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Preventing Suicide

"Perhaps the first recorded suicide prevention initiative was that reported by Plutarch (46-110 AD) in the Greek city of Miletus. Here an epidemic of suicide amongst young women is said to have been terminated by the public display of the naked bodies of those committing suicide."

This quote is taken from the highly readable and beautifully written monograph `The Potential for Preventing Suicide: a review of the literature on the effectiveness of interventions aimed at preventing suicide' by David Gunnell of the Health Care Evaluation Unit in Bristol. This peer reviewed report contains 243 references sources from the medical literature by standard techniques. There are about 50 pages of text and tables, and a few hours of reading brings the problems concerning suicide prevention into stark contrast.

Reducing the rate of suicide in the population by 15% by the end of the decade is one of the targets set for Health of the Nation.

How big is the problem?

In 1991 just under 6,000 people took their own lives and suicide is the second most frequent cause of death in 15-34 year olds. Suicide accounts for 2% of male and 1% of female deaths and 8.5% and 3.8% respectively of years of life lost before age 64 years. Parasuicide (a deliberate non-fatal act) accounts for over 100,000 admissions to hospital in England every year.

Self poisoning by solid or liquid substances was the most common method of suicide in 1991, used in 24% of suicides. Other major methods were carbon monoxide poisoning (mostly from car exhausts) and hanging (each 20%), whilst other methods constituted the remaining 36% (drowning 6%, jumping from a height 5%, jumping from a moving object 4%, firearms 3%, self-burning 2% and others).

Of those who died from self poisoning, 39% took analgesics or anti-rheumatics, while 24% took tranquillisers or other psychotropic drugs.

High risk groups

Suicide risk is increased in males (male suicide rates outnumber female by 3:1) and those who are separated, single or divorced. There are a number of groups of people recognised as having an increased risk of suicide. No more than 1-2% of the members of any of these groups commit suicides in a year, and at least a third of suicides do not belong to any high risk group.

Contact with GPs

About a quarter of those committing suicide have contact with a health care professional (usually the GP) in the week before death, and about 40% in the month before death. However, in a health district of 1,000,000 people there will be 56 suicides in one year. The average GP will experience a suicide in one of his patients once every four or five years, with a patient consulting before this episode only once every eight or nine years.

Potential for prevention

This thoughtful monograph goes into great detail on possible prevention strategies, the evidence that these may actually work, and what research is needed to demonstrate the effectiveness of prevention measures. It points out, for instance, that to show a 15% reduction in suicide rates in the UK would require a study with a population size of 13 million!

A number of probably effective strategies could be put in place now. Most of them are pretty obvious, and include measures such as greater safety measures at suicide `hot spots', safety measures on underground railways, gun control and the enforced and monitored reporting guidelines to prevent imitative episodes of suicide.

A more significant measure would be changing availability of OTC medicines like paracetamol. Over 200 people die each year from paracetamol poisoning. In France the contents of each pack are limited to eight grams; in 1974-83 there were only 3 deaths from paracetamol overdose, and all three had British packaging of the drug. Similar arguments could be made for changing the design of car exhausts to prevent the attachment of pipes (20% of suicides), and to legislation to ensure that plastic bags have holes (100 suicides a year).

The full list of pragmatic suggestions, with the caveat that further research is required to assess their effectiveness is:-
  • Measures to reduce risk of suicide amongst those recently discharged from psychiatric care.
  • Limiting quantity and packaging of paracetamol and aspirin.
  • Schemes to limit size of individual prescriptions and dose per tablet of high risk drugs.
  • GP education on recognition and treatment of depression, highlighting the drugs most often taken in fatal overdoses.
  • Regular reminders of media guidelines on the reporting and showing of fictionalised suicide.
  • Audit of suicide and parasuicide.
  • Strategies/research into means of reducing suicide in those recently discharged from psychiatric care.
  • Car exhaust and plastic bag redesign.

Copies of "The Potential For Preventing Suicide" can be obtained from Health Care Evaluation Unit, Department of Epidemiology and Public Health Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR (Fax 0272 238568).

This is one of a series of excellent reviews. Others in the series include:-

  • Total Hip Replacement
  • Total Knee Replacement
  • Hernia Repair
  • Cataract Surgery
  • Palliative Cancer Care: Provision in The South West

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