Suicide prevention

Methods of intervention

Restriction of lethal means

Restriction of dangerous means ⁠— ⁠reducing the odds that a person attempting suicide will use highly lethal means ⁠— ⁠is an important component of suicide prevention. This practice is also called "means restriction". It has been demonstrated that restricting lethal means can help reduce suicide rates, as delaying action until the desire to die has passed. In general, strong evidence supports the effectiveness of means restriction in preventing suicides. There is also strong evidence that restricted access at so-called suicide hotspots, such as bridges and cliffs, reduces suicides, whereas other interventions such as placing signs or increasing surveillance at these sites appears less effective.

One of the most famous historical examples of means reduction is that of coal gas in the United Kingdom. Until the 1950s, the most common means of suicide in the UK was poisoning by gas inhalation. In 1958, natural gas (virtually free of carbon monoxide) was introduced, and over the next decade, comprised over 50% of gas used. As carbon monoxide in gas decreased, suicides also decreased. The decrease was driven entirely by dramatic decreases in the number of suicides by carbon monoxide poisoning. A 2020 Cochrane review on means restrictions for jumping found tentative evidence of reductions in frequency.

In the United States, firearm access is associated with increased suicide completion. About 85% of suicide attempts with a gun result in death, while most other widely used suicide attempt methods result in death less than 5% of the time. Matthew Miller, M.D., Sc.D. conducted research comparing the number of suicides in states with the highest rates of gun ownership, to the number of suicides in states with the lowest rates of gun ownership. He found that men were 3.7 times more likely to die by firearm suicide and women were 7.9 times more likely to die by firearm suicide living in states with high rates of gun ownership. There was no difference in non-firearm suicides. Although restrictions on access to firearms have reduced firearm suicide rates in other countries, such restrictions are difficult in the United States because the Second Amendment to the United States Constitution limits restrictions on weapons.

For those who decide to end their lives impulsively, a 24-hour waiting period for firearm access could substantially reduce suicide success rates. Contrary to the popular notion that suicidal people will simply find another way to kill themselves, many people who survive suicide attempts go on to lead long lives. "In 2023, more than 42,967 people died from gun related injuries. Over half of those deaths were suicides" in the United States.

Spiritual counseling

The majority of known religions consider that suicide is a sin (or an equivalent fault). Their priests are available to guide in this problem and their circumstances.

Psychological counseling

There are multiple talking therapies that reduce suicidal thoughts and behaviors.

In the group therapies, suicides can participate with other people (usually other patients with whom the patient of suicidal tendence would talk without major problems). The rest of the patients can have the same psychological problem or any other. A psychologist would direct the chat.

Psychotherapies that have been shown most successful, or evidence based, are dialectical behavior therapy (DBT), which has shown to be helpful in reducing suicide attempts and reducing hospitalizations for suicidal ideation, and cognitive behavioral therapy for suicide prevention (CBT-SP), a form of DBT that is adapted for adolescents at high risk for repeated suicide attempts, and has shown to improve problem-solving and coping abilities.

The brief intervention and contact technique developed by the World Health Organization has also shown benefit.

Crisis hotlines and associations that provide help

Crisis hotlines connect a person in distress to either a volunteer or staff member of an association that provides comfort and help. This may occur via telephone, online chat, or in person. Even though crisis hotlines are common, they have not been well studied. One study found a decrease in psychological pain, hopelessness, and desire to die from the beginning of the call through the next few weeks; however, the desire to die did not decrease long term.

Direct conversation for intervention

It cannot be despised that a reliable person talks directly with the person with suicidal tendences.

Some guides about conversation with suicidal patients have been distributed between people with certain probabilities to find that situation.

Caring letters

The "Caring Letters" model of suicide prevention involved mailing short letters that expressed the researchers' interest in the recipients without pressuring them to take any action. The intervention reduced deaths by suicide, as proven through a randomized controlled trial.

The technique involves letters sent from a researcher who had spoken at length with the recipient during a suicidal crisis. The typewritten form letters were brief – sometimes as short as two sentences – personally signed by the researcher, and expressed interest in the recipient without making any demands. They were initially sent monthly, eventually decreasing in frequency to quarterly letters; if the recipient wrote back, then an additional personal letter was mailed. The approach was partly inspired by Jerome Motto's experience of receiving letters during World War II from a young woman he had met before being deployed. Motto was the psychiatrist who first devised the experiment. Although the exact mechanisms have been debated, researchers generally think that the letters communicate a genuine interest and social connection that the recipients find helpful.

Caring letters are inexpensive and either the only, or one of very few, approaches to suicide prevention that has been scientifically proven to work during the first years after a suicide attempt that resulted in hospitalization.

Coping planning

Coping planning is an intervention that is based in the strengths of patient for solving the problems or at least reducing and damping their impact. It aims to meet the needs of people who ask for help, including those experiencing suicidal ideation. By addressing why someone asks for help, the risk assessment and management stays on what the person needs, and the needs assessment focuses on the individual needs of each person. The coping planning approach to suicide prevention draws on the health-focused theory of coping. Coping is normalized as a normal and universal human response to unpleasant emotions, and interventions are considered a change continuum of low intensity (e.g., self-soothing) to high intensity support (e.g. professional help). By planning for coping, it supports people who are distressed and provides a sense of belongingness and resilience in treatment of illness. The proactive coping planning approach overcomes implications of ironic process theory. The biopsychosocial strategy of training people in healthy coping improves emotional regulation and decreases memories of unpleasant emotions. A good coping planning strategically reduces the inattentional blindness for a person while developing resilience and regulation strengths.

Improval of the physical condition

According to researches, a proper diet, correct sleeping and physical exercise have a positive influence in the mood and the activity of the person.

In diet

About 50% of people who die of suicide have a mood disorder such as major depression. Sleep and diet may play a role in depression (major depressive disorder), and interventions in these areas may be an effective add-on to conventional methods.

According to Healthdirect, the national health advice service in Australia, risk of depression may be reduced with a healthy diet "high in fruits, vegetables, nuts, and legumes; moderate amounts of poultry, eggs, and dairy products; and only occasional red meat". Consuming oily fish (e.g., salmon, perch, tuna, mackerel, sardines and herring) may also help as they contain omega-3 fats. Consuming too much refined carbohydrates (e.g., snack foods) may increase the risk of depression symptoms. The mechanism on how diet improves or worsens mental health is still not fully understood. Blood glucose levels alterations, inflammation, or effects on the gut microbiome have been suggested. More information about food (e.g. oily fish with omega-3 fats, a class of PUFA), drink (e.g. water), healthy, balanced diet and mental health can be found on Healthdirect's website.

Vitamin B₂, B₆ and B₁₂ deficiency may cause depression in females.

Vitamin B₁₂, for humans, is the only vitamin that must be sourced from animal-derived foods or from supplements. Only some archaea and bacteria can synthesize vitamin B₁₂. Foods containing vitamin B₁₂ include meat, clams, liver, fish, poultry, eggs, and dairy products. Many breakfast cereals are fortified with the vitamin.

Sources of Vitamin B₂ (riboflavin):

• meat
• fish and fowl
• eggs
• dairy products
• green vegetables
• mushrooms
• almonds

Access of health professionals

Contact with health professionals is important in the fight against suicide, because it makes possible to detect suicidal intentions and attempts.

Medication

Common treatments may include antidepressants, antianxiety, antipsychotics, stimulants, mood stabilizers, and all kinds of SSRI medications. Alongside medications, a health team often includes therapy and other beneficial resources to support good outcomes for individuals and their communities.

Some antidepressant medications may increase suicidal ideation in some patients under certain conditions. Medical professionals advise supervision and communication during the usage of these medications. In case of a psychiatrist prescribes any of the medications, the problem would be taken to the field of psychiatry, with its own contexts and plannings, that are usually more rigid than those of other fields.

It is also important that, in a proportion of cases of use of drugs to prevent suicide, a "paradoxical reaction" can happen, consisting of an increase in suicidal intention, mainly on the following occasions: the beginning of the period of taking the medication, any change of dose to adjust it, and the end of its intake period (its abandonment or discontinuation). Therefore, a bigger caution is recommended at those times.

Lithium

Lithium is proven to reduce the risk of suicide in mood disorders by 87% in randomized double-blind placebo-controlled trials. Lithium has been shown to reduce the risk of suicide in people with major depression or bipolar disorder to close to the same level as that of the general population. It is thought to exert this effect by treating the underlying mood disorder and through a reduction in impulsivity and aggressiveness. In addition to its effect on suicide, lithium use lowers the risk of death from any cause in people with mood disorders. The increased presence of trace amounts of lithium in drinking water is correlated with lower overall suicide rates, especially among men.

Barriers and physical protections

Physical protection systems, such as barriers and anti-suicide nets, are sometimes installed in bridges, buildings and other dangerous points, to prevent suicides in them. The decision can be influenced by the frequent use for suicide attempts of those dangerous points, and the possibility of hurting someone else in those attempts (something very feasible if jumping from skyscrapers and similar situations). Sometimes, the problem is not a possible use of those points for suicide, but a simple lack of security in them that makes people to be involuntarily exposed to the danger of accident.

Preventive programs to reduce the cause

Some plans try to avoid suicide by avoiding previous problems that could produce it. For example: violence in a relationship, in the family, school bullying, workplace mobbing, and any other. The World Health Organization recommends "specific skills should be available in the education system to prevent bullying and violence in and around the school".

Information campaigns

Prevention of suicide also implies informing to the general public, or only to a sector, about the signs of suicide, to be able to detect them, and about the existing means of help. Informative campaigns must be correctly made to work as planned. In a review of communication campaigns against suicide, only two studies of three considered that the effect of those campaigns was positive.

Whether or not mentions of suicide increase suicidal thoughts or thoughts of self harm is dependant on the context it is mentioned in and how it is presented.

Media guidelines

Recommendations around media reporting of suicide include not sensationalizing the event or attributing it to a single cause. It is also recommended that media messages include suicide prevention messages such as stories of hope and links to further resources. Particular care is recommended when the person who died is famous. Including specific details of the method or the location is not recommended.

There is little evidence, however, regarding the benefit of providing resources for those looking for help, and the evidence for media guidelines generally is mixed at best.

TV shows and news media may also be able to help prevent suicide by linking suicide with negative outcomes such as pain for the person who has attempted suicide and their survivors, conveying that the majority of people choose something other than suicide to solve their problems, avoiding mentioning suicide epidemics, and avoiding presenting authorities or sympathetic, ordinary people as spokespersons for the reasonableness of suicide.

General strategies for society

In the United States, the 2012 National Strategy for Suicide Prevention promotes various specific suicide prevention efforts including:

• Developing groups led by professionally trained individuals for broad-based support for suicide prevention.
• Promoting community-based suicide prevention programs.
• Screening and reducing at-risk behavior through psychological resilience programs that promotes optimism and connectedness.
• Education about suicide, including risk factors, warning signs, stigma related issues and the availability of help through social campaigns.
• Increasing the proficiency of health and welfare services at responding to people in need. e.g., sponsored training for helping professionals, increased access to community linkages, employing crisis counseling organizations.
• Reducing domestic violence and substance abuse through legal and empowerment means are long-term strategies.
• Reducing access to convenient means of suicide and methods of self-harm. e.g., toxic substances, poisons, handguns.
• Reducing the quantity of dosages supplied in packages of non-prescription medicines e.g., aspirin.
• School-based competency promoting and skill enhancing programs.
• Interventions and usage of ethical surveillance systems targeted at high-risk groups.
• Improving reporting and portrayals of negative behavior, suicidal behavior, mental illness and substance abuse in the entertainment and news media.
• Research on protective factors & development of effective clinical and professional practices.

Specific strategies in society

Suicide prevention strategies focus on reducing the risk factors and intervening strategically to reduce the level of risk. Risk and protective factors unique to the individual can be assessed by a qualified mental health professional.

Some of the specific strategies used to address are:

• Crisis intervention
• Structured counseling and psychotherapy
• Hospitalization for those with low adherence to collaboration for help and those who require monitoring and secondary symptom treatment
• Supportive therapy like substance abuse treatment, psychotropic medication, family psychoeducation, access to emergency phone call care with emergency rooms, suicide prevention hotlines, etc.
• Restricting access to lethality of suicide means through policies and laws
• Creating and using crisis cards, an easy-to-read uncluttered card that describes a list of activities one should follow in crisis until the positive behavior responses settles in the personality
• Person-centered life skills training, e.g., problem solving
• Registering with support groups like Alcoholics Anonymous, suicide bereavement support group, a religious group with flow rituals, etc.
• Therapeutic recreational therapy that improves mood
• Motivating self-care activities, like physical exercise, a regular sleep schedule, and meditative relaxation

After a suicide

Postvention is for people affected by an individual's suicide. This intervention facilitates grieving, guides to reduce guilt, guides to reduce anxiety and depression, and helps to decrease the effects of trauma. Bereavement is ruled out and promoted for catharsis and supporting their adaptive capacities before intervening depression and any psychiatric disorders. Postvention is also provided to minimize the risk of imitative or copycat suicides, but there is a lack of evidence based standard protocol. The general goal of the mental health practitioner is to decrease the likelihood of others identifying with the suicidal behavior of the deceased as a coping strategy in dealing with adversity.

Legislation

Suicide is a crime in some parts of the world. However, while suicide has been decriminalized in many countries, the act is almost universally stigmatized and discouraged. In some contexts, suicide could be utilized as an extreme expression of liberty, as is exemplified by its usage as an expression of devout dissent towards perceived tyranny or injustice which occurred occasionally in cultures such as ancient Rome, medieval Japan, or today's Tibet Autonomous Region.

While a person who has died by suicide is beyond the reach of the law, there can still be legal consequences regarding treatment of the corpse or the fate of the person's property or family members. The associated matters of assisting a suicide and attempting suicide have also been dealt with by the laws of some jurisdictions. Some countries criminalise suicide attempts.

Support organizations

Many non-profit organizations exist, such as the American Foundation for Suicide Prevention in the United States, which serve as crisis hotlines; it has benefited from at least one crowd-sourced campaign. The first documented program aimed at preventing suicide was initiated in 1906 in both New York, the National Save-A-Life League, and in London, the Suicide Prevention Department of the Salvation Army.

Suicide prevention interventions fall into two broad categories: prevention targeted at the level of the individual and prevention targeted at the level of the population. To identify, review, and disseminate information about best practices to address specific objectives of the National Strategy Best Practices Registry (BPR) was initiated. The Best Practices Registry of Suicide Prevention Resource Center is a registry of various suicide intervention programs maintained by the American Association of Suicide Prevention. The programs are divided, with those in Section I listing evidence-based programs: interventions which have been subjected to in depth review and for which evidence has demonstrated positive outcomes. Section III programs have been subjected to review.

Examples of support organizations

• American Foundation for Suicide Prevention
• Befrienders Worldwide
• Campaign Against Living Miserably
• Crisis Text Line
• International Association for Suicide Prevention
• The Jed Foundation
• National Suicide Prevention Lifeline
• Samaritans
• Suicide Prevention Action Network USA
• Trans Lifeline
• The Trevor Project

Economics

In the United States it is estimated that a suicide results in costs of about $1.3 million. The loss of productivity from the deceased individual accounts for 97 percent of these costs. The remaining 3 percent of the costs were from medical expenses. Money spent on intervention programs is estimated to result in a decrease in economic losses that are 2.5-fold greater than the amount spent.