The Challenge of Suicide Prevention

Dis Manage Health Outcomes 2005; 13 (4): 245-253REVIEW ARTICLE 1173-8790/05/0004-0245/$34.95/0

© 2005 Adis Data Information BV. All rights reserved.

The Challenge of Suicide PreventionAn Overview of National Strategies

Martin Anderson1,2 and Rachel Jenkins3

1 School of Nursing, Faculty of Medicine & Health Services, University of Nottingham, Nottingham, England2 National Institute for Mental Health in England, East Midlands, England3 WHO Collaborating Centre for Research and Training for Mental Health, Institute of Psychiatry, London, England

ContentsAbstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2451. Suicide as a Global Phenomenon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

1.1 Overview of Suicide Rates in Different Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2461.2 Specific Variations in Suicide Rates According to Age and Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2461.3 Examples of Variations in Suicide Rates According to Culture and Religion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

2. Economic Implications of Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2483. Common Themes for National Suicide Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2494. National Suicide Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2495. Discussion and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

Suicide is a global phenomenon. It is estimated that 0.5–1.2 million people worldwide die by suicide eachAbstractyear. Taking into account the global epidemiologic data concerning suicide and the economic impact of thisphenomenon on diverse societies, this review aims to examine national suicide prevention strategies. Recogni-tion of suicide as an international public health problem, increased reporting by countries on suicide rates to theWHO, and recognition of the costs (associated with suicide) to society have been crucial influences on theestablishment of national strategies. Past reviews on national suicide prevention strategies highlight the fact thatthose countries with established national strategies share a number of themes relating to intervention. These aregrounded in international guidance on suicide prevention and accepted epidemiologic and treatment-basedresearch. This paper highlights comparative rates of suicide around the world, explores the economic implica-tions of suicide and the nature of specific established national strategies for prevention. This paper highlights theurgency for the development of national suicide prevention strategies in all countries. Clearly, countries canlearn from each other and integrate established, shared themes. It is argued that nations need to move towardsnation-specified prevention strategies with effective structures for research, monitoring, and evaluation. This hasbeen seen in countries such as Finland and New Zealand, where strategies have been effective in buildinginter-agency working and so benefiting different stake-holders.

Suicide is a global phenomenon. It is estimated that between tries.[1] This increase is reflected in the escalation of global suicide500 000 and 1.2 million people worldwide die by suicide each rates reported by WHO.[2] Figures reported by WHO note a 60%year,[1] resulting in substantial personal, psychological, social, increase between 1950 and 1995 from 10.1 per 100 000 populationpolitical, cultural, and economic impact on societies. A number of to 16 per 100 000 population. This rise has to be examinedgovernments across the world have developed suicide prevention carefully. In 1950, the figures were based on information from 21programs, at least partly in response to the marked increase in countries but gradually increased over subsequent decades, withsuicide among young people (particularly men) in different coun- 105 countries reporting on rates of suicide in 1995. Such an

246 Anderson & Jenkins

improvement in the number of countries reporting suicide may New Zealand). The ‘old world’ cluster included nations that hadhave an impact on the increase in recorded suicides worldwide. shared characteristics and the ‘new world’ cluster of nations hadThe increase may also be related to the disbanding of the USSR (in briefer histories, large distances between communities, indigenous1991), after which time some of the former Soviet Republics populations, climatic extremes, and other similarities, such as(some indicating the highest rates of suicide in the world) began to firearm ownership. The data underpinned the hypothesis thatsupply individual reports, thus inflating the global rate. However, suicide rates would be very similar in all eight nations. However,the distribution of global suicide rates grouped by age and sex does when comparing countries in clusters, similarities and dissimilari-highlight an increase in most age groups for men compared with ties appeared. It is evident that many of these dissimilarities arethose age groups for women.[2,3] determined by continued cross-national differences, such as tradi-

tions, customs, religions, social attitudes, and climate.[5]Although the increase in suicide rates globally has led to arecognition of the need for national policies, ‘prevention’ in vari- It is possible to observe other variations in Western worldous nations may seem to range from prevention of all suicides to a countries. For example, in Southern Europe, suicide rates amongclear acceptance of an individual’s right to take his or her own life. men are low within countries in this location (figures taken forThe world faces a whole spectrum of issues including: the exis- early to mid 1990s).[5] Portugal has a rate of 12.3 per 100 000tence of suicide bombers in Israel; the question of an individual’s population, which is slightly higher than Italy, with 12.1 perright to take their own life in the face of a degenerative disease; 100 000 population. Greece has 5.5 per 100 000 population andand physician-assisted euthanasia. This paper does not address Spain has 11 per 100 000 population. Overall, Western Europeanthese wider issues, but focuses on preventable suicides. A starting countries show a higher rate of suicide than those in Southernpoint is to recognise the argument that any planned local, national, Europe. The Netherlands reported a rate of 14.3 per 100 000 of theor international intervention is dependent on the attitudes of a population. The suicide rates in Switzerland and Austria at thissociety toward suicide as a phenomenon. point were 30.9 per 100 000 population and 33 per 100 000

population, respectively. These countries share similar culturalfactors and economic backgrounds, and, therefore, suicide rates1. Suicide as a Global Phenomenonacross ages tend to be the same. West Germany, with a rate of 22.9per 100 000 population, showed similar trends in rates to other

1.1 Overview of Suicide Rates in Different CountriesEuropean nations. Suicide rates in Scandinavian countries, withthe exception of Finland (43.6 per 100 000 population), wereEpidemiologic research has contributed a great deal to ourlower than in Western Europe.[2,5] In England and Wales, theunderstanding of suicide and related diseases and has underpinnedsuicide rate peaked at around 12.5 per 100 000 population in theinvestigations on the efficacy of preventative strategies. Theearly 1990s. During the same period, a higher suicide rate wasknowledge gathered from this work has aided the development offound in Scotland (22.0 per 100 000). Also at this time, the suicideapproaches in the reduction of mental health problems and suicide.rates in Ireland and Northern Ireland were 13.0 per 100 000This has led to various nations paying closer attention to those riskpopulation and 12.0 per 100 000 population, respectively.[7]

factors which might be linked to increased rates of suicide.[4] Themove from a classical infective disease model of health/illness to abroader concept of public health, integrating behaviors such as 1.2 Specific Variations in Suicide Rates According to Ageinjury and suicide, has facilitated the development of programs to and Sexdeal with such issues.

The suicide rates in ‘new world’ countries show similarities toEpidemiologic accounts of suicide offering information onthe rates found in the UK, the rates among men in new worldrates in diverse nations indicate that Eastern European countriescountries were nearly double those found in men in the UK, acrosshave higher suicide rates than Western Europe and have increasedall age groups.[8]steadily, particularly between 1987 and 1992.[5,6] Cantor[5] recog-

nized the need to look at suicide rates in nations with similarities to Male suicide rates are high in Russia, Belarus, Ukraine, and thegain an insight into national trends. Cantor’s[5] study examined other Baltic countries. These rates increased during the 1990s andeight English-speaking nations and discovered similar rates of now represent the highest in the world.[9] In Finland, individualssuicide between countries in the years between 1960 and 1989. aged 35–64 years appear to be at a higher risk for committingThese nations were divided into two clusters (two clusters of four suicide, with a much higher risk among men than for womennations): ‘old world’ (England and Wales/Scotland/Northern Ire- within this age group.[5] In contrast, in Sweden, there appear to beland/Ireland) countries; and ‘new world’ (USA/Canada/Australia/ higher rates among older (aged 50–75+ years) men and women in

© 2005 Adis Data Information BV. All rights reserved. Dis Manage Health Outcomes 2005; 13 (4)

National Strategies for Suicide Prevention 247

comparison with other age groups.[5] Suicide was clearly an older land, which is also a Buddhist country.[11] The WHO reports aage group (50–75+ years) problem in England and Wales in steady upward trend in the suicide rate in India from the 1980s1950.[2] The male suicide rates for those aged ≥65 years were onwards; indicated by a 41% increase between 1980 and 1990 andcomparable to countries with the highest suicide rates in the a 39% increase between 1985 and 1995.[2]

world.[2] By 1995, England and Wales witnessed a shift in the In the 1990s, the suicide rate in Japan showed an increase fromdirection of suicide, with it becoming a younger age-group prob- 18.8 per 100 000 population (26.0 per 100 000 population for menlem. The rates of suicide for young men in England and Wales in and 11.9 per 100 000 population for women) in 1997 to 25.4 perthe 15–34 years-of-age band had more than doubled.[2] In New 100 000 population (36.5 per 100 000 population for men and 14.7Zealand, there is also a high rate of suicide among 15–24 and per 100 000 population for women) in 1998.[13] The rise in the25–34 year olds, with a marked risk of suicide for men in the suicide rate in Japan may be related to more pervasive social15–24 years bracket.[8] In New Zealand, there was an increase in isolation than in the past and to an absence of personal spiritualthe total population suicide rate between 1975 and 1995, which development compared with financial success.[13] Moreover, thewas almost entirely accounted for by the increase in male youth decade-long depression of the Japanese economy may have had asuicide. These suicides also accounted for the increases in rates of strong influence on the suicide rate, especially in middle agedsuicides by hanging and, to a lesser extent, vehicle exhaust gas.[10] men.[13]

In New Zealand, the suicide rates among the group aged 15–24 A recent study has provided an overview of the suicide rate inyears have declined in recent years, which would impact on the China.[14] Philips et al.[14] took suicide rates for 1995–1999 byoverall suicide rate. Yet, young people still have higher rates of 5-year age group, sex, and region (grouping the regions as rural orsuicide than other age groups.[8] In Australia, the male to female urban). These statistics, provided by the Chinese Ministry ofratio for suicide increased from 2.9 : 1 in 1950 to 4.3 : 1 in 1995.[2]

Health, were adjusted first for any regions that were not represent-ed by projecting the sex, age, and region-specific mortality rates in

1.3 Examples of Variations in Suicide Rates According tothe vital registration data for each year to the total population for

Culture and Religioneach year reported by the Statistics Bureau. The rates were thenadjusted for general unreported deaths, which were obtained byThere are significant variations in suicide rates among Asiancomparing information from the Ministry of Health vital registra-populations, in particular China (where there have been sharption system and Statistics Bureau data on mortality estimates. Theincreases in suicide), and Far Eastern countries.[11] The range instudy estimated an annual suicide rate of 23 per 100 000 popula-rates for these countries spans from below 1.0 per 100 000 popula-tion and a total of 287 000 deaths by suicide per year. Suicidetion in countries such as Iran, Syria, Kuwait, and The Philippinesaccounted for 3.6% of all deaths in China and was the fifth mostto the much higher rate of 47.3 per 100 000 population in Sriimportant cause of death. Suicide was found to be the leadingLanka. Indeed, Sri Lanka has experienced a nearly 8-fold increasecause of death in young adults aged 15–34 years, accounting forin the incidence of suicide over the past 50 years (in 1950 the rate19% of all deaths. A particularly significant finding was thewas 6.5 per 100 000 population). Thailand has also witnessed andifferences in the size and direction of the sex ratio and rural urbanupward trend in suicide, with a 66% rise between 1960 (3.5 perratio.[15] The rate in women was 25% higher than in men, mainly100 000 population) and 1985 (5.8 per 100 000 population). Tobecause of the number of suicides in young women in rural areas.some extent, these differences may be explained by differences inRural rates were 3-fold higher than urban rates. These findingsreligion. That is, a study identified two clusters of variablescontrast sharply with the rates reported in Western countries.[14]associated with national suicide rates; one cluster had the highest

loading (meaning a lower suicide rate) from Islamic religion and Specific reasons for increases in suicide by women might bethe second cluster seemed to assess economic development.[12] that the act constitutes a traditional coping and revenge strategy forTherefore, low rates of suicide in Islamic groups could be associat- women in Chinese society. This may be connected to women’sed with the Islamic religion, which places heavy sanctions against lower social status in the family, the one-child policy, and lack ofsuicide. Sri Lanka is a multi ethnic/cultural country and a large control over their own lives.[11] Other factors relevant to theproportion of the inhabitants are Sinhalese, most with Buddhism suicide rate in rural areas of China might be that such regions oftenas their religion. In 1995, the estimated rates of suicide show a do not have sufficient psychiatric and medical services. There isslight over-representation of Sinhalese and an under-representa- also evidence from other Asian countries to suggest that risk oftion of Tamil people committing suicide.[11] Although Buddhism suicide among young women in rural areas might be linked to themay appear to be associated with suicide in Sri Lanka, this religion ready availability of pesticides that are potent poisons. Thus, whatcannot account for the much lower incidence of suicide in Thai- may have been an impulsive suicidal gesture becomes a completed



suicide.[15-17] Indeed, the National Institute of Mental Health states disability, important results appear for suicide. Intentional injuriesthat suicide methods differ between men and women and that account for 4.1% DALYs lost worldwide and this statistic is thewomen in all countries are more likely to ingest poisons than same in both developing and developed countries. Self-inflictedmen.[18] Epidemiological studies have found that rates of at- injuries are 17th in the rank ordering for the world as a whole,tempted suicides are higher in women than in men;[19-21] however, accounting for 1.4% of DALYs lost.[4] They are ninth in developed“in countries where poisons are highly lethal and/or treatment countries, accounting for 2.3% of the total, and 19th in developingresources are scarce, rescue is rare and hence completed suicides countries, accounting for 1.3% of the total. In the group agedby women outnumber those of men”.[18] The high rates of suicide 15–44 years, self-inflicted injuries are the fifth highest causeamongst Chinese women may also reflect the considerable stresses accounting for 3.5% of DALYs lost, ranking higher in the devel-arising alongside the social, cultural, and economic changes that oped regions of the world. The proportion of mortality fromChina has undergone in recent times. Such changes appear mainly injuries overall is expected to rise from 10% in 1990 to 12% inin rural areas.[14]

2020 and self-inflicted injuries shift from 12th to 10th on theThese epidemiologic data provide an overview of suicide as a potential causes of death.[4] In essence, >1.4 million people com-

global phenomenon. The impact of suicide in every country brings mitted suicide in 1990, accounting for approximately 1.6% of thesignificant personal loss for all involved. In addition, suicide world’s mortality in that year.[4]

presents considerable costs to healthcare systems and society inInevitably, suicide mortality has become a major cost not only

general, which need to be considered in the planning of nationalto the health sector but also to society as a whole, partly because of

suicide prevention strategies.premature loss of life, and also because of increased costs, whichcan be expected in the provision of medical (including accident

2. Economic Implications of Suicide and emergency services), surgical, mental health, and rehabilita-tive services for people engaging in non-fatal suicide attempts.

Suicide is a major public-health problem, particularly in thoseThis includes the costs resulting from increased use of primary

countries with high suicide rates. In addition to the tragedy of acare and specialist services and the costs of the necessary basic

loss of life, suicide may also result in the loss of a breadwinner andtraining and continuing education programs for health profession-

parent for a family, long-lasting psychological trauma for children,als. The economic cost of self-harm is significant for health

friends, and relatives, and the loss of economic productivity for theservices. A study carried out in England revealed estimated direct

nation for example, through increased sicknesses and work ab-hospital costs of self-poisoning to be £425 per episode

sences.[15]

(1992–1993 values).[22] This average cost may vary depending onEconomic changes within a country can be related to increases

the economic conditions. For example another study carried out inin suicide. A comprehensive review of the relationship between

England suggests that it is expensive to provide psychosocialsuicidal behavior and the labor market is available.[16] Many

assessments and even more so to admit people who have taken anstudies carried out in Western countries show that there is an

overdose to medical beds.[23] Therefore, if specialist services areincreased risk of suicide and self-harm among the unemployed,

offered and the majority of patients are admitted to hospital, thewhich corresponds with the increases in male suicides in Western

cost is similar to that reported above – approximately £400 percountries. There is no strong evidence to indicate that rises in

episode of self-harm (1997–1999 values).women participating in the labor force have led to increasedThere will be loss of productivity for those engaging in suicidalsuicide rates in both men and women. The risk of suicide and self-

behavior and those people affected by it (other family members).harm are inversely related to social class (the lower the social classMany of those who die by suicide may have experienced signifi-the higher the suicide rate). In relation to occupational groups,cant mental health problems preceding the final event. This maythose exhibiting the greatest proportional mortality ratios for sui-have made them unable to work. Finally, but in no way equal to thecide are found in professional (class I) and managerial and techni-personal loss of suicide, is the economic impact of bereavement.cal (class II) occupations and people working in medical and alliedFamily and friends of people completing suicide or attemptingprofessions.[16]

suicide often require subsequent psychological and emotional helpAlthough economic conditions can have an effect on the direc-themselves. Again, the economic cost of suicide is increased post-tion of the suicide rate itself, there is a significant economic cost ofevent, with an added requirement of services to offer care andsuicide to society and healthcare service. In terms of disability-treatment to maintain the mental health of those bereaved byadjusted life-years (DALYs), which is a composite measure ofsuicide.[24]time lost as a result of premature mortality and time lived with



It is important to acknowledge that the costs and consequences mental health problem.[29,30] Secondary prevention involves theof intervention are not incurred by the health service alone and identification and intervention with a wide range of individuals,tend to involve other government departments/sectors. So social, many of whom may never commit suicide. This entails the trainingeducational, judicial, and non-statutory agencies will be involved of frontline general practice, mental health, and emergency health-in the overall economic cost of the event of suicide. The financial care professionals. Those charged with the duty of commissioningimplications of suicide and self-injury for any country is impor- and budgeting of services may not consider this to be an economictant, particularly when there are calls for all nations to develop priority. However, it is argued that early treatment offers financialnational prevention strategies. as well as health benefits.[33]

Tertiary prevention encompasses people who present obviousconcerns relating to suicidal behavior. This population constitutes3. Common Themes for National Suicidepeople who have already attempted suicide and those peoplePrevention Strategiesaffected by the death of others, including family, friends, andsurvivors.[29]The WHO has recognized suicide as a key phenomenon within

the public health arena.[25] Subsequently, it publicized guidelines4. National Suicide Prevention Strategiesto member states to facilitate and co-ordinate comprehensive

national and international strategies. The recommendations to theThere are a number of factors that appear to have immediate

respective states were as follows:relevance to national suicide prevention strategies. General popu-

1. To recognize the problems as priority in public health;lation strategies in their evolution have come to focus on the

2. To develop national preventive programs, interlinked totreatment of depression. Further to this, there has been growing

other public health polices where possible; andrecognition of the role of alcohol and other substance misuse in the

3. To establish national coordinating communities.[26]progression toward suicide. This is backed up by established and

The United Nations suggested five main components as guide- convincing evidence that suicides rarely occur without the pres-lines on the content of National Suicide Prevention Strategies. ence of depression or some other form of breakdown in mentalThese were an open government policy, a coherent model for health.[9] What is also apparent is that interventions in variousprevention of suicidal behavior, general aims and goals, measura- countries share common themes within national suicide preventionble objectives, monitoring, and evaluation.[4,27]

strategies. These themes are detailed in table I.A traditional model of prevention is described by Caplan[28] and The review carried out by Taylor et al.[25] in 1997 highlights the

involves primary, secondary, and tertiary prevention.[28-30] A con- level of global suicide prevention policy development. There are atemporary explanation of the three concepts is offered in the number of nations with now comprehensive strategies sharing thecontext of a public health model.[31] Initially, primary, secondary, common themes highlighted in table I. These include Finland,and tertiary prevention was developed for diseases with clear Norway, Australia, Sweden, Slovenia, Denmark, Ireland, England,onsets followed by early and later phases. Primary preventiontargets populations, not individuals. When it is applied to anuncommon condition or behavior (with a fatal outcome), it musthave reduced potential to harm and be economically viable. It alsohas to be appropriate and acceptable to the population. Awarenessprograms on suicide as examples of primary prevention strategiesimplemented in schools have been found to fail the above require-ments. One particular review revealed that American states withschool suicide awareness programs experienced increased suicidetrends compared with those where no program was in place.[32]

However, teaching of coping and relationship skills does appear tobe favored in policy and practice. Primary prevention may befocused on modification of environmental factors, for exampleenhanced social support,[33] and may be focussed on particularsettings, such as prison environments.

Secondary prevention includes the early treatment of all indi-viduals at risk of harming themselves and people with an identified

Table I. Themes used in comprehensive national suicide prevention strate-gies

Public education

Responsible media reporting

School-based programs

Detection and treatment of depression and other mental disorders

Attention to those abusing alcohol and drugs

Attention to individuals experiencing somatic illness

Enhanced access to mental health services

Improvement in assessment of attempted suicide

Postvention

Crisis intervention

Work and unemployment policy

Training of health professionals

Reduced access to lethal methods



and New Zealand (suicide prevention strategy for youth suicide The Finnish suicide prevention strategy outlines six recommen-only).[34] Countries with national preventative programs, again dations that are set out for intervention in suicide prevention.with some of the shared themes, included The Netherlands, the Additional recommendations have also been prepared for youngUSA, France, and Estonia. Those without explicit national action and older (50–65+ years of age) people. Health professionals arewere Japan, Denmark, Austria, Canada, and Germany.[34] expected to build an understanding of each for the purposes of

assessment and future care. The following is a list of six recom-The UN guidelines[27] were established as a template for coun-mendations.tries to follow. Finland was the first country to implement the1. Focus on the requirement that life circumstances of an individu-guidelines; therefore, this review will attend to this strategy inal after a suicide attempt should be investigated and the appropri-more detail. The Finnish strategy was initiated by a nationalate treatment/care implemented.research project, which included an audit of suicides occurring in

Finland and, subsequently, evaluated by reviewing the 1397 sui- 2. Focus on awareness of the relationship between life events,cides between 1986 and 1996.[35] Following the 1986 audit, Fin- problems, and intoxication with substances.land set out their assumptions and principles of suicide prevention. 3. Focus on the higher risk among people who may be experienc-These assumptions were that suicide tends to include a cumulative ing mental health problems.effect of life events and burdens, which sometimes endure over the

4. Focus on building awareness of the fact that significant physicalspan of an individual’s life. Such burdens can build up into

illness and disability can be predisposing factors to depression.insurmountable problems and lead to suicide, which may not be

5. Focus on situations when a person faces a crisis, which haveexpected or predicted by friends, neighbors, or colleagues. The

culminated over a period of time.risk factors can be understood as either antecedent or precipitat-

6. Focus on ensuring that professionals are perceptive of the facting.[27] With these assumptions in mind, the subsequent approachthat many people who engage in suicidal behavior come fromto suicide prevention in Finland focussed on the need to helpunderprivileged backgrounds.[4]

people identify their own and other resources in specific stages ofSome of the common themes of suicide prevention strategieslife and so incorporated four stages.

(outlined in table I) have been incorporated in comprehensive1. Prevent suicide from occurring.national strategies. Norway proposes education programs on tele-

2. Prevent problems from becoming worse and becoming insur-vision and radio to combat the stigma of suicide, whereas Finland

mountable, e.g. by supporting resources.has set up a system of primary mental health promotion as part of

3. Prevent those circumstances that lead to problems. public education.[4] Norway and Finland include steps relating to4. Teach individuals to manage their own lives, while providing representations of suicide in the media. England and New Zealandalternatives and support.[4,31] have included a specific goal to improve the appropriateness of

media reporting of suicidal behavior.[4,8,32]The Finnish government believed that the suicide rate could bereduced if: Detection and early treatment of depression are recognized as

fundamental elements of all strategies. In England, and, subse-• everyone who attempts suicide receives effective help as soonquently, Australia and New Zealand, governments have used theas possible;approach of setting specific national targets for mental illness and• depression is recognized and the individual is offered all thesuicide rates.[36-39] Active programs to detect depression have beensupport he/she requires; everyone experiencing serious depres-undertaken in a number of countries, including the USA andsion should get appropriate and effective treatment;Canada.[4] Improved mental health services as part of the national

• alcohol can be prevented from being used as a universal solu-strategy have been implemented in England and Australia.

tion to problems and find better means of support to cope better;Assessment of suicidal behavior is a major issue and has led to

• mental and social support is enhanced within the treatment ofguidelines being incorporated in all national strategies. Australia,

somatic illness;Finland, England, and also New Zealand, with the youth suicide

• a person in a life crisis receives appropriate support from prevention strategy, have included steps and guidance on howrelatives and friends and professionals when necessary; people who engage in suicide attempts are to be assessed.[4] In

• the risk of young people becoming alienated from life can be particular, developments are targeted on procedures and servicesavoided and individuals can be offered ways of coping; for people presenting at casualty/emergency services with mental

• the cultural climate in the Finnish education system becomes health problems, and/or episodes of self-harm or substance mis-more relaxed, less guilt promoting, stigmatizing, and punitive. use. This is linked to increased awareness that there is a considera-



ble overlap between completed suicide and suicidal behavior. improved for young men and greater availability of family coun-Alongside this is the acknowledgment of high-risk groups (Fin- seling is advocated in the Finnish strategy. Clearly, there is a needland and England are clear examples) and the high prevalence of a to ensure that effective, responsive, and accessible services arerange of deliberate self-harm and risk-taking behaviors.[39] The developed for people experiencing mental health problems andevidence that the risk of suicide escalates in the 12 months after a who display suicidal behavior.[8]

suicide attempt alone underpins the reason for explicit aims and The recommendations in the Finnish strategy did not empha-guidance within national strategies.[40] size reducing access to the means of suicide, tackling facilitating

risk factors such as alcohol, or supporting high-risk occupationalAll countries with comprehensive strategies include postven-groups, although some attention was paid to these issues as thetion activity in which counseling and support for relatives andstrategy evolved.[35] The focus of attention in initiatives tend to befriends of suicide victims are recommended. England and Austra-on changing means of obtaining/gaining opportunity to certainlia include such an approach.[8,36] Norway has extended such workmethods, such as reducing hanging and strangulation in hospitalto provide outreach services. Finland has carried out extensiveand prison settings. However, it can be argued that reducing thework on developing crisis intervention services, for those who areavailability and access to lethal methods of suicide is a priority fordealing with unemployment or a family crisis related to the deathall countries. This is an area of work in which there is a consensusof a relative or friend from suicide.[4,35] There is a strong recom-that the government may have a role in a population-based ap-mendation in the strategy for England that crisis intervention andproach – developing policy on the means of suicide.[4] There hasprompt access to services should be established. The strategy alsobeen acceptance by governments of the need for the introductionfocuses the promotion of mental health among those who misuseof catalytic converters in motor vehicles to lower the risk ofdrugs or alcohol, both in accident and emergency departments andmorbidity and mortality associated with exhaust gas inhalation.[36]secondary services for such people. Young people and school-Other polices include policies relating to access to prescription andbased work are also included in the strategy for England, includingnon-prescription drugs and the availability of toxic substances andmapping out ways to promote mental health in schools.[32]

pesticides. Australia has imposed restrictive legislation on theUnemployment stands in its own right as a significant area to beavailability of barbiturates. In England, maximum pack size foraddressed within national suicide prevention strategies. New Zea-over the counter sales of paracetamol (acetaminophen) and aspirinland and Finland offer specific recommendations on unemploy-(acetylsalicylic acid) was reduced to 32 for pharmacies and 16 forment, and both countries wish to increase work opportunities forother outlets. This appeared to have led to an initial fall inyoung people.[8,35] Finland has aimed to help people retain theiroverdoses involving this method of self-poisoning.[36]

working capacity alongside supporting them in developing theircoping abilities.

5. Discussion and ConclusionsTraining is endorsed by all of the countries with comprehensivestrategies; however, the target group tends to vary. Finland singles

Suicide is clearly a major global concern. The direct andout health and welfare staff for training. New Zealand’s youthindirect costs of suicide have a huge economic impact on manyprevention strategy includes a range of professionals:countries. The economic burden of suicide is much more complex• community personnel, which includes clergy, teachers, coun-than simply the loss of productive years from premature death.selors, corrections staff, youth workers, and police;One quantifiable cost for service commissioners is the care provid-

• primary health professionals, including general practitioners,ed for people who self-harm. Such patients are regarded as high

midwives, public health nurses, practice nurses, Maori healthrisk and are often prioritized in national strategies, yet service

workers, and Pacific Island health workers;managers might be reluctant to advocate for investment in a

• mental health professionals, including those who work in resi- comprehensive self-harm service in general hospitals. On the otherdential, community, and inpatient services; hand, the financial cost of providing comprehensive and planned

• emergency department professionals.[8]services is possibly less than providing disjointed and disorga-

Norway has included a similar range of professionals for train- nized services, but also essential on public health grounds givening.[4] Much of this education is concerned with early case finding the growing size of the problem.[23]

and identification of individuals at risk, although most include The implications of suicide have to be looked at – not just intraining for doctors in the management of depression. terms of the costs of service provision, but also with regard to the

Access to appropriate mental health services is advocated in all costs incurred to those bereaved by suicide. Various countries nowestablished strategies. In England, access to services is to be have comprehensive national suicide prevention strategies (Fin-



land, New Zealand [for youth only], England, Norway, Australia, These are healthy developments for such nations but there isconcern for countries without established strategies, such as ChinaSweden, Slovenia, Denmark, and Ireland) and others are providingand those in the Far East. Evidently, suicide is a major publicpreventative programs (The Netherlands, the USA, France, andhealth problem in China that is only gradually being recognized.Estonia). In terms of the effect of suicide strategies on stakehold-Controversy over the overall suicide rate may delay the develop-ers (patients, healthcare providers and commissioners), it is evi-ment of specific suicide-prevention programs for China.[14] How-dent that there will be differences for countries with comprehen-ever, The Ministry of Health, in collaboration with the WHO, heldsive strategies and those with preventative programs. That is, somea workshop on suicide prevention in March 2000, which can becountries will have strategies that are not the exclusive responsi-regarded as the first move towards the establishment of a nationalbility of any one sector of society or health service. For example,strategy.[41] The workshop identified the unique characteristics ofmental health services have a crucial part to play in suicidesuicide in China and highlighted the need to test the feasibility ofprevention but a high proportion of people who commit suicide areseveral different preventative steps. The workshop highlighted thenot in contact with mental health services. Such strategies can bepotential for a range of plans found in established national preven-seen as comprehensive (covering a range of healthcare services),tion programs. These plans included: ongoing public educationwhereas preventative programs may target a specific group ofprograms concerning suicide; control of access to agriculturalpeople only and possibly only within one health service sectorchemicals frequently employed in suicides; control of access to(older people or young people in primary care). In view of thedangerous medications; training individuals who come into con-complex etiology of suicide and lack of an easily identifiable high-tact with persons who are at risk of suicide; train rural doctors and

risk population that constitutes a sizeable proportion of overallemergency room physicians in emergency management of suicide

suicides, it is not surprising that individual interventions have notattempts; improved access to mental health services, particularly

been shown to reduce suicide in controlled trials. Indeed, the rangein rural areas; and the development of services in urban areas. As

of influences on suicidal behavior is beyond the capacity of ain any country, The Ministry of Health in China would at first want

single service. Preventative programs may have little demonstra-the initiative to test the cost effectiveness of a variety of such

ble benefit for stakeholders in isolation and where there is moreinterventions before they were put in place.[41]

than one program there may be duplication and conflict, leading toAn overriding conclusion is that, irrespective of the stage at

discrediting programs. Therefore, strategies should co-ordinatewhich a nation’s suicide prevention strategy is at, the national

interventions and facilitate communication between agencies.centre coordinating the strategy should undertake research to build

The comprehensive national suicide prevention program set in an evidence base. It should also consider the diverse experiencesFinland can serve as an example to many other countries without a of other countries and include relevant structures for monitoringnational strategy. The strategy with its four stages commenced and evaluation. With this approach, a nation can progressivelywith a research project evaluating the 1397 suicides that had adapt its strategies to take account of changing circumstances andoccurred in a single year. Target areas, interventions and those needs.responsible were identified. The implementation of local sub-projects involved local decision making, incorporating local infor- Acknowledgmentsmation about suicide in the area. This merging of an ’umbrella’

No sources of funding were used to assist in the preparation of this review.policy at a national level with local implementation is a particularThe authors have no conflicts of interest that are directly relevant to the

strength of the Finnish project. The significant decrease in death content of this review.by suicide over the past decade in Finland may well be attributableto this strategy.[29] It is evident that the Finnish, English, and New

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The Challenge of Suicide Prevention