Challenging Dogma

...Using social sciences to improve the practice of public health

Thursday, April 26, 2007

Suicide Prevention Programs in the U.S.: More Smoke Than Fire - Samantha Kreshover

Public Health's Current Approach to Suicide

Suicide is one of the leading causes of death in the United States resulting in more deaths every year than homicide (1). Little has been done to help combat this problem with suicide only being widely recognized in this past decade as a problem requiring national attention and action. Public health programs
have largely failed to decrease the incidence of suicide for a variety of reasons including approaching the problem from a rather limited biomedical perspective, centering programs around intervening either shortly before or after suicide attempts rather than after identification of early warning signs, and failing to reach in-need populations.

The Biomedical/Individual Approach to Suicide

The problem of suicide is a result of complex population processes, interdependencies, and multilevel causality. It reflects a wide array of risk factors and would be best understood through a social-contextual model that includes social, behavioral and psychiatric factors. Currently public health efforts use a purely biomedical approach to a disease whose basis is mostly societal. The consequences of this include badly flawed efforts to statistically predict who is at risk of suicide. The basis usually used for detecting suicidal ideation and/or constructing "risk-profiles" for suicidal persons relies on studies conducted on middle-aged white men. The results of these studies should not be extrapolated to the entire population. Public health officials should instead be focusing their prevention efforts on fully understanding the variability of individual and population's patterns of suicide, violence, depression, personality predispositions and psychological states. This can be accomplished by investigating the contributions of biological and psychological factors during different life stages of individuals in various populations (2).

Clinicians, public health officials, and epidemiologists are still not prepared to expand their current efforts of suicide prevention beyond this individualized, medical approach. Unlike other medical conditions or outcomes, such as cardiovascular disease, suicide prevention has never gone through a transitional phase of clinical recognition of risk to population-based approaches based on prospective, longitudinal studies of risk factors (2). Currently there is almost a complete lack of outcome research on this topic as well as lack of research and focus on diverse populations that are even more in need.

Suicide prevention has narrowly focused on identifying specific individual-level risk factors instead of broadening thinking to complex social and ecological relations of entire populations (3). Currently, perspectives behind these prevention programs still remain largely focused on suicide as an "individual act". Much of this focus stems from early United States debates in the 1930s and 1940s between psychoanalysts who largely interpreted suicide as an interpersonal or individual act (4). This belief was further cemented in the 1970s when suicide prevention centers were created around this "individual" premise. Volunteers who knew very little about the behaviors and attitudes of the individuals that came to seek their help ran these centers thus furthering the inadequacies and failures in these centers (5).

The problem persists today despite some progress in bringing more qualified and informed professionals into suicide programs. As a result there has been only a very small decline in the incidence rates of suicides over the years. The only prevention efforts shown to have a measurable impact on self-induced deaths have employed population-oriented approaches (2). One such approach has been seen recently in the United States Air Force. In response to alarming rates of suicide in the mid-1990s, the Air Force implemented an education and outreach campaign to expand awareness and promote action in circles far wider than the medically based suicide “prevention clinics’ that had previously existed. This new approach instituted an "ongoing commitment from leadership, consistent and regular communication around the topic of suicide prevention, destigmatization of individuals seeking help for a mental health problem, and improving collaboration among the community prevention agencies." The result of this program was a dramatic decrease in suicide rates that have since been sustained (6).

This is just one example that shows that improving the overall community health—both physically and mentally—can effectively reduce the incidence of suicide. Still, even with successes such as this, social determinants remain under-studied despite their high potential to prevent suicide. (2).
Current Suicide Prevention Programs

Present efforts to prevent suicide mainly focus on intervening or detecting just before or after a suicide attempt. These programs do not help in the overall prevention of suicide. Instead they focus solely on individuals that are past the threshold of suicidal ideation and are actively seeking help. In many cases this type of prevention fails as it is seen as being "too-late" in stopping individuals from taking their own life.

Examples of these types of programs are crisis telephone hotlines. An
evaluation of studies conducted in the United States suggests that suicide hotlines are very minimally effective in reducing both suicidal behavior and community suicide rates (7). Another study found that crisis center clients were more likely to commit suicide than were members of the general population and individuals who committed suicide were more likely to have been clients than were members of the general population (8).

Another widely used public health strategy for suicide prevention is suicide education programs in schools. The goals of these programs are to raise awareness of the problem and risk factors of suicide as well as to educate students about the community health resources available (9). Although these pertain less to those in immediate suicidal
distress, they tend to take risk factors found in specific individuals and extrapolate them to an entire population. Not only do these campaigns in schools miss excluded students, they also have been shown to aid in perpetuating complex and possibly harmful effects on attitudes to suicide and completed suicide (10).

Other studies have reported similar results, focusing further light on the dangers of this program. One United States based survey examined the effects of
school-based suicide prevention programs and found that they were ineffective in the short term in preventing suicide in self-identified adolescent suicide attempters. The survey went even further by suggesting that it was possible that these programs might actually facilitate suicide by not "allowing adequate time to deal with issues raised by program content" (11). Another related study, which compared 758 teenagers to 658 control subjects on pre/post attitudes of curriculum-based suicide prevention programs, found that the program had little impact. It even reflected the conclusion of the previous study stating that it might stimulate vulnerable teenagers to imitate suicidal behavior (12).
Overall, most studies evaluating suicide prevention in school based
intervention programs, community based suicide prevention centers and/or hospital based intensive follow-up situations have not shown any significant reduction in the incidence of suicide (7).
In-Need Populations
Most public health intervention programs to prevent suicide have focused on treating only individual cases especially those with a diagnosed mental illness; however many suicides are not from this population. Research shows, for example, that there is a substantial and increasing problem in suicide among the disabled population where most who committed suicide were never diagnosed with a mental illness (13, 14, 15). Prevention efforts need to be shifted to looking at communities as a whole and the common risk factors associated with each. Public health interventions should be researching suicide rates and risk factors across all different communities and populations within the United States to be able to develop effective public health programs (2).

An example of a community that has received little attention even though their risk of suicide is ever-growing, as mentioned earlier, are persons with disabilities. The suicide rates among this population—most specifically those presenting with multiple sclerosis (MS), mental retardation, or spinal cord injury—are higher than the general population: persons with MS were found to have suicide rates 7.5 times greater than the general age-matched population (13); persons with SCI have a suicide mortality rate 3.3 to 4.9 times more common than in the general population (14); and persons with mental retardation have a higher rate of suicide fatalities at 16.2 per 100,000 persons compared to the general population of 10.6 suicides per 100,000 (15). Risk
factors behind these rates show that persons with disabilities that have suicidal ideation seem to have inadequate social supports; expressions of shame, apathy and hopelessness; difficulty in developing effective skills for dealing with stressful life events; and problems unique to specific disabilities such as decreased bowel function and bladder control as well as decreased mobility. Persons with disabilities are also much more likely than the general population to have a mood disorder such as depression, but are less likely to be diagnosed with it. There is little public attention to this problem—with very few published studies, no current suicide interventions or screenings and a limited understanding of risk factors (13, 14, 15).

Youth also comprise a large portion of suicide rates in the United States—with suicide as the third leading cause of death for those aged 15 to 24 years, at 10.4 suicides per 100,000 persons (1). However this population is less likely to have or be diagnosed with a mental illness. Although youth are just starting to receive public attention due to their increasing rates of suicide, there is still
little known about the risk factors and reasons behind these suicides. There are also very few suicide interventions that focus on this population.

The lesbian, gay and bisexual population is also at an increased risk
of suicide, however there is little to no interventions that deal with the underlying risk factors behind these rates, such as parental efforts at discouraging gender atypical behavior, gay related verbal and physical abuse, etc. These risk factors can be seen as precursors to depression, etc. (20), however many public health interventions fail to address these issues in suicide prevention and therefore only focus on those with a current diagnosed psychological illness. This could in turn account for the rising numbers of suicide in this population.

Due to public health's individualized-biomedical approach to suicide,
numerous communities whose rates are rising have little awareness of symptoms, lack sufficient public health infrastructures to address their needs, and also lack of political will to mobilize to address the issue (2). There must be a more comprehensive approach that looks at the societal, contextual and biological factors of populations as a whole. Investigators should and must enrich their study samples with not only groups thought to bear key risk and but also groups with protective factors. It is essential to assess the impact of protective factors that act in the presence of suspected risk factors to help alleviate unfavorable outcomes for these under-studied populations (2).
The Future
To effectively reduce the number of individuals committing suicide or with suicidal ideation there must be a shift from a biomedical-individualized-high risk approach to a population-based-societal approach. This involves applying strategies to the whole population and sub-populations (such as youth, men, women, etc.) in order to decrease the amount of persons at dangerous levels of suicidal ideation. This should be done in two distinct stages. First there should be suicide prevention measures that relate to the entire population—such as restricting access to the means of suicide through gun control, creating and enforcing regulations for control of dangerous medical substances and changing the media portrayal of suicide. Even though these problems don't seem to be the
most important antecedent, this is believed to have the strongest and most immediate effect in reducing suicide rates (16).

The second stage should involve intensive research on sub-populations and communities within the United States so as to identify common risk factors that pertain to each group. For example, the youth tend to show suicidal ideation due to such antecedents as family breakdown and alienation, relationship losses, school failure and suspension (17), while older populations tend to be susceptible to loneliness and physical morbidity (18). These antecedents should then be addressed and dealt with as a community, not in an individual basis. Prevention strategies for these problems should involve an integration of medical, educational, societal and contextual approaches. Although these social antecedents may be harder to alleviate they will most likely result in the most profitable and longer lasting reduction in suicide (19).

In conclusion, the current frontal assault on suicide must be abandoned in all accounts. The public health prevention programs and campaigns driven by the risk of suicide in individuals cannot be justified. Although the current approach's goal is to prevent suicide, it is in fact doing the opposite and impeding on suicide prevention (9). A more population-based approach will be more effective not only in the immediate sense but also in the long run.


1. Centers for Disease Control and Prevention. National Vital Statistics Reports. Atlanta, GA: 2007.

2. Caine E., Conwell Y., Knox K. If suicide is a public health problem, what are we doing to prevent it?. American Journal of Public Health 2004; 94: 37-45.

3. McMichael AJ. Prisoners of the proximate: Loosening the constraints on epidemiology in an age of change. American Journal of Epidemiology 1999;148:887–897.

4. Kushner H. Self-destruction in the Promised Land: Psychocultural Biology of American Suicide. New Brunswick, NJ: Rutgers University Press, 1989.

5. Lester D. The myth of suicide prevention. Compr Psychiatry 1972;13:555–560.

6. Litts DA, Moe K, Roadman CH, Janke R, Miller J. Suicide prevention among active duty Air Force personnel—United States 1990–1999. MMWR Morb Mortal Wkly Rep 1999;48:1053–1057.

7. McNamee J., Offord, D. Prevention of suicide. Canadian Medical Association Journal 1990. (454-467).

8. Dew M. et. al. A quantitative literature review of the effectiveness of suicide prevention centers. J Consult Clin Psychol 1987;55: 239-244.

9. Rosenman S. Preventing suicide: What will work and what will not. The Medical Journal of Australia 1998;169:100-102.

10. Hazell P., King R. Arguments for and against teaching suicide prevention in schools. Aust N Z J Psychiatry 1996; 30: 633-642.

11. Gould M. et al. Psychosocial risk factors of child and adolescent completed suicide. Arch Gen Psychiatry 1996; 53: 1155-1162.

12. Draper B. Prevention of suicide in old age. Medical Journal of Australia 1995; 162: 533-534.

13. Sadovnick, et. al. Cause of Death in Patients Attending Multiple Sclerosis Clinics. Neurology 1991; 41: 1193-1196.

14. Hartkopp et. al. Suicide in a spinal cord injured population: Its relation to functional status. Archives of Physical Medicine and Rehabilitation 1998; 79: 1356-1361.

15. Patja et. al. Suicide mortality in Mental Retardation: A 35-year follow-up study. Acta Psychiatrica Scandinavica 2001; 103:307-311.

16. Haddon W, Baker S. Injury control. In: Clark DW, McMahon B. Preventive and community medicine. Boston: Little Brown, 1981.

17. Gould M., et al. Psychosocial risk factors of child and adolescent completed suicide. Arch Gen Psychiatry 1996; 53: 1155-1162.

18. Draper B. Prevention of suicide in old age. Med J Aust 1995; 162: 533-534.

19. Zigler E, Taussig C, Black K. Early childhood intervention: A promising preventative for juvenile delinquency. Am J Psychol 1992; 47: 997-1006.

20. D’Augelli A, McDaniel J, Purcell D. The relationship between sexual orientation and risk for suicide: Research findings and future directions for research and prevention. Suicide and Life-Threatening Behavior 2001; 31:84-105.

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