Intervening early in the continuum of suicidal behaviour

Suicidal behaviour is believed to exist along a continuum, therefore early intervention in the continuum of suicidal behaviour should reduce suicide rates.

Suicide accounts for nearly 800,000 deaths each year globally and is the second-leading cause of death in young people. Suicidal ideation, suicide attempt and deliberate self-harm are more common, problematic in their own right and are associated with risk of future suicide.

Approximately one-third of young people who report suicidal ideation will attempt suicide within one year, and about one in 25 people who present to hospital with deliberate self-harm will die by suicide within five years. 

Moreover, the period immediately following discharge from psychiatric inpatient treatment is associated with the highest risk for suicide. Mental health problems are also common in people who die by suicide, with depression occurring in up to two-thirds of all people who die by suicide.

Despite the negative outcomes associated with suicidal thoughts and behaviours, many people do not seek professional help, with only one in five people who die by suicide presenting to any health service within two weeks prior to death.

Health services, in particular, primary care services and hospital emergency departments, clearly have a role to play in the detection of, and response to, those at risk of suicide.

Major barriers to help-seeking by young people at risk of suicide include lack of time, preference to self-manage, and concerns related to stigma. When young people do seek help for suicidal thoughts they often do so from informal sources such as family or friends, who may not be equipped to respond appropriately.

As many people do not seek professional help, other measures are warranted. Page and colleagues investigated the potential impact of five different intervention strategies on the Australian suicide rate over a 10-year period (2015-2025). Strategies included GP training, coordinated aftercare for people who attempt suicide, mental health literacy programs in schools, brief contact interventions in hospital settings, and psychosocial treatment.

Results indicated GP training and coordinated aftercare were associated with the largest predicted reductions in the suicide rate — 6% and 4% respectively. Combined, these approaches were predicted to reduce the suicide rate in Australia by 12% thus providing some indication as to where resources may be best targeted.

Suicide is a relatively rare outcome, and present our ability to accurately predict who is at risk of dying by suicide is poor. Services must, therefore, be prepared to respond adequately when people do seek professional help, as well as making efforts to increase their availability and accessibility to improve rates of help-seeking more generally.

Services should capitalise on the ways in which young people would like to engage with the healthcare system, for example by considering technology-based solutions. The onus should not just be on the service system, however.

Prevention efforts should also include stigma reduction measures and bolstering the capacity of all those who come in to contact with vulnerable young people, such as employers, friends and family, and school staff.

Taken together, these strategies will improve the identification and response to risk early in the suicidal trajectory, thereby increasing the likelihood of saving young lives.

This article was posted in support of World Suicide Prevention Day.

About Dr Jo Robinson:

Dr Jo Robinson is a senior research fellow based in Australia and leads Orygen, the National Centre of Excellence in Youth Mental Health’s suicide prevention research unit. She currently coordinates several research projects in collaboration with Australian and overseas universities.

Dr Robinson’s work focuses on the development, and rigorous testing, of novel interventions that specifically target at-risk youth across settings, on evidence synthesis, and on the translation of research evidence into practice and policy.

Examples of some current projects include the development of a multi-layered and systematic approach to youth suicide prevention across north-west Melbourne, the establishment of a self-harm monitoring program in six emergency departments across Victoria, and a suite of studies examining the potential utility of social media platforms in suicide prevention. The latter includes a national study, funded by the Commonwealth Department of Health that will lead to the development of evidence-based best practice guidelines for safe peer-peer communication about suicide online and a national social media-based suicide prevention campaign designed by, and for, young people.

Dr Robinson has also led the production of a series of systematic reviews that have informed clinical practice and service development.

About Eleanor Bailey:

Eleanor Bailey is a research assistant in suicide prevention at Orygen, the National Centre of Excellence in Youth Mental Health in Australia and a PhD (ClinPsych) candidate at Swinburne University of Technology.

To hear more, you can follow Dr Jo Robinson @JoRobinson_Aus and Eleanor Bailey @eleanorbailey_1

References for further reading:

• World Health Organization. Mental health: suicide data. 2018. (Accessed August 18 2018).
• Sveticic J, De Leo D. The hypothesis of a continuum in suicidality: a discussion on its validity and practical implications. Mental Illness 2012; 4(2): e15.
• Nock MK, Green J, Hwang I, et al. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: Results from the national comorbidity survey replication adolescent supplement. JAMA Psychiatry 2013; 70(3): 300-10.
• Carroll R, Metcalfe C, Gunnell D. Hospital Presenting Self-Harm and Risk of Fatal and Non-Fatal Repetition: Systematic Review and Meta-Analysis. PLOS ONE 2014; 9(2): e89944.
• Hunt IM, Kapur N, Webb R, et al. Suicide in recently discharged psychiatric patients: a case-control study. Psychological Medicine 2009; 39(3): 443-9.
• Hawton K, Casanas ICC, Haw C, Saunders K. Risk factors for suicide in individuals with depression: a systematic review. J Affect Disord 2013; 147(1-3): 17-28.
• O׳Neill S, Corry CV, Murphy S, Brady S, Bunting BP. Characteristics of deaths by suicide in Northern Ireland from 2005 to 2011 and use of health services prior to death. Journal of Affective Disorders 2014; 168: 466-71.
• Rasmussen ML, Hjelmeland H, Dieserud G. Barriers toward help-seeking among young men prior to suicide. Death Studies 2018; 42(2): 96-103.
• Czyz EK, Horwitz AG, Eisenberg D, Kramer A, King CA. Self-reported barriers to professional help seeking among college students at elevated risk for suicide. Journal of American college health : J of ACH 2013; 61(7): 398-406.
• Michelmore L, Hindley P. Help-seeking for suicidal thoughts and self-harm in young people: a systematic review. Suicide & life-threatening behavior 2012; 42(5): 507-24.
• Page A, Atkinson J, Heffernan M, McDonnell G, Hickie I. A decision-support tool to inform Australian strategies for preventing suicide and suicidal behaviour. Public Health Res Pract 2017; 27(2): e2721717.
• Franklin JC, Ribeiro JD, Fox KR, et al. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological bulletin 2017; 143(2): 187-232.