ways that people take their own lives.

Government responses to economic circumstances

Economic (and employment) circumstances can have major effects on mental health and suicide risk in all countries; irrespective of their World Bank income status. Unemployment and poverty appearing to increase suicide rates across High Income Countries (HICs) and LMICs worldwide.

• National economic situation: it has been shown that for every $1,000 increase in per capita Gross Domestic Product there was an associated 2% reduction in suicide rates.
• Financial hardship: A $1 increase in the US minimum wage was associated with an average 1.9% reduction in the annual state suicide rates. Beneficiaries of cash transfers in Brazil (income supplement to those below an agreed threshold) were 56% less likely to die by suicide over a 12-year period compared with non-beneficiaries.
• Unemployment: A study using data from 175 countries between 1991 and 2017 showed that for every 1% increase in unemployment, there was a 2–3% increase in suicide rates in those aged 30–59 years.

Overall, it looks like relatively small changes in an individuals economic situation can have major impact on the rates of suicide (positive and negative).

Reducing financial hardship and unemployment can have a positive effect on suicide rates.

Addressing risk factors and determinants of suicide:

Risk factors at a societal level

Social determinants, mentioned above in the public health model, can create inequities within a population placing certain sociodemographic groups at higher risk of suicide. Four key risk factors in society are:

• Alcohol use: alcohol consumption and alcohol use disorder have been linked with increased rates of suicidal behaviour.
• Gambling: gambling problems increase lifetime suicidal ideation and lifetime suicidal attempts.
• Domestic violence and abuse: Interpersonal violence and domestic violence and abuse are major risk factors for suicide.
• Suicide bereavement: suicide of a relative increased individual risk of suicide or suicide attempt x3, suicide of a friend or acquaintance increases these risks by 2.5.

Social determinants, cultural factors, and societal responses, can be addressed by society-level approaches e.g. reducing access to alcohol or gambling, increasing awareness of support for domestic violence and postvention input following a suicide. The complicating factor is the influence of industries that profit from these activities.

We can prevent suicides by reducing access to alcohol or gambling, increasing awareness of support for domestic violence and postvention input following a suicide.

Transmissibility of suicide

Little attention has been paid to the transmissibility of suicide and acknowledging that individuals do not exist in isolation and their actions are shaped by those around them helps us to understand the problem and find solutions.

• News and entertainment media: News reports that sensationalise or normalise suicide or provide detail about suicide methods increase rates of suicide. Guidelines exist to help journalists produce safe content.
• Social media: #chatsafe guidelines increase participants confidence in expressing suicidality and responding to suicidality online in a manner that is safe. Using algorithms to detect concerning content and directing to supportive measures is showing promise.
• Suicide clusters: contagion effect (suicides within close network) or assortative relating (suicides within similar characteristics). Initiating postvention practices after one suicide in vulnerable groups and settings might minimise subsequent suicides while meeting the needs of bereaved individuals.
• Secondary schools: risks for transmission combine baseline risks within the community, neurodevelopmental risks in the age group and social transition. Risk taking and the onset of mental illness also occur in this period.
• Media suicide prevention campaigns: The literacy of the general population in terms of suicide prevention could be significantly improved. Media representations of coping, hope and recovery are associated with reductions in suicide (Papageno effect).

Cultural change is necessary to develop widespread coping skills that address the underlying factors contributing to suicide.

If we ensure that suicide guidelines are followed by journalists and people talking about suicide online, we can reduce the rates of suicide transmission.

Conclusions

This Series…

stresses the need for selective and universal interventions that tackle the pervasive problem of suicide in a more upstream way, preventing people reaching a crisis point. Many social determinants can best be addressed by sectors outside health, so we are calling for a whole-of-government commitment to suicide prevention.

Strengths and limitations

The quantity of research in some of these areas is limited; likely because it hasn’t been considered as being relevant. The data that is available in relation to suicide rates often has a lag period and can be based on estimates as opposed to accurate recording of suicides. Real time suicide registers have been developed in some areas, but these are far from universal.

In relation to implementing the Public Health model, the authors highlight that steps 4 and 5 (implementation at scale and evaluation of impact) require political will and stakeholder commitment and support. This has meant that some of the most effective interventions and approaches have not been implemented and some which may be less effective have been, e.g. alcohol and gambling industries actively block attempts to introduce supply reduction interventions (e.g. external regulation of alcohol sales or gambling opportunities) and instead promote interventions that rely on individuals moderating their own behaviour (e.g. limiting drinking or gambling) which are less effective.

High quality evidence is required to be able to improve the case for suicide prevention measures, however as mentioned the data is currently limited, suicide as an event is (thankfully) rare, reducing the power of potential studies and large-scale changes in macroeconomic, public and social policies do not fit well into the RCT model.

Implications for practice

Many social determinants are best addressed by sectors outside health and for the public health approach to succeed it will require a whole-of-government commitment to suicide prevention working with a range of stakeholders. Specific recommendations for actions have been made in paper 6 (pg 4) including who needs to take responsibility for them:

• Policy actions (8): Governmental responsibility
• In practice actions (6): Community based welfare services, suicide prevention services, mental health services in collaboration with each other
• Research actions (3): Government departments, researchers and coroners, medical examiners and Police
• Advocacy action (2): All stakeholders

People with lived experience of suicide should have genuine involvement as stakeholders in all of these actions.

It is worthwhile reviewing the actions and also looking at WHO’s approach to suicide prevention, known as LIVE LIFE, which provides guidance on implementing suicide prevention activities through cross-sectoral collaboration (WHO 2021c) and join the call to action to reduce suicide.

I wanted to do my own version of a universal intervention for you all and have included below the 2022 updated video for Christina Aguilera’s Beautiful; images and lyrics as a supportive intervention. There is also some info at the end if social media is causing you or your loved ones concern.

Statement of interests

I have no conflicting interests in relation to this paper.

Links

Series papers:

• The full series: A public health approach to suicide prevention. The Lancet Public Health, September 2024.
• Editorial: A public health approach to suicide prevention The Lancet Public Health, The Lancet Public Health, Volume 9, Issue 10, e709
• Paper 1: Preventing suicide: a public health approach to a global problem Pirkis, Jane et al. The Lancet Public Health, Volume 9, Issue 10, e787 – e795
• Paper 2: Restriction of access to means used for suicide Hawton, Keith et al The Lancet Public Health, Volume 9, Issue 10, e796 – e801
• Paper 3: The effect of economic downturn, financial hardship, unemployment, and relevant government responses on suicide Sinyor, Mark et al. The Lancet Public Health, Volume 9, Issue 10, e802 – e806
• Paper 4: Public health measures related to the transmissibility of suicide Pirkis, Jane et al. The Lancet Public Health, Volume 9, Issue 10, e807 – e815
• Paper 5: Addressing key risk factors for suicide at a societal level Pirkis, Jane et al. The Lancet Public Health, Volume 9, Issue 10, e816 – e824
• paper 6: Preventing suicide: a call to action Hawton, Keith et al. The Lancet Public Health, Volume 9, Issue 10, e825 – e830

Other references

WHO (2021a). Comprehensive mental health action plan 2013–2030. Geneva: World Health Organization 2021.

WHO (2021b). Suicide worldwide in 2019: global health estimates. Geneva: World Health Organization 2021.

WHO (2021c). LIVE LIFE: an implementation guide for suicide prevention in countries. Geneva: World Health Organization 2021.

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