Suicide prevention: what works, what might work, and what does not work

Suicide prevention is a global public health priority, with many countries adopting national suicide prevention strategies over the past 30 years. Global suicide rates decreased by almost one third between 1990 and 20161. Notably, recent data indicate that US rates have markedly defied this trend. It is difficult to demonstrate that reductions in suicide rates seen in most countries reflect the introduction of national suicide prevention strategies. However, there is evidence regarding some of the specific initiatives that often comprise such strategies, including what is effective and what seems not to work. The suicide prevention field is also rapidly evolving, with many promising approaches still needing fuller evidence. Modification of access to the means for suicidal acts is the suicide prevention policy for which there is the best evidence of effectiveness. This has ranged from removing access to specific methods to introducing policies for detecting and intervening when individuals may be about to initiate a suicidal act in a public place. Ingestion of pesticides has been a major means of suicide in many lower-and-middle income countries. With removal of more toxic pesticides in some countries, the most recent data from the World Health Organization (WHO) indicate fewer deaths involving this method. In China, for example, national bans on highly hazardous pesticides in 2008 and 2016 were followed by major reductions in suicides involving pesticides, and a marked decrease in overall national suicide rates2. Notably, introduction of safer storage policies for pesticides has not had a similar impact. Erection of safety barriers on bridges, and other safety measures at public sites frequently used for suicide, have been shown in several studies to reduce deaths at those locations, with limited displacement to other potential nearby sites3. There is also support for interventions that encourage help-seeking at such sites3. Initiatives to prevent suicides on rail networks are ongoing in several countries, but have less evidence of effectiveness at the moment. Restricting pack sizes of analgesics commonly used in self-poisoning, or complete removal for particularly toxic drugs, have been found to have a preventive effect. Although more than half of all suicides in the US involve firearms, there has been relatively little effective action to restrict access to guns in that country, probably due to a combination of cultural and commercial factors, together with a strong gun lobby. This is likely to have contributed to suicide rates in the US failing to follow recent global declines. Dramatic reporting and portrayal of suicides in traditional, social and entertainment media can increase risk of suicidal behavior in those exposed to these influences. The WHO and many countries have developed guidelines aimed at improving how suicide is reported or portrayed. These have generally led to improved quality of suicide-related content, although there is less evidence regarding their potential contribution to reducing suicides. However, public health messaging sharing narratives of survival and modelling help-seeking, especially when done by a celebrity, can have positive effects on both attempts to get help and suicide rates4. Several school-based suicide prevention interventions have been developed, with mixed evidence for efficacy in the context of methodological concerns for some studies. There is reasonable support of impacts on suicidal thoughts and behaviors for a European programme focused on mental health literacy and coping skills development, and an American one focused on helping students recognize warning signs and on help-seeking, for both themselves and friends5. Broad socioeconomic conditions also contribute to suicide risk and can be leveraged for prevention, with many studies linking macroeconomic policy and suicide rates in both high and lower-and-middle income countries. Increasing employment rates appear to reduce suicide in middle-aged adults. Likewise, increases in social welfare spending, minimum wage, per capita gross domestic product, and investment in active labor market programs, all tend to reduce suicide rates. Strategic spending may also be particularly important in counteracting the effects of economic downturn on suicide rates. Large proportions of people dying by suicide have psychiatric disorders, especially mood disorders, but also personality, psychotic, substance use or eating disorders. There has been considerable controversy about whether antidepressant treatment helps prevent suicide. A meta-analysis of observational studies found that exposure to selective serotonin reuptake inhibitors was associated with increased risk of suicide death or attempt among adolescents, but somewhat decreased risk among adults, and had a clear protective effect in those aged 65 years and above, although this last finding was based on just two studies6. Attention has also focused on the role of mood stabilizers in reducing the high risk of suicide in bipolar disorder. A review of systematic reviews showed substantial evidence that lithium can reduce the occurrence of suicidal acts7. The potential role of ketamine, electroconvulsive therapy and clozapine in reducing risk of suicide in specific patient populations requires further substantiation. Some psychotherapies have shown promising results in reducing self-harm, a much more frequent phenomenon than suicide, that can be more easily studied in clinical trials. These include cognitive behavioral therapy (CBT)-type interventions for people presenting to hospital following self-harm, and dialectical behavior therapy (DBT) for similar presenting people with a history of borderline personality disorder and repeated self-harm8. However, interventions effective for prevention of repeated self-harm in children and adolescents other than DBT have not so far been identified. Also, the size of trials required to show an impact of these psychotherapies on suicide is very large. Historically, a major and understandable focus of prevention efforts in psychiatric services has been to try to identify patients most at risk of suicide. However, increasing evidence indicates that these efforts are largely ineffective, with prediction estimates being very low, and indeed the majority of suicides occurring in individuals identified as at lower risk9. Like population-level efforts, the most effective clinical interventions must be available for as many patients as possible. This approach also aligns with standard clinical practices across medicine, which generally emphasize treatment that lowers risk across an entire group rather than prediction of who will experience a sentinel event (e.g., myocardial infarction). There is good evidence that safety planning – through which clinician and patient work together to plan and document measures that the patient will take if a crisis is developing – is effective in reducing the occurrence of suicidal acts. This should be offered along with comprehensive biopsychosocial care and therapeutic risk management, including a focus on clinical interventions likely to improve patients’ well-being. While requiring further evaluation, this overall approach is likely the optimal strategy for preventing suicide in people with mental disorders9. In conclusion, suicide prevention through national strategies and other coordinated actions must include a combination of public health and clinical policies, with the former likely having a greater impact on suicide rates. Population-level interventions should include a focus on decreasing access to the means of suicide, increasing access to information about how to seek help and survive (including via the media and educational programs), and creating economic conditions that decrease stress on populations. Clinical interventions should focus on high-quality, humane care, including safety planning and targeted evidence-based treatment according to the individualized needs of patients.

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