Why a suicide prevention strategy needs to include injury prevention
A version of this commentary appeared in the Winnipeg Free Press, Hill Times and Policy Options
Despite recent headlines, Canadian rates of suicide and attempted suicide have remained largely unchanged over the last several decades (11 per 100,000). What has changed is that we’ve seen increasing rates of suicide in the Canadian military recently, after stable rates for decades.
With over 40,000 Canadian soldiers deployed to the mission in Afghanistan, there has been an understandable concern about mental health problems and suicides among military personnel and veterans. Both the Minister of Defense and Minister of Veterans Affairs have rightly made suicide prevention a top priority.
The problem of suicide is not limited to the military in Canada; indigenous populations, especially in northern remote communities, have high rates of suicide.
We need a unified approach across provincial and federal sectors to reduce suicides in the military, among veterans and civilians. Here are five promising evidence-based strategies for suicide prevention.
1. Implement a National Deliberate Self-Harm Registry
The single most important predictor of future suicide attempts is a history of previous self-harm behavior. It is important to develop a confidential, administrative national registry of people with self-harm behavior, similar to the national registry created in Ireland, in order to record accurate data and to target and measure our evidence-based approaches to reduce the risk of future attempts.
2. Invest in anti-suicidal psychological treatment
For patients presenting with suicide attempts, current practices and programs focus on treating the underlying mental health problem and/or addiction. Recent work is challenging this practice by showing that there is also a need for psychological interventions that directly address suicidal behavior. Two such treatments have shown to reduce suicide attempts among people with a history of self-harm behavior — cognitive behavior therapy and dialectical behavior therapy.
Both types of therapy focus on understanding the causes of suicidal thoughts, improving coping skills in managing distressing emotions and developing careful plans to reduce future attempts. Strong investments nationally are required to increase the availability of these therapies for people with a history of self-harm behavior.
3. Reducing access to lethal means
This approach has the greatest evidence for suicide prevention worldwide. Suicide can often be an impulsive act. Access to firearms is a risk factor for suicide and is a factor in half of the completed suicides in the United States.
In the Swiss military, when access to guns was reduced, almost 80 percent of people were deterred from suicide. Although firearm related deaths are less common in Canada, 20 percent of male suicides in Canada are related to firearms.
In the UK, limiting pack sizes of Tylenol per bottle was also shown to reduce suicide. In Canada, prescription medications, especially opioids, anti-anxiety and anti-depressant medications are common causes of both intentional and unintentional deaths. Limiting access to large quantities of prescription and over-the-counter medications for people with a history of self-harm may reduce suicides and accidental deaths.
4. Accidental deaths and undetermined deaths need to be tracked with suicide deaths
Accidental or undetermined deaths look like suicides. We know that suicide rates around the world are widely underestimated, perhaps by as much as 30 percent or more. This is because it is often difficult to determine the nature of the death, and specifically whether it is definitively a suicide or an accident. Often, the case can be unclear, and the coroner classifies the death as undetermined.
There is evidence to indicate that some mechanisms of suicide are more likely to lead to the undetermined classification. In fact, in the UK, injury deaths of undetermined intent are routinely included in their suicide statistics for this reason.
5. Suicide prevention strategy should include injury prevention
We have learned that individuals dying by either suicide or by accident share many similar risk factors including male sex, younger age, being unmarried, lower education and income, impulsivity, mental health problems and addictions.
Generally speaking, prevention efforts for accidental injuries and suicide are distinct. But given the shared vulnerability of these populations along with the finding that many of the accidental or undetermined deaths may in fact be misclassified suicide deaths, a more broad approach to suicide prevention must include injury prevention.
If we really want to change the rates of suicide in Canada, we need to look at areas of medicine that have been successful in reducing mortality. For example, HIV disease prevention and cancer prevention have created national registries and invested heavily in innovative prevention programs that specifically target these deadly diseases. We need a concerted national effort that uses evidence-based strategies to specifically target suicidal behavior.
Jitender Sareen is an expert advisor with EvidenceNetwork.ca, professor of psychiatry at the University of Manitoba and team leader of the Manitoba Population Mental Health Research Group.
Cara Katz is a junior researcher with the Manitoba Population Mental Health Research Group and a Psychiatry resident at the University of Manitoba.