Prevention

Some preventive strategies aim to improve the management of individuals at high risk; others to reduce factors associated with suicidality in society as a whole. Reduction of suicide rates, both for the general population and for psychiatric patients, is among the targets in the government's 'Health of the Nation' strategy.

A recent systematic review (Mann et al, 2005) indicates that 'physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates.' However, it is important to remember that not only depression but also all mental disorders (apart possibly from learning disability and dementia) carry an increased risk of suicide (Harris and Barraclough, 1997).

Medical care of the mentally ill

Many suicides have been in contact with GPs or psychiatrists shortly before death, suggesting that better medical management might have prevented the fatal act. Psychiatric patients who have voiced suicidal thoughts, have a past history of suicide attempts, or possess the socio-demographic factors listed above should be considered at high risk.

Prompt and energetic physical treatment of psychiatric illness should help prevent suicide in the mentally ill. High doses of psychotropic drugs may be required, but potentially suicidal patients should not be given large supplies, which might be used in overdose. ECT may be indicated for the suicidally depressed. In the long term, prophylactic medication and care may help to reduce suicide.

Suicidal patients who live with responsible relatives or friends can often be managed at home, but must have frequent follow-up reviews, and 24-hour access to professional help in case of emergency. Hospital admission, with close nursing observation, is indicated for the very severely ill and those without adequate home support.

In cases where more chronic psychiatric and social problems existed, a growing alienation from professional carers sometimes seems to have been a factor in the suicide. This can happen if staff themselves become hopeless or cynical in relation to an unrewarding case, and points to the importance of supportive care in suicide prevention.

Other strategies

• counselling services, such as the confidential telephone helpline for despairing and suicidal people run by the Samaritan organization.

• restricting availability of methods, such as catalytic converters for cars; controls on sale and possession of medicines, guns, and poisons. Restricting the amount of analgesics that can be bought without prescription, seems to have been associated with reduced suicide rates in the UK (Hawton et al., 2004).

• physical considerations such as making psychiatric wards as safe as possible (for example, by removing potential ligature points, from which a patient might hang himself) and preventing public access to bridges or cliffs from which others have jumped to their death. Removal of a method can have a significant long-term effect, as it is not necessarily replaced by other methods; in the 1960s, changing the domestic gas supply from coal gas (containing carbon monoxide) to non-toxic natural gas was followed by a sustained reduction in total UK suicide rate.

• educational programmes; for example, efforts to improve the recognition and management of potentially suicidal patients in general practice, or to dissuade young people from suicidal behaviour.

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