top of page

Suicide prevention; intrinsic uncertainty and clinician’s responsibility

 

Suicide is a complex and not well-understood phenomenon. In a meta-analysis of the international literature, we estimated that around 27% of people dying by suicide had been in contact with specialized services in the year before death. Although mental disorders including substance dependence along with male gender, previous suicidal behavior and numerous other risk factors for suicide are well established, much less is known regarding the effect of preventive interventions, both on a general population level and in clinical populations.



Suicide is a complex and not well-understood phenomenon. Nevertheless, dating back to the antiquity, a strong connection with mental disorders has been evident. Research from the Nordic countries has been highly influential in establishing this link and expanding our understanding of suicide in both in the general population and among people in contact with care. The availability of nationwide registers has been an important asset here (Aaltonen et al., 2024; Qin & Nordentoft, 2005; Runeson et al., 2010).

 

In a meta-analysis of the international literature, we estimated that around 27% of people dying by suicide had been in contact with specialized services in the year before death (Walby et al., 2018). These figures are considerably higher in the Nordic countries due to our shared welfare state model that provides relatively easy access to care at no or low costs. A high proportion of people in contact with health care services preceding suicide should be viewed as an opportunity for prevention, and not equated at default with errors of care.

 

Although mental disorders including substance dependence along with male gender, previous suicidal behavior and numerous other risk factors for suicide are well established, much less is known regarding the effect of preventive interventions, both on a general population level and in clinical populations.


Our limited ability to predict suicide should not be interpretated to say that mental health care has a limited role in suicide prevention.

 

Prediction of suicide and suicide risk assessment

 

Despite the high risk of suicide in clinical populations, in particular in the first weeks and months after discharge from inpatient care (Qin & Nordentoft, 2005), suicide remains a rare event.  Therefore, along with other reasons, suicide cannot routinely be predicted at an individual level. This has been known in the literature for at least 70 years (Rosen, 1954) and confirmed in many studies including and meta-analysis (Belsher et al., 2019). Contradictory to the robust research evidence and given the simple statistical explanation of the effect of the low base rate, expectations from both society in general, the media, suicide survivors, health authorities and even us as clinicians, often don’t seem to acknowledge this fact. The reasons for that can be many, including that suicide is almost always a dramatic and traumatic event, the increased expectations towards healthcare services and disciplines including psychiatry and an increased focus on medical-legal issues to name a few. Although healthcare authority’s usually have quality improvement and prevention of serious events such as suicides at the forefront of their aims, such authorities are often perceived by anxiousness by clinicians and clinical directors, and little is known about their effect on preventing future suicides. Interestingly, a recent review from Swedish authors reported little positive effect of health authority investigations in order to prevent future suicides, and called for the need for development of new approaches for investigation of suicide as a patient safety issue (Fröding et al., 2024).


Despite the high risk of suicide in clinical populations, in particular in the first weeks and months after discharge from inpatient care (Qin & Nordentoft, 2005), suicide remains a rare event. Image by Unsplash.
Despite the high risk of suicide in clinical populations, in particular in the first weeks and months after discharge from inpatient care (Qin & Nordentoft, 2005), suicide remains a rare event. Image by Unsplash.

What to do given the intrinsic uncertainty?

 

A first step should be to accept the intrinsic uncertainty.  Our limited ability to predict suicide should not be interpretated to say that mental health care has a limited role in suicide prevention. At the contrary, on and individual level, treatment have been shown to be lifesaving for many disorders, with treatment interventions ranging from psychotherapy such as Dialectical Behavioural Therapy (Mehlum et al., 2014) to psychopharmacologic treatment with Lithium for major affective disorders (Tondo et al., 2001) just to name two examples.  

 

Albeit few clinicians will doubt the role of good clinical management and treatment of individual patients to prevent suicide, interventions to prevent suicide at a system level in health care organizations are often forgotten. Such interventions probably hold an even greater promise for improved suicide prevention.  In the United Kingdom While et al. (2012) reported an reduction of suicide rates as a result of the implementation of a set of higher lever recommendations to health care systems. In the USA a similar systematic approach to prevention in outpatient clinics have reported optimistic findings (Layman et al., 2021)

 

Due to the many years of life lost, suicide is rightly considered as a public health issue. But as the tragic and traumatic result of a suicide and the sever impact on survivors as well as on clinicians and on health-care systems, suicide prevention is often put in a single event and individual responsibility perspective. Such a perspective is insufficient to target a complex tragedy such as suicide-Due to our very limited ability to predict suicides at and individual level, suicide prevention must be broadened to include systemic or organizational interventions. This should be included in both basic education and routine clinical training as well as in quality improvement activities to prevent both future suicides. The same systemic perspectives should be governing postvention efforts after an incident of suicide in the services.

 

The Norwegian Health Directorate very recently published a revised version of the Norwegian Practice Guidelines for Suicide Prevention in Mental-Health and Addiction Services (https://www.helsedirektoratet.no/retningslinjer/selvmordsforebygging-i-psykisk-helsevern-og-tsb). One of the main aims of the revised version is to help clinicians and clinical managers to apply a more systematic perspective in the difficult task of suicide prevention.

 

Refereces by request

 

  • Aaltonen, K., Sund, R., Hakulinen, C., Pirkola, S., & Isometsä, E. (2024). Variations in Suicide Risk and Risk Factors After Hospitalization for Depression in Finland, 1996-2017. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2023.5512

  • Belsher, B. E., Smolenski, D. J., Pruitt, L. D., Bush, N. E., Beech, E. H., Workman, D. E., Morgan, R. L., Evatt, D. P., Tucker, J., & Skopp, N. A. (2019). Prediction Models for Suicide Attempts and Deaths: A Systematic Review and Simulation. JAMA Psychiatry, 76(6), 642–651. https://doi.org/10.1001/jamapsychiatry.2019.0174

  • Fröding, E., Vincent, C., Andersson-Gäre, B., Westrin, Å., & Ros, A. (2024). Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention. Archives of Suicide Research: Official Journal of the International Academy for Suicide Research, 28(1), 1–19. https://doi.org/10.1080/13811118.2022.2133652

  • Layman, D. M., Kammer, J., Leckman-Westin, E., Hogan, M., Goldstein Grumet, J., Labouliere, C. D., Stanley, B., Carruthers, J., & Finnerty, M. (2021). The Relationship Between Suicidal Behaviors and Zero Suicide Organizational Best Practices in Outpatient Mental Health Clinics. Psychiatric Services (Washington, D.C.), appips202000525. https://doi.org/10.1176/appi.ps.202000525

  • Mehlum, L., Tørmoen, A. J., Ramberg, M., Haga, E., Diep, L. M., Laberg, S., Larsson, B. S., Stanley, B. H., Miller, A. L., Sund, A. M., & Grøholt, B. (2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: A randomized trial. Journal of the American Academy of Child and Adolescent Psychiatry, 53(10), 1082–1091. https://doi.org/10.1016/j.jaac.2014.07.003

  • Qin, P., & Nordentoft, M. (2005). Suicide risk in relation to psychiatric hospitalization: Evidence based on longitudinal registers. Archives of General Psychiatry, 62(4), 427–432. https://doi.org/10.1001/archpsyc.62.4.427

  • Rosen, A. (1954). Detection of suicidal patients: An example of some limitations in the prediction of infrequent events. Journal of Consulting Psychology, 18(6), 397–403. https://doi.org/10.1037/h0058579

  • Runeson, B., Tidemalm, D., Dahlin, M., Lichtenstein, P., & Långström, N. (2010). Method of attempted suicide as predictor of subsequent successful suicide: National long term cohort study. BMJ (Clinical Research Ed.), 341, c3222. https://doi.org/10.1136/bmj.c3222

  • Tondo, L., Hennen, J., & Baldessarini, R. J. (2001). Lower suicide risk with long-term lithium treatment in major affective illness: A meta-analysis. Acta Psychiatrica Scandinavica, 104(3), 163–172. https://doi.org/10.1034/j.1600-0447.2001.00464.x

  • Walby, F. A., Myhre, M. Ø., & Kildahl, A. T. (2018). Contact With Mental Health Services Prior to Suicide: A Systematic Review and Meta-Analysis. Psychiatric Services, 69(7), 751–759. https://doi.org/10.1176/appi.ps.201700475

  • While, D., Bickley, H., Roscoe, A., Windfuhr, K., Rahman, S., Shaw, J., Appleby, L., & Kapur, N. (2012). Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: A cross-sectional and before-and-after observational study. Lancet (London, England), 379(9820), 1005–1012. https://doi.org/10.1016/S0140-6736(11)61712-1

Comentarios


Los comentarios se han desactivado.
bottom of page