96 The World Health Organization's role in suicide prevention

Suicide is not only a personal tragedy, but a serious international public health problem. The majority of suicides in the world (85 per cent) occur in low- and middle-income countries (Krug et al. 2002). Suicide is among the top three causes of death in the young population aged 15–34 (World Health Organization 2001).

Whereas national data about completed suicide exists for many countries, similar statistics on attempted suicide are largely missing, reflecting a lack of official or systematic national data collection. Hence, the scale of suicide attempts is not clearly known. Relying on hospital records and population surveys, it is estimated that attempted suicides are 10–20 times more frequent than completed suicides (Wasserman 2001).

The Secretary-General of the United Nations in his report to the General Assembly in 1991 drew attention to the fact that suicide was a significant and growing problem, particularly among youth. The ensuing monitoring process revealed a lack of comprehensive national strategies for preventing suicide and, in many countries, rapidly rising suicide rates. In 1993, a United Nations (UN) and World Health Organization (WHO) International Expert Meeting on Guidelines for the Formulation and Implementation of Comprehensive National Strategies for the Prevention of Suicidal Behaviour was held in Canada, which culminated in a report (United Nations 1996) that included a comprehensive set of guidelines, together with a case study of the Finnish national strategy. These guidelines encouraged the development of national suicide-prevention strategies around the world, for instance, in the United States (US Department of Health and Human Services 2001), where suicide was recognized as a national problem, and suicide-prevention as a national priority, as well as in Europe (WHO 2002b; Wasserman et al. 2004). In 1999, WHO launched the worldwide initiative for suicide prevention (SUPRE) with the overall goal of reducing the mortality and morbidity of suicidal behaviours.

The WHO, a specialized agency of the UN, is an intergovernmental organization, established by the formal agreement of, and ultimately governed by, 193 Member States. As the directing and coordinating authority on international health work, WHO stimulates international action on health issues of global concern with the ultimate objective of the attainment by all people of the highest possible level of health (WHO 2003). The WHO's normative function and advocacy role, as well as its convening power in establishing global partnerships, places it in a unique position to provide leadership at global, regional and country levels.

The activities of the WHO suicide-prevention initiative reflect core functions of the WHO Department of Mental Health and Substance Abuse and of the organization as a whole.

The suicide-prevention initiative is building global partnerships and collaborating with governments, international non-governmental organizations, professional associations, academic institutions, and relevant UN agencies. Early on, a WHO advisory network for the prevention of suicide was established to draw from the knowledge and experience of experts in the field around the world. Regional and national workshops on suicide-prevention brought together representatives of countries with a high burden of suicidal behaviours with the aims of:

In its efforts, the WHO Department of Mental Health and Substance Abuse works closely with Ministries of Health of Member States, WHO Regional and Country Offices, and with WHO Collaborating Centres.

The WHO plays a key role in the collection, compilation and dissemination of essential epidemiological data on suicide. By providing a reliable information base in this area, it has become a widely used source of such data in the world. Information is not only furnished on the magnitude of the problem (World Health Organization 1999), but also on risk and protective factors associated with suicidal behaviours, on preventive measures and effective interventions. A relevant research agenda has been proposed.

In the mid-1980s, the WHO European multi-centre study on suicidal behaviour was established. It monitored trends of attempted suicides for nearly 15 years (De Leo et al. 2004). This study was a collaborative, coordinated, multinational project with up to twenty-one participating centres, which provided an unprecedented picture of attempted suicide in Europe. At the global level, the WHO Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS) was launched in 2002 to:

These data provide, in most cases for the first time, comprehensive information on suicide attempters in eight low- and middle-income countries (i.e. Brazil, Estonia, India, Islamic Republic of Iran, People's Republic of China, South Africa, Sri Lanka, and Vietnam).

WHO Member States need scientifically sound, clear, and reliable technical guidance for suicide-prevention programmes, the management of those at risk of suicide or those who attempted suicide, and for the development and implementation of national strategies for suicide-prevention. Examples of countries receiving technical assistance include Brazil, Estonia, Mauritius, Guyana, India, Islamic Republic of Iran, Lithuania, People's Republic of China, South Africa, Sri Lanka, Thailand, Trinidad and Tobago, Uruguay, and Vietnam.

To this end, WHO has prepared a series of resources (World Health Organization 2000a–f; 2006a, b) addressed to specific social and professional groups particularly relevant to the prevention of suicide (i.e. general physicians, media professionals, teachers, primary health care workers, prison officers, counsellors, workplaces). Another resource targets survivors (those who are left behind after a completed suicide) to help them start a survivors' group. These resources have been translated into many languages and are widely used.

The WHO has produced an updated inventory of national strategies for suicide-prevention in WHO's European Member States (World Health Organization 2002b; Wasserman et al. 2004). It advocates for the development of national strategies for suicide-prevention and provides technical support in their preparation and implementation.

The WHO encourages the establishment of effective and innovative services, and proposes cost-effective interventions for preventing suicidal behaviours and treating those at risk for or having attempted suicide. All efforts to assist governments of Member States in strengthening mental health systems follow the principles of equity, sustainability and involvement of all stakeholders.

As suicide is a complex, multifactorial phenomenon, resulting from the interaction of biological, psychological, social and environmental factors, an equally complex approach is needed for its prevention. It is the WHO's role not only to generate political will and to raise the awareness among policy-makers to have suicide-prevention placed as a priority in the public health agenda, but also to reach beyond the health sector and to advocate for mainstreaming the issue of suicide-prevention in non-health sectors, such as education, jurisdiction, economics, media, legislation, and agriculture.

Even though the WHO has an important role to play in the prevention of suicide, it is ultimately the governments who have a responsibility for the health of their people.