Abstract
The current scientifically informed view of suicide is that, while complex, suicide is a health-related outcome. Driven by a convergence of health factors along with other psychosocial and environmental factors, suicide risk is multifactorial. Like most health outcomes, a set of genetic, environmental, and psychological/behavioral factors are relevant. It is critically important that health professionals develop a current understanding of suicide as older views have permeated and clouded societal understanding leading to assumptions and judgment that have silenced generations of people suffering suicidal struggles or loss of a loved one to suicide.
A Introduction: Science, Culture, and Readiness to Act
The current scientifically informed view of suicide is that, while complex, suicide is a health-related outcome. Driven by a convergence of health factors along with other psychosocial and environmental factors, suicide risk is multifactorial. Like most health outcomes, a set of genetic, environmental, and psychological/behavioral factors are relevant. It is critically important that health professionals develop a current understanding of suicide as older views have permeated and clouded societal understanding leading to assumptions and judgment that have silenced generations of people suffering suicidal struggles or loss of a loved one to suicide.
Evolving attitudes toward suicide are not limited to the scientific or medical field. Science is impacting popular culture as well. Recent polls in the USA show that public perceptions of mental health and suicide are changing quite rapidly toward greater awareness, open-mindedness, and diminishing stigma.1 For example, 90% of respondents believe that mental health is as valid and important as physical health, and say they would help if someone they know were to become suicidal. However many add they are not necessarily equipped with skills and language to know how to help.
Key Point
Suicide, while complex, is a health-related outcome.
Figures 1.1, 1.2, 1.3 Examples of positively evolving attitudes toward mental health and suicide prevention among the American public
New attitudes toward mental health in general and suicide in particular are reflected in the growing suicide prevention movement that has emerged in recent years in the USA, UK, Australia, and other nations. The truth is that for millennia, people who had lost loved ones and people who experienced a loved one’s suicidal crisis or their own largely kept their experiences to themselves, but now are speaking out and are part of leading the movement to advance change. Advocates on all sides of the issue have come together to raise public awareness, to advocate for changes in national policy for increases in research funding, improved healthcare access, for enforcement of mental health parity, and to call for an end to discriminatory practices in school and workplace settings. This public movement has led to hundreds of thousands of people participating in events in the USA such as the Out of the Darkness Walks for suicide prevention in all 50 states, advocacy activities at state and federal levels, and educational programs on how to prevent and respond to suicide in workplaces, schools, and faith-based settings.
The bottom line is that in today’s environment, healthcare providers need not be hesitant to address mental health concerns with their patients. The truth is that many patients may be open to dialog and in need of support but 1) may not be sure if their health provider will respond in a compassionate and knowledgeable way related to suicidal thoughts or mental health concerns, and 2) they may not know how to bring up their symptoms or concerns and may not have sophisticated language for symptoms. But even with these concerns present or with current robust mental health, many patients appreciate having their mental health screened and addressed in a manner similar to physical health.
While culture and attitudes toward mental health are opening up, it is a time of transition in culture and belief systems with natural unevenness to the pace and regionality of changing views. Thus, in general, the public’s level of mental health literacy in terms of when and how to take action remains relatively low.2 Health professionals can help deepen their patients’ understanding of mental health in the same way they do for physical health. As is the case for many physical health targets such as cardiovascular health, for patients who carry any degree of elevated risk, patient education, clinical treatment, family support, and personalized lifestyle habits can improve prognosis and change outcomes.
Key Point
Patients appreciate having their mental health addressed in a similar manner as their physical health. Routine health maintenance in primary care should include mental health and suicide risk reduction. For all health professionals, basic principles included in this handbook will facilitate caring, competent handling of patients who are at risk for suicide.
B Principles
From a public health perspective, suicide is considered a generally preventable cause of death. This does not mean all suicides can be prevented, or that suicide is a predictable event.
Health systems and providers across disciplines have a vital role to play in suicide prevention.
The combination of scientific discovery and voices of people with lived experience and loss is advancing culture change and a new societal readiness when it comes to suicide prevention.
Cultural norms in many regions of the world are changing in relation to mental health and suicide, with people beginning to open up and speak out about mental health, reducing the stigma around mental health, help seeking, and suicide prevention.
While the absolute number of suicides around the globe has been on the rise since 2000, the overall rate has been decreasing as the world’s population grows.
Suicide risk is complex and multi-faceted for individuals and for populations.
A multi-pronged approach is needed to prevent suicide in a population. Efforts must include basic public health strategies such as universal education, community based initiatives, effective and available clinical care, and better surveillance of suicide attempts and deaths.
Other critical components of an effective suicide prevention effort are investments in research and the development of new suicide prevention focused treatments for clinical use.
Federal and local investments in suicide prevention research, community programs, and clinical treatments can reduce suicide mortality.
Key Concept “Prevention” versus “Prediction”
Research shows that suicide can be prevented.
From a public health perspective, suicide is considered a generally preventable cause of death.
This does not mean all suicides can be prevented, nor that suicide is a predictable event.
In the same way that death due to myocardial infarction is not a predictable event on the individual patient level or with a pinpoint on the timing or severity of an event, but cardiologists and primary care understand that aggressively addressing risk factors of cardiovascular disease can save lives. The same principles are true for suicide.
Lack of predictability does not mean a health outcome is not preventable by using upstream, population health approaches, in addition to individualized clinical interventions and family/peer strategies.
C Scope of the Problem and Trends
Global Perspective
We are living in a time of pressing urgency: suicide is a global problem, a leading cause of death with a staggering loss of 800,000 lives each year. Suicide cuts across high- and low-income countries, with lower- and middle-income countries bearing the largest burden (80% of all suicides), but with suicide continuing to be a serious problem in high-income countries as well. In recent years, the World Health Organization (WHO) and the United Nations (UN) have adopted action plans focused on mental health and suicide prevention, and have set goals to reduce the rate of suicide by 10% by 2020 in the case of WHO and by 33% by 2030 in the case of the UN Sustainable Development Goals.3 Presently, 40 countries have enacted national strategies to prevent suicide,4 several of which are proving effective, with reductions in suicide rates in many countries such as China, Denmark, England, Switzerland, the Philippines, and South Korea.5 And although the absolute number of suicides globally continues to increase, a recent study accounting for population growth found the global rate of suicide has dropped by 32.7% over the past three decades.5
Key Point
Suicide is a global health problem and a national priority for many countries.
Figure 1.4 WHO global map of suicide rates by region of the world
National suicide rates vary widely throughout the world. Illustrated by color coding with darker colors showing the countries with higher suicide rates, this map shows the variability across nations. It is important to note that some countries’ suicide data is more accurate than others related to the complexity of vital statistics and death investigation systems as well as the variability of the approach and progress between countries. See Figure 1.7 for more information about countries’ quality of vital statistics and suicide data.
