Preventing the Crisis: A Proactive Approach to Solutions

This blog post takes a unique approach as we delve into the significant findings from The Lancet Public Health Series released in September 2024. This extensive six-paper series presents a comprehensive public health strategy for suicide prevention, exploring various intervention opportunities. Here, I will summarize the most impactful insights to raise awareness and encourage action.

At The Mental Elf, we have examined a multitude of topics related to suicide prevention. This year alone, we have investigated issues ranging from ethnic disparities in suicide mortality to clinical groups at increased risk, such as those suffering from bipolar disorder and first-time fathers experiencing depression. We also discussed the correlation between rising temperatures and suicidal behaviors. Over the past decade, we have published more than 70 blogs, synthesizing the latest and most reliable research in suicide prevention.

The Comprehensive Mental Health Action Plan set by the WHO (2021a) aims for a 30% reduction in global suicide rates by 2030. While there was a 10% decrease in the age-adjusted global suicide rate from 2013 to 2019, this downward trend seems to be leveling off. Furthermore, there are evident disparities in reduction rates across various countries worldwide (WHO 2021b). This emphasizes the need for sustained efforts and innovative strategies to continue reducing these rates.

To enhance the effectiveness of suicide reduction efforts, this Series adopts a public health perspective for two primary reasons:

1. Substantial reductions in suicide rates can be most effectively achieved through public health measures that encompass the entire population, rather than focusing solely on individual cases.
2. The availability of sufficiently trained mental health professionals is insufficient to provide one-on-one treatment for all individuals experiencing suicidal ideation.

Key Steps in a Public Health Strategy for Suicide Prevention

The public health approach encompasses five crucial steps:

1. Define and quantify the suicide problem to understand its scope.
2. Identify the risk factors that exacerbate suicide vulnerabilities.
3. Propose evidence-based methods for preventing or alleviating the issue.
4. Implement effective strategies on a large scale to reach the broader population.
5. Evaluate the success and impact of these strategies to ensure continuous improvement.

This series focuses particularly on the second and third steps, which can be scaled up to effectively mitigate the likelihood of suicidal crises.

Understanding the Public Health Model for Suicide Prevention

The layering of vulnerabilities can lead to the development of suicidal thoughts and behaviors. A combination of social determinants, commercial influences, sociodemographic risk factors, and individual vulnerabilities can significantly increase the risk of suicide. Therefore, by addressing and providing interventions across these various domains, we can reduce overall vulnerability. The range of interventions includes:

• Universal interventions: Strategies aimed at the entire population to promote mental well-being.
• Selective interventions: Targeted approaches for individuals not currently experiencing suicidal thoughts but who may be at risk in the future, such as those facing financial difficulties or exhibiting signs of mental health issues.
• Indicated interventions: Directly addressing individuals actively contemplating suicide or displaying suicidal behaviors.
• Postvention: Support for individuals impacted by the suicide of someone close to them, helping them navigate their grief and potential risk.

Each paper in this series is linked in the references section. However, I’ve highlighted the essential points from each paper below for easier navigation:

• Paper 1: Pirkis et al introduce a public health model for suicide prevention, emphasizing necessary changes in perspective and policy.
• Paper 2: Hawton et al present quantitative studies on reducing access to suicidal means and their impact on suicide rates.
• Paper 3: Sinyor et al examine international government initiatives and their influence on unemployment and financial circumstances related to suicide rates.
• Paper 4: Pirkis et al explore five different ways suicide transmission occurs and propose various preventative strategies.
• Paper 5: Pirkis et al analyze specific societal risk factors and their association with increased suicide risk, offering suggested preventative measures.
• Paper 6: Hawton & Pirkis provide an overview of the series and present a call to action for policymakers to prioritize universal and selective interventions beyond clinical approaches, making key recommendations across various domains.

Essential Findings and Effective Interventions

The primary messages from the series can be categorized into two key areas: public health interventions, primarily universal strategies, and the reduction of critical risks and determinants associated with suicide, mainly through selective interventions.

Effective Public Health Interventions for Suicide Prevention

Strategically Reducing Access to Means of Suicide

• National bans on highly hazardous pesticides: Implementing bans in low to middle-income countries has resulted in a significant drop in suicide rates without causing method substitution. For instance, in Sri Lanka, a 20-year ban led to nearly 93,000 fewer suicides than projected.
• Reducing access to firearms: There is a well-established correlation between firearm availability and suicide rates. Emerging evidence suggests that limiting access to firearms can effectively decrease suicide rates without leading to method substitution.
• Limiting access to toxic medications: The withdrawal of coproxamol in the UK resulted in a 61% decline in suicides linked to this drug. Additionally, reducing the permissible purchase size of paracetamol has led to fewer deaths and instances of liver toxicity.
• Enhancing safety in public spaces: In locations where bridges are known for suicides by jumping, the installation of barriers or nets has proven effective, with an average reduction of 91% in suicides at these sites. Similarly, restricting access to railway tracks has also shown to diminish railway suicides.

Government Strategies Addressing Economic Influences on Mental Health

Economic conditions and employment status significantly influence mental health and suicide risk globally, regardless of a country’s income classification. Data shows that unemployment and poverty can elevate suicide rates in both high and low-income countries.

• National economic health: Studies indicate that for every $1,000 increase in per capita Gross Domestic Product (GDP), there is a corresponding 2% decrease in suicide rates.
• Financial struggles: A $1 increase in the US minimum wage correlates with an average 1.9% reduction in annual state suicide rates. Furthermore, individuals receiving cash transfers in Brazil (income supplements for those below a certain threshold) were found to be 56% less likely to die by suicide over 12 years compared to non-recipients.
• Unemployment trends: Research analyzing data from 175 countries between 1991 and 2017 revealed that a 1% rise in unemployment is associated with a 2-3% increase in suicide rates among individuals aged 30-59 years.

Overall, even minor adjustments in an individual’s economic situation can significantly impact suicide rates, both positively and negatively.

Identifying and Addressing Societal Risk Factors for Suicide

Exploring Societal-Level Risk Factors Contributing to Suicide

Social determinants, as discussed in the public health model, lead to inequalities within populations, placing certain demographic groups at heightened risk for suicide. The primary societal risk factors include:

• Alcohol consumption: High levels of alcohol use and alcohol use disorders are closely linked to increased rates of suicidal behavior.
• Gambling behaviors: Issues related to gambling can elevate both suicidal ideation and attempts throughout a lifetime.
• Domestic violence: Interpersonal violence, including domestic abuse, is a significant risk factor for suicide.
• Suicide bereavement: Losing a relative to suicide increases an individual’s risk of suicide or attempt by threefold, while losing a friend or acquaintance raises these risks by 2.5 times.

Societal-level strategies can address these social determinants and cultural influences. For example, initiatives aimed at reducing access to alcohol and gambling, increasing awareness of domestic violence support services, and implementing postvention strategies following a suicide can make a significant difference. However, the challenge remains due to industries that profit from these activities, complicating efforts for intervention.

Understanding the Contagion Effect of Suicide

Despite its importance, the transmissibility of suicide has received insufficient attention. Recognizing that individuals exist within social networks, where those around them influence their actions, is crucial for understanding and addressing the issue of suicide.

• Media reporting: Reports that sensationalize or normalize suicide, or provide detailed accounts of methods, can lead to increased suicide rates. Guidelines are available to help journalists create responsible and safe content.
• Social media influence: Initiatives like the #chatsafe guidelines empower participants to express suicidal thoughts and respond to others’ suicidality safely. Additionally, algorithms that detect concerning content and direct individuals to support resources show promise in addressing this issue.
• Suicide clusters: The contagion effect, where suicides occur within close-knit networks, necessitates implementing postvention practices after incidents to support vulnerable groups and address the needs of those grieving.
• Secondary school environments: The risks of suicide transmission are heightened due to a combination of community baseline risks, neurodevelopmental factors, and social transitions that occur during adolescence.
• Media campaigns for prevention: Enhancing the general population’s understanding of suicide prevention can lead to significant reductions in suicide rates. Positive media portrayals of coping, hope, and recovery are linked to the Papageno effect, which can help reduce suicide rates.

To effectively combat suicide, a cultural shift is needed to cultivate widespread coping mechanisms that tackle the underlying issues contributing to suicidal behavior.

Key Takeaways for Suicide Prevention

This Series emphasizes the pressing need for both selective and universal interventions that address the complex issue of suicide, focusing on prevention strategies that intervene before individuals reach crisis points. Many social determinants of suicide can be effectively tackled by sectors beyond health, prompting a call for a comprehensive governmental approach to suicide prevention.

Evaluating Research Strengths and Limitations

The volume of research available for certain areas of suicide prevention is limited, possibly because these topics have not been deemed significant enough for rigorous study. The suicide rate data often experiences a lag and may be based on estimates rather than precise records. While some regions have developed real-time suicide registries, these are not yet widespread.

Implementing the Public Health model requires significant political will and commitment from stakeholders, particularly for steps 4 and 5, which involve scaling up interventions and evaluating their impact. Unfortunately, this has resulted in the non-implementation of some of the most effective strategies, while less effective measures have been promoted, often due to resistance from industries like alcohol and gambling that obstruct attempts to enforce supply reduction interventions. Instead, they advocate for individual moderation strategies, which are generally less effective in preventing suicide.

To strengthen the case for suicide prevention initiatives, high-quality evidence is essential. However, as previously mentioned, the current data is limited, and because suicides are thankfully rare events, this diminishes the statistical power of potential studies. Large-scale macroeconomic, public, and social policy changes do not lend themselves well to randomized controlled trial (RCT) models.

Practical Implications for Suicide Prevention

Many social determinants of suicide are best addressed outside the healthcare sector. Thus, for the public health approach to be effective, it requires a whole-of-government commitment to suicide prevention that collaborates with a diverse array of stakeholders. Paper 6 provides specific recommendations for actions, detailing who should assume responsibility:

• Policy actions (8): Governmental accountability is essential.
• Practical actions (6): Community-based welfare services, suicide prevention initiatives, and mental health services must work together.
• Research actions (3): Collaboration is needed among government departments, researchers, coroners, medical examiners, and law enforcement.
• Advocacy actions (2): Involvement from all stakeholders is crucial.

Individuals with lived experience of suicide should be genuinely engaged as stakeholders across all these actions, ensuring their insights and perspectives are valued and integrated.

For further exploration, consider reviewing WHO’s suicide prevention approach, known as LIVE LIFE, which offers guidance on implementing suicide prevention activities through cross-sectoral collaboration (WHO 2021c), and join the movement to reduce suicide rates.

To contribute to a universal intervention, I have included the updated 2022 video for Christina Aguilera’s “Beautiful,” showcasing images and lyrics as a supportive resource. Please find additional information at the end if you or your loved ones are facing challenges related to social media.

 

Disclosure of Interests

I have no conflicting interests related to this paper.

Resource Links

Access to 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