52 Strategies in suicide prevention

Strategies in suicide prevention have developed throughout the years, and progressed into conceptual models that are defined by a set of restrictive definitions. In this chapter, classifications of two suicide preventive strategic models, namely the Primary/Secondary/Tertiary (PST) and Universal/Selective/Indicated (USI) are described, as well as a pragmatic suggestion for health care and public health-oriented strategies in suicide prevention. Health care-oriented strategies use the individual-centred approach with the focus on the treatment of patients. Public health strategies in prevention of suicide are directed toward groups and whole populations.

Preventive strategies age back decades and continue to develop and expand across a wide spectrum of disease and illness. Mental disorders, with suicide in particular, have increasingly gained special interest among the scientific community, essentially for the fact that aspects behind suicide entail many mental disorders, and prevention of those mental disorders would lead, in itself, to the prevention of suicide (Bertolote 2004).

Strategic preventive models are designed to target short- and long-term initiatives on either individual or population levels. The traditional preventive continuum often consists of targeting the early onset of a particular disease or disorder, treating those who currently endure the disease or disorder, and following up with those who have received intervention or treatment. Suicide preventive strategies too work along this prevention continuum by addressing the onset, treatment and follow-up aspects of suicide risks.

There are several conceptual models for suicide prevention as referenced in Silverman's commentary: ‘Gordon's Universal/Selective/Indicated; Haddon's Injury Control Model (Pre-injury, Injury, Post-Injury); the classical triad of Primary/Secondary/Tertiary; and the alternative of Prevention/Intervention/Postvention’ (Silverman 2004, p. 153).

Traditionally, in suicide preventive strategies, the primary/secondary/tertiary (PST) prevention model is, and has been, often employed as fundamental principles in the development of suicide preventive strategies. The primary/secondary/tertiary classification scheme has been noted to be attractive and simple in its design to effectively target risk factors associated with suicide in the short- and long-term goals. The strategic initiatives for this model are as follows.

Along the prevention continuum, the primary prevention addresses prophylaxis of the onset of the disease (Dwight et al. 2005).

Reducing the incidence of suicidal behaviours, by eliminating or reducing risk factors and strengthening the protective factors, is the goal of primary prevention, which falls outside the health care sector, involving for example, media, legislators, etc. However, mental health professionals should be actively involved in this type of prevention, as their profound knowledge of suicidal persons' mind and their social networks functioning is, at the moment, underestimated in this kind of preventive activity, which would gain a lot in effectiveness and precision. Good examples of the involvement of mental health professionals are: European Alliance Against Depression (EAAD) activities, as described by Hegerl and colleagues in Chapter 66 of this book, and Suicide awareness and mental health among youth in the community; Exposing dark secrets: what must be told by Hoven et al. in Chapter 67 of this book.

The primary prevention sets the foundation by increasing awareness of suicide and suicide risks before suicidal behaviour occurs. De Leo and Meneghel (2001) describe the primary prevention as approaching subjects (in this case the elderly) who currently do not feel suicidal, and decrease such risks that would later inflict suicidal feelings and ideations among this group. Of course, in order to decrease latter suicidal risks, one would have to identify target populations. Examples of interventions utilized in the primary prevention model for suicide are:

Other examples of primary prevention strategies are to involve media in responsible reporting of suicides, and supporting occupational groups with a high risk for suicide, such as doctors, farmers, pharmacists, and policemen.

The next stage along the prevention continuum is referred to as secondary prevention. The ultimate goal of secondary prevention is reducing the prevalence of already existing mental disorders by treatment and early detection of unknown cases and their appropriate treatment (Dwight et al. 2005). The secondary preventive strategy addresses individuals at risk for self-harm, and those identified with a mental disorder, by providing early treatment that can be broadly accessible (Andersson and Jenkins 2006).

This type of prevention focuses also on reducing or eliminating suicidal risks factors by intervening and treatment (De Leo and Meneghel 2001). In other words, the secondary preventive strategy is intended to implement treatment to persons who are actively considering or even attempted suicide. Examples of interventions for this strategy are as follows:

The final strategy on the prevention continuum is tertiary prevention. The goal of tertiary prevention is to reduce the incidence of relapses through rehabilitation, after having experienced suffering from a disease or disorder, to prevent supplementary deterioration (Dwight et al. 2005).

In the ideal of suicide prevention, the tertiary approach attempts to reduce the consequences of individuals that surpassed at-risk status, after having previously been suffering from suicide ideation and attempts (Andersson and Jenkins 2006). De Leo and Meneghel (2001) describe this tactic as also a way to manage those who have already been inflicted and suffered a loss by a relative or loved one who committed suicide.

Tertiary suicide prevention requires multidisciplinary services according to the principles of the modern psychiatry with easy access, continuity of care and rehabilitation and inclusion of the family in the process. Reintegration into society, supply of housing, educational possibilities, prevocational and vocational training and work are the most important components. In some countries, legislation allows tailoring of comprehensive rehabilitation programmes.

The primary/secondary/tertiary prevention strategy has proven effective in outlining and the formation of suicide preventive strategies. Below, a prevention model used in public health called universal/selective/indicated is presented.

The universal/selective/indicated classification scheme in forming suicide preventive strategies was proposed in a 1994 report (Mrazek and Haggerty 1994) by the Institute of Medicine (IOM) in Washington D.C. The definitions are based upon a classification proposed by Gordon (1983) a decade earlier, and are related to health behaviour and health risks in target populations. According to this conceptual model, all three strategies are aimed at target populations.

Universal prevention is aimed at general populations, selective prevention is aimed at populations who have an above average risk to develop diseases, and indicated prevention is directed at persons who have already experienced symptoms.

The strategic initiatives for this model are as follows.

The universal strategy method is beneficial for everyone in a population (Yip 2005). In a report by Kimokeo (2006), the author describes universal prevention as being directed towards entire populations (not individuals), and is principally aimed at decreasing risk factors for suicidal behaviour and increasing protective factors for suicidal behaviour (Greenberg et al. 2001). Activities target entire communities and programmes reach asymptomatic individuals at low risk.

Bertolote (2004) explains that an example of universal strategies for prevention of suicide could entail the limitation of access to toxic substances, which are used as means of suicide. This strategy also entails measures like different welfare, social, educational and working policies and improved health care availability, for example, different community-based programmes giving social support, or educational programmes teaching substance use dangers (Yip 2005).

The selected strategy is targeted at subgroups with increased risk of suicide, which could be based on age, gender, occupation or family history. Kimokeo (2006) states that the selected prevention scheme is targeted particularly at subgroups with signs of elevated biological or social risk factors for suicide or suicidal behaviour, although currently they may be clinically asymptomatic (Burns and Patton 2000). The group-level characteristics place them considerably higher than the average risk for suicide (Dwight et al. 2005), e.g. isolation, antisocial behaviour, negative life events, etc. (Burns and Patton 2000; Bertolote 2004).

Examples of an intervention for the selected scheme could be treatment of people with mental disorders and substance use disorders, psychological support to persons in crisis situations or with physical disabilities (Bertolote 2004). Intervention programmes for children with clinically depressed parents, or victims of physical or sexual abuse (Yip 2005) or an event-centred intervention focused on adverse life events (Burns and Patton 2000), or interventions focused on groups who are victims of war, violence and the bereaved are other examples.

Indicated strategies are aimed at persons who display significant signs of a disorder or condition, which is known as a high risk for future development of an illness (Burns and Patton 2000; Katschnig and Schrank 2003; Yip 2005; Dwight et al. 2005; Kimokeo 2006). For instance, an intervention in the indicated scheme is treatment and close follow-up of people with depression, bipolar disorders, recurrent psychotic episodes and intensive psychosocial follow-up of suicide attempters (Bertolote 2004; Yip 2005).

Other examples are programmes for parents of children with high levels of aggression and behavioural disturbances.

There are substantial similarities and dissimilarities between the two conceptual models of PST and USI prevention.

Katschnig and Schrank (2003) suggests that the PST scheme has a temporal perspective, i.e. there are specific stages before and during the progression of the disease, whereas a USI scheme has both a temporal perspective and target populations perspective, in which the universal and selective strategies aim at those who are not ill yet (first in the general population, and second in subgroups with risk factors and exposure to risk situations); and indicated prevention intended for persons who currently display symptoms of a disorder, e.g. depression, substance abuse, etc. (Burns and Patton 2000; Katschnig and Schrank 2003; Dwight et al. 2005; Yip 2005; Kimokeo 2006).

In a closer analysis of PST, the primary prevention is compared to a prevention in the traditional sense, whereas secondary and tertiary prevention is equated with treatment and rehabilitation, accordingly (Katschnig and Schrank 2003). In the USI model, the universal prevention addresses prevention in the general population, similar to primary prevention in the PST model. Selective prevention addresses groups at risk, which is similar to secondary prevention and, to some extent, to primary prevention; the indicated prevention aims at those who individually have been identified as having a disorder, comparable to secondary prevention in the PST scheme (Katschnig and Schrank 2003).

The primary prevention can be universal or in cases when occupational groups with high risk for suicide are targeted, selective. The secondary prevention corresponds to both selective and indicated prevention (in which case the latter aims at persons known for having symptoms of mental disorders or suicidal behaviours). Tertiary prevention strives to avoid relapses, which are often seen among men-tally ill and suicidal persons, and has no distinct place in the USI model (Katschnig and Schrank 2003). The tertiary suicide preventive strategies are essential when suicide prevention is concerned, as studies show that rehabilitation of suicide attempters diminishes relapses of suicidal behaviour, i.e., repetition of attempted suicide or completed suicide (Hawton et al. 1998; Fleishmann et al. 2008).

Both conceptual models are used in practical and preventive work. An American study was conducted to evaluate the effectiveness of a public health approach suicide prevention among American Indian tribal nations over a 15-year span. The universal/selected/indicated conceptual model was utilized. The results concluded that during the 15-year period, suicide gestures and attempts dropped dramatically (May et al. 2005).

In a systematic meta-analysis on suicide prevention by Mann et al. (2005), it was found that the primary and secondary suicide preventive measures according to the PST model, including treatment intervention strategies such as medication, education for physicians and restricting access to lethal means, were successful in lowering suicide rates.

The previous sections described classifications of two conceptual models used in suicide prevention. This section will focus on the assorted types of interventions that are implemented within those conceptual models.

Preventive intervention strategies can be applied according to (i) the health care approach, and (ii) the public health approach (Wasserman 2001).

For the sake of simplicity, evidence-based suicide preventive measures presented in the following chapters of this book are classified as having a health care or public health perspective.

Strategies for suicide prevention are crucial in the struggle to reduce suicidal behaviours. As discussed in this chapter, conceptual models and intervention strategies have come a long way since their development, however, further research, evaluation and creativity is still needed in the arena of suicide prevention. As stated by Bertolote (2004), if a universal prevention programme existed, it would already have been adopted by everyone. Moreover, research of effective suicide prevention, a seemingly obvious task, has been until now heavily neglected and under-resourced area around the world, which calls for attention.