Giving support to a suicidal personBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5680 (Published 18 October 2011) Cite this as: BMJ 2011;343:d5680
- Anthony F Jorm, professorial fellow,
- Betty A Kitchener, senior lecturer
- 1Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Parkville, Vic 3052, Australia
Despite the substantial contribution of suicide to the worldwide burden of disease, evidence on effective preventive strategies is limited. A systematic review concluded that the only two strategies with convincing evidence were educating doctors about how to recognise and treat depression and restricting access to lethal methods.1 Another strategy that was promising and needed further testing was gatekeeper training. This type of training teaches particular groups of people how to identify those at risk and refer them for treatment.2 Most gatekeeper training is aimed at health professionals or others involved in human services such as teachers, police, or clergy. However, it has been suggested that family and friends may make better gatekeepers because they have the greatest contact with the suicidal person.3
In the linked qualitative study (doi:10.1136/bmj.d5801), Owens and colleagues present findings on the potential role of family and friends as gatekeepers.4 The authors carried out open ended interviews with family and friends of 14 people who had completed suicide and analysed the data for three main barriers to recognition of suicidal distress and intervention to help the person. The first barrier was that the person who had completed suicide had difficulties in communicating distress, either by not expressing their distress or giving ambiguous signals. This finding shows that members of the public need greater awareness of the warning signs of suicide. The American Association of Suicidology has published a consensus set of warning signs that show how varied the presentations may be.5 People at risk may not necessarily express suicidal feelings or actions, hopelessness, or distress. Other signs include risky behaviours, increasing use of alcohol or drugs, withdrawal from family or friends, rage, and dramatic changes in mood. Evidence exists that making members of the public aware of these warning signs can increase their ability to recognise that a person is suicidal.6
The second barrier involved difficulties in interpreting and heeding distress signals. This could occur, for example, if family members or friends had problems of their own that preoccupied them, if they normalised the signals they saw and explained them away, or if they thought the person was not the type to attempt suicide. The essence of this barrier seems to be too high a threshold for taking concerns seriously, with more concern with false positives than false negatives. The message that needs to be promoted to the public is that all thoughts of suicide need to be taken seriously and that “watchful waiting” is not an appropriate strategy.
The third barrier involved difficulties in taking action. Such difficulties included a reluctance to raise the topic of suicide, to involve others in the social network, or to encourage seeking professional help. Evidence from community surveys also supports the finding that members of the public are reluctant to ask about suicidal feelings.7 However, guidelines for the public on how to help a person who is suicidal, which are based on the consensus of both mental health professionals and people who have been suicidal, state that explicitly asking the person about suicidal feelings is the right thing to do.8 Despite fears that this might cause harm or even “put the idea in the person’s head,” evidence shows that asking about suicidal feelings does no harm and, if anything, reduces the person’s distress.9
The reluctance to involve others when someone expresses suicidal feelings is understandable, given concerns about confidentiality. However, again there is clear guidance from experts. Mental health professionals and people who have been suicidal agree that telling others is appropriate if the suicidal person is involved in the decision, and that it is never appropriate to promise to keep a person’s suicidal plans a secret.8 Furthermore, the involvement of a professional provides the opportunity for the person to get treatment, and there is evidence that treatment of suicidal patients in primary care can reduce suicide.1 Thus, the benefits of asking a person if they are feeling suicidal and involving others who could help need to be widely promoted to the public.
Owens and colleagues see these barriers as a challenge for efforts to train family and friends in how to handle suicidal crises. However, their evidence comes from family and friends who had received no information or training and who had lost a loved one to suicide. Fortunately, most people who feel suicidal do not act on these feelings,10 and an interesting complementary study would be to find out whether actions by family and friends had any positive influence in these cases. Such findings could inform public information campaigns and training programmes. Ultimately, however, large scale controlled trials are needed to assess whether greater public knowledge about how to support a suicidal person has a positive effect on suicidal behaviours.
Cite this as: BMJ 2011;343:d5680
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.
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