SUICIDE IS ONE OF LEADING CAUSES OF MORTALITY.
COMMENT ON APPROACHES TO SUICIDE PREVENTION FROM PUBLIC HEALTH PRESPECTIVE ?
A 4 INTRODUCTION
1 Suicide prevention is an umbrella term for the collective efforts of local citizen organizations, health professionals and related professionals to reduce the incidence of suicide.
2 Beyond direct interventions to stop an impending suicide, methods also involve -
a) treating the psychological and psycho-physiological symptoms of depression
b) improving the coping strategies of persons who would otherwise seriously consider suicide
c) reducing the prevalence of conditions believed to constitute risk factors for suicide
d) giving people hope for a better life after current problems are resolved.
DEFINITION
Suicide is the act of deliberately killing oneself or more specifically, an act deliberately initiated and performed by the person concerned in the full knowledge, or expectation, of its fatal outcome.
ETIOPATHOGENESIS / FACTORS RESPONSIBLE FOR SUICIDES
According to Interpersonal model of suicide by van orden etal. There are 2 factors that are involved -
A ) The first major factor is a desire for death and
B ) the second acquired capability.
A ) Desire for death occurs through ideations of thwarted belongingness it is described as feeling alienated from others emotionally and perceived burdensomeness it is described as feeling that one is incompetent and therefore a burden on others.
B ) The acquired capability in this context is used because people naturally fear death and painful experiences.
1 - The capability to carry out the suicide attempt is usually formed from emotional and physical pain and disrupted cognitive status and is acquired through previous suicide attempts (self-directed violence), rehearsing suicide through behavior or imagery, and getting used to painful or dangerous experiences in other ways ( vv imp )
2 - Individuals who are suicidal often have tunnel vision about the situation and consider permanence of suicide as easy way out of a difficult situation.
Other significant risk factors for suicide include ( v imp ) -
A ) psychiatric disorders
B ) substance abuse
3 Individuals who have good interpersonal social relationship and family support tend to have lower risk of suicide
4 - People who have greater self-control, greater self-efficacy, intact reality-testing, and more adaptive coping skills are at less risk.
5 - Those who are hopeful, having future plans or events to look forward to, and having satisfaction in life has normalized protective factors against suicide.
Prevention Strategies
1 In recognition of the need for comprehensive approaches to suicide prevention, various strategies have been developed with the support of evidence.
A ) The traditional approach -
1 - has been to identify the risk factors that increase suicide or self-harm, though meta-analysis studies suggest that suicide risk assessment might not be useful and recommend immediate hospitalization of the person with suicidal feelings as the healthy choice.
2 - In 2001, the U.S. Department of Health and Human Services, under the direction of the Surgeon General, published the National Strategy for Suicide Prevention, establishing a framework for suicide prevention in the U.S.
3 - The document calls for a public health approach *** to suicide prevention -
A ) By focusing on identifying patterns * of suicide and suicidal ideation throughout a group or population (as opposed to exploring the history and health conditions that could lead to suicide in a single individual).
4 Thus the American Association of Suicidology outlines 10 important suicide warning signs, listed below -
1 Suicidal Ideation: thinking, talking, or writing about suicide, planning for suicide.
2 Substance abuse
3 Purposelessness
4 Anxiety
5 agitation and unable to sleep or not sleeping all the time.
6 Trapped.
7 Hopelessness
8 Social Withdrawal from friends, family, or society.
9 Anger, rage or seeking revenge.
10 Recklessness or impulsiveness.Mood changes.
B ) Specific strategies
1 - Crisis intervention - Structured counseling and psychotherapy.
2 - Hospitalization for those with low adherence to collaboration for help and those who require monitoring & secondary symptom treatment.
3 - Supportive therapy like substance abuse treatment, Psychotropic medication, Family psychoeducation and Access to emergency phone call care with emergency rooms, suicide prevention hotlines…etc.
4 - Restricting access to lethality of suicide means through policies and laws.
5 - Creating & using crisis cards, An uncluttered card formatted readably that describes list of activities one should follow in crisis still the positive behavior responses settles in the personality.
6 - Person-centered life skills training. e.g., Problem solving.Registering with Support groups like Alcoholics Anonymous, Suicide Bereavement Support Group, Religious group with flow rituals…etc.
7 - Therapeutic recreational therapy that improves mood.
8 - Motivating self-care activities like physical exercise’s and meditative relaxation.
C ) Psychotherapies that have shown most successful or evidence based are -
Dialectical behavior therapy (DBT), it has shown to be helpful in reducing suicide attempts and reducing hospitalizations for suicidal ideation and Cognitive therapy (CBT), it has shown to improve problem-solving and coping abilities.
D ) Application of Interventions
The general methods include: direct talks, screening for risks, lethal means reduction and social intervention.
A ) Direct talks - Contrary to popular misconceptions, talking with people about suicide does not plant the idea in their heads. However, such discussions and questions should be asked with care, concern and compassion.
1 The tactic is to reduce sadness and provide assurance that other people care.
2 The WHO advises to not say everything will be all right nor make the problem seem trivial, nor give false assurances about serious issues.
3 The discussions should be gradual and specifically executed when the person is comfortable about discussing his or her feelings.
4 ICARE (Identify the thought, Connect with it, Assess evidences for it, Restructure the thought in positive light, Express or provide room for expressing feelings from the restructured thought) is a model of approach used here.
B ) National Suicide Prevention Lifeline, a nationwide crisis line in the United States also available in Canada
C ) The World Health Organization (WHO) has noted a very effective way to assess suicidal thoughts is to talk with a person directly, to ask about depression, and assess suicide plans as to how and when it might be attempted.
E ) Screening Methods
1 The U.S. Surgeon General has suggested that screening to detect those at risk of suicide may be one of the most effective means of preventing suicide in children and adolescents.
2 There are various screening tools in the form of self-report questionnaires to help identify those at risk such as the Beck Hopelessness Scale .
3 A number of these self-report questionnaires have been tested and found to be effective for use among adolescents and young adults
4 In approximately 75 percent of completed suicides, the individuals had seen a physician within the year before their death, including 45 to 66 percent within the prior month.
5 Approximately 33 to 41 percent of those who completed suicide had contact with mental health services in the prior year, including 20 percent within the prior month. These studies suggest an increased need for effective screening.
6 Research has shown that many suicide risk assessment measures were not sufficiently validated, and do not include all three core suicidality attributes (i.e., suicidal affect, behavior, and cognition).
F ) Lethal means reduction
1 Means reduction, reducing the odds that a suicide attempter will use highly lethal means, is an important component of suicide prevention
Vv imp This practice is also called “means restriction”.
2 Researchers and health policy planners have theorized and demonstrated that restricting lethal means can help reduce suicide rates, as delaying action until depression passes.
3 In general, strong evidence supports the effectiveness of means restriction in preventing suicides.
4 There is also strong evidence that restricted access at so-called suicide hotspots, such as bridges and cliffs, reduces suicides, whereas other interventions such as placing signs or increasing surveillance at these sites appears less effective.
Eg - One of the most famous historical examples, of means reduction, is that of coal gas in the United Kingdom.
1 Until the 1950s, the most common means of suicide in the UK was poisoning by gas inhalation.
2 In 1958, natural gas (virtually free of carbon monoxide) was introduced, and over the next decade, comprised over 50% of gas used.
3 As carbon monoxide in gas decreased, suicides also decreased.
4 The decrease was driven entirely by dramatic decreases in the number of suicides by carbon monoxide poisoning.
G ) Social Intervention
Such as - A telephone connected to a crisis hotline at Niagara Falls State Park
H ) National Strategy for Suicide Prevention promotes and sponsors various specific suicide prevention endeavors:
1 Developing groups led by professionally trained individuals for broad-based support for suicide prevention.
2 Promoting community-based suicide prevention programs.Screening and reducing at-risk behavior through psychological resilience programs that promotes optimism and connectedness.
3 Education about suicide, including risk factors, warning signs, stigma related issues and the availability of help through social campaigns.
4 Increasing the proficiency of health and welfare services at responding to people in need. e.g., Sponsored training for helping professionals, Increased access to community linkages, employing crisis counseling organizations.
5 Reducing domestic violence and substance abusethrough legal and empowerment means are long-term strategies.
6 Reducing access to convenient means of suicideand methods of self-harm. e.g., toxic substances, poisons, handguns.
7 Reducing the quantity of dosages supplied in packages of non-prescription medicines e.g., aspirin.School-based competency promoting and skill enhancing programs.
8 Interventions and usage of ethical surveillance systems targeted at high-risk groups.
9 Improving reporting and portrayals of negative behavior, suicidal behavior, mental illness and substance abuse in the entertainment and news
10 It has also been suggested by NSSP that media should prevent romanticising of negative emotions and coping strategies which can lead to vicarious traumatization.
11 vv imp - The Centers for Disease Control and Prevention (from a 1994 workshop) and the American Foundation for Suicide Prevention (1999) have suggested that -
A ) TV shows and news media can help prevent suicide by linking suicide with negative outcomes such as -
1 pain for the suicide and their survivors, conveying that the majority of people choose something other than suicide in order to solve their problems
2 avoiding mentioning suicide epidemics, and avoiding presenting authorities or sympathetic, ordinary people as spokespersons for the reasonableness of suicide.
12 Postvention
A ) Postvention is for people affected by an individual’s suicide, this intervention facilitates grieving, guides to reduce guilt, anxiety, and depression and to decrease the effects of trauma.
B ) Bereavement is ruled out and promoted for catharsis and supporting their adaptive capacities before intervening depression and any psychiatric disorders.
C ) Postvention is also provided to intervene to minimize the risk of imitative or copycat suicides, but there is a lack of evidence based standard protocol.
D ) But the general goal of the mental health practitioner is to decrease the likelihood of others identifying with the suicidal behavior of the deceased as a coping strategy in dealing with adversity.
13 Teaching self esteem techniques
14 Implementation of support groups