Useful links

With the increasing recognition of suicide as a major health and social care issue, many suicide prevention organisations have been established locally, nationally and internationally. This chapter includes a number of links to the most prominent of these, but the list is indicative rather than exhaustive. These include the International Association for Suicide Prevention, the International Academy of Suicide Research, the Samaritans, the World Health Organization, and national suicide prevention organizations from across the world.

Psychological and other non-pharmacological approaches

This chapter discusses psychological and non-pharmacological interventions for suicidal behaviour in more detail. All people who present with suicidal thoughts and behaviour warrant some treatment, but the nature and intensity of this will depend on individual needs. Psychological treatments may include cognitive behavioural therapy, interpersonal therapy, problem-solving therapy, and mindfulness-based cognitive behavioural therapy. Dialectical behaviour therapy is specifically designed for those with a diagnosis of borderline personality disorder. Broader non-pharmacological approaches such as crisis centres, volunteer organizations, brief-contact interventions, and safety plans may be promising but require further research. Common therapeutic elements include a non-judgemental approach, empathy, respect, warmth, and genuineness.

A brief history of suicidal behaviour

This chapter places suicide and suicidal behaviour in a European historical context. Although suicide has been documented throughout history, its meaning and functions have varied over time. In the Middle Ages, suicide was regarded as sinful but, subsequently, was conceptualized in terms of social influences or mental illness. Systematic research into suicidal behaviour has been undertaken for more than two centuries. The contributions of Morselli, using statistical and epidemiological techniques, were particularly notable. Many of the accepted social and psychiatric antecedents of suicide we talk about today were well described by the nineteenth century.

Preventing suicide through population-based approaches

This chapter discusses population-based approaches to suicide prevention. These can often be the most powerful strategies to prevent suicide. Restriction to access to means of suicide (e.g. reducing pack sizes of analgesics, banning pesticides) is effective but usually requires legislation to introduce at a national level. It is most relevant when there is a common high-lethality method. Responsible media reporting can also help to prevent some deaths. Other population-based strategies, for example those designed to reduce the availability of alcohol, reduce the stigma of help-seeking, and increased welfare spending may be effective. National programmes of suicide prevention are needed to have a major impact.

Pharmacological approaches

This chapter discusses the role of pharmacological approaches to the treatment of people who present with suicidal thoughts or behaviours. Use of medication has been controversial, particularly for children. However, the balance of evidence suggests that if there is a psychiatric disorder for which there is an effective pharmacological treatment, then this treatment should be offered. Antidepressants, mood stabilizers (particularly lithium), and antipsychotic medication can reduce suicidality. Ketamine, a short-acting anaesthetic and NMDA receptor antagonist, is potentially useful and is the subject of much research interest for its possible role in treatment.

Psychiatric disorders and biological factors

This chapter discusses the role of psychiatric disorders, biological factors, and genetic factors in suicidal behaviour. These increase risk and the susceptibility of some individuals to react more severely to stress but do not inevitably lead to suicide. All psychiatric disorders are associated with a higher risk of suicide, particularly mood disorders, schizophrenia, and drug and alcohol misuse. Comorbidity (multiple psychiatric disorders at the same time or psychiatric and physical disorders together) is common. The vulnerability to suicidal behaviour is partly inherited. The serotonin and hypothalamic–pituitary–adrenal systems are associated with suicide; however biological factors lack specificity. There is an important interaction between genetic susceptibility and the environment—stressors may have more of an impact in individuals who carry particular genes.

Definitions

This chapter discusses definitions of suicidal behaviour and some of the terminology used. There is no universally agreed nomenclature and a variety of terms have been used to capture the diversity of suicidal behaviour. Broadly speaking, approaches have tried to either categorize suicidal behaviour on the basis of intent or else regarded suicidal behaviour as along a continuum. Of course suicidal behaviour is exactly that—a behaviour and not a psychiatric disorder in its own right. A simple pragmatic approach to terminology might be most useful because this allows for flexible individualized clinical management.

Clinical examples

This chapter includes three clinical vignettes which highlight some of the basic principles of assessment and management. The case studies describe a young person with interpersonal issues, a person with a long history of behaviours that might fit the criteria for borderline personality disorder, and a man in mid-life with a severe psychiatric illness. All those who present with suicidal thoughts and behaviour warrant a full assessment. The treatment offered depends on the presence and nature of any psychiatric and physical illness identified, as well as wider patient needs. Older people may have more prominent mental disorders. Some form of follow-up should be offered wherever possible.

Conclusion

This concluding chapter suggests that no single approach is suitable for all. Effective strategies are available but these need to be tailored to individuals. It is sometimes suggested that the evidence base is weak but suicide prevention research is proceeding at an increasing rate. The management of mental health problems remains important. Future work might harness the power of large datasets, investigate the implementation and development of interventions, make use of new technology, and focus on low- and middle-income countries where most deaths occur. There are a number of challenges, including ageing populations and health services which are under increasing pressure. By using some of the strategies that have been developed internationally, there is every reason to be optimistic that rates of suicide worldwide can be reduced.

Epidemiology

This chapter examines the global epidemiology of suicidal behaviour. Up to one million people die by suicide every year, and about three quarters of these are in low- and middle-income countries. Twenty to thirty times this number harm themselves or attempt suicide. Global rates are probably under-reported, and the iceberg model of suicidal behaviour (showing that much suicidal behaviour is ‘under the waterline’ and thus hidden) is a helpful way of conceptualizing this. In most countries, men are greatly over-represented amongst people who die by suicide. There is a current concern about men in midlife in many high-income settings. Although suicidal behaviour can vary widely in incidence, it tends to share common antecedents. However, it should be borne in mind that the results of large population-based studies do not always apply to individuals.