117 Suicide prevention in France

France has often been described as an ideal place to live: fine wining and dining, lovely villages and cities, where the pursuit of happiness defines the quality of life. Despite this positive image, another face of French society emerges in a country with one of the highest suicide rates in Europe.

Every year, more than 10,000 people commit suicide in France; representing 1 suicide every 50 minutes. However, recent publications from the High Level Committee on Public Health (Haut comité de Santé publique), state that these figures are underestimated by about 20 per cent. Reasons for underestimation are mainly due to the fact that most suicides are ‘hidden’ behind other more obvious causes of death, such as accidents and drug poisoning, or the simple fact that suicide is not identified as such.

After a significant increase in the 1980s, suicide rates in France have been gradually dropping since 1993. However, today, death by suicide remains high, which is double of that by car accidents. Furthermore, it has been reported that between 160,000 and 180,000 suicide attempts take place every year, representing 16–18 times the number of completed suicides.

In France, suicide is the first cause of death in the 35–44 age group, and the second cause of death in the 15–24 age group, according to the latest statistical analysis (INSERM 2005).

France gave birth to the human rights constitution. To better understand the process of suicide prevention in France, key historical dates are outlined below.

The word suicide is Latin for suicidium, from sui caedere, to kill oneself. It was initially introduced in France in 1734 by Abbé Prevost, and later confirmed, in 1737, by Abbé Desfontaines (Soubrier 1999). In 1762, the French Academy officially accepted the inclusion of ‘suicide’ in its dictionary as ‘to kill oneself’.

In 1810, Napoleon stated that the act of suicide is no longer a ‘punishable act’, however, socially, morally and politically, committing suicide has remained taboo (Minois 1995).

Jean Etienne Esquirol declared in 1838 that suicide was ‘an act only committed by mental patients in a moment of delusion’ (Esquirol 1838), which opened a wide-scientific discussion on suicide.

In 1888, Emile Durkheim was the first to provide a sociological explanation of suicide, linking social disintegration and suicide, and lending support to current assumptions that social capital is a protective factor in the mental health of the general population (Durkheim 1888). This was a big step in France, where the question of suicide was no longer a matter of morality or immorality, but rather a psychological or a social problem. In the twentieth century, Halbwachs (1930) and Baecheler (1975) further explored the sociological background of suicide, the latter discussing the challenge of suicide prevention: L'illusion des spécialistes (Baecheler 1975).

After the Second World War, the French Health Care System was created. Shortly after this, and using the English model of Chad Varad and the Samaritans (1953), associations in France such as Recherche and Rencontres (Research and Meetings, 1958) and telephone help lines such as SOS Amitié (the Friendship hotline) were initiated.

In 1969, the Suicide Studies and Prevention Group (Groupement d'Etude et de Prevention du Suicide—GEPS), was founded by mainly intensive care psychiatrists and child/adolescent psychiatrists—Professors Pierre Pichot, Pierre Moron, Jacques Vendrinne and Jean-Pierre Soubrier—played a crucial role in disseminating information concerning suicide, and increasing public awareness on the issue. This group also developed surveys and research protocols in order to demonstrate the objective and the subjective importance of suicide within the society. GEPS also created forums (Vedrinne et al. 1981) to complete sensitization work; these forums were, and still are, a place of exchange between field experts and researchers, and contribute to suicide-prevention implementation.

In 1982, the Association Against Suicide Promotion (Association de Défense Contre l'Incitation au Suicide—ADIS) was created after publication of the book Suicide: How to make it. Following this publication, widespread political debate occurred, and in 1985, the National Academy of Medicine requested the government to take action (Soubrier 1985). The senate proposed a law against incitation to suicide. However, in 1987, a law against provocation to suicide was finally passed by the National Assembly.

In 1992, the Economic and Social Council's Report 18 (Conseil économique et social 1993) issued a report in which suicide was the main topic. For the first time in France, this report acknowledged that suicide was a major public health concern. It triggered several initiatives, a major one being the snapshot of the French situation revealed by the data collected from the Regional Observatory between 1995 and 1997 (FNORS 2005).

At the end of 1996, a new association titled the National Day for Suicide Prevention and celebrated on 5 February each year (Journée Nationale pour la Prévention du Suicide—JNPS), was created as the result of joint efforts of six associations working in the field of suicide prevention. Its goal is to increase awareness by informing the public that suicide, contrary to being taboo, should be discussed as a first step in prevention (Box 117.1). It also strengthens the need for multidisciplinary approach.

The year 2000 was an important development for the association, which became known as the National Union for Suicide Prevention (Union Nationale pour la prevention du suicide—UNPS), enlarging its scope of activities beyond the major communication event of 5 February and developing action in the regions.

Today, UNPS includes over twenty associations, which are dedicated directly or indirectly to suicide prevention, and presently there is also a dedicated website ‘Info suicide’ (http://www.infosuicide.org).

In 1998, the first national prevention programme was launched and suicide became one of the top ten national public health priorities. In addition, The National Strategy for Suicide Prevention (2000–2005) was officially launched in September 2000 (Ministre délégué de la santé 2001). At this juncture, suicide prevention became a priority for public health services.

Part of this strategy was regionally implemented with a specific ‘train the trainers’ programme, organized by psychiatrists and psychologists for people interested or involved in suicide prevention. The French strategy closely followed the launch of the WHO worldwide SUPRE suicide prevention ‘Live your Life’ initiative in 1999 (World Health Organization 1999).

The French Federation of Psychiatry, in partnership with ANAES (Agence Nationale d'Accreditation et d'Evaluation de la Santé), organized a Consensus conference in October 2000, on suicide crisis (Conference de Consensus 2000). A model to assess and better manage suicidal people was created. Following this first consensus conference, other task force meetings elaborated more specific guidelines targeting children and adolescents (FFP 1998). Along with this conference, a French translation of the WHO's resource material Preventing suicide: a resource for teachers and other school staff (WHO 2000a), was disseminated to all public health professionals via the regional school system. Another of the WHO's resource materials, Preventing suicide: a resource for prison officers (WHO 2000b), was also translated into French and has been recognized as an ideal model in the official report on suicide prevention in prisons, which was written by JL Terra (Terra 2003).

For general practitioners, DepRelief and Lundbeck's initiatives, WHO resources (WHO 2000c), a CD-ROM on evaluation of suicide risk (Soubrier 2000) and interactive seminars were disseminated throughout France.

Over the last 10 years, sensitizing school staff, as well as specific training for school doctors and nurses on-site, has been a major goal for prevention. Today, it is a requirement to assess all adolescents' and teenagers' mental health, and observe any changes in their behaviour or appearance. Referral to a specialist can be organized within the care network.

First introduced as a mental health issue, suicide remains a public health priority in France. A lot has already been done, however, more efforts and continuous education of society and health care professionals will be needed to decrease the French suicide rate in the near future.