A national target for reducing suicideBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7152.156 (Published 18 July 1998) Cite this as: BMJ 1998;317:156
Important for mental health strategy as well as for suicide prevention
- Keith Hawton (), Professor of psychiatry.
The mental health target in the green paper Our Healthier Nation is “to reduce the death rate from suicide and undetermined injury by at least a further sixth (17%) by 2010, from a baseline at 1996.”1 The former government's Health of the Nation strategy included two suicide targets—namely, a 15% reduction in the overall suicide rate and a 33% reduction in the rate in the severely mentally ill.2 The initial suicide targets were controversial, argument centring on the advisability of a target for a relatively uncommon event (about 5000 suicides and open verdicts each year in England and Wales), the difficulty of predicting suicide, and the pressure the targets might place on psychiatric services. Nevertheless, the overall suicide rate has declined since the original targets were set. Most importantly, the previous rapid rise in suicides in men aged 15-44 years has started to reverse.1 Why do we still need a suicide target and can suicide rates be reduced further?
Suicide is usually the tragic end point of various possible pathways, influenced by mental ill health and psychological, socioeconomic, familial, interpersonal, and genetic factors. Media influence and the availability of means of suicide also seem to be important.3 These pathways embrace many factors relevant to mental health in general, and a suicide target is therefore a valuable peg for a range of mental health strategies. Suicide prevention is not, however, solely the concern of mental health services. Some two thirds of all people who commit suicide have not received specialist psychiatric care in the year before death.4
A focus on suicide is directly relevant to mental health strategy in primary care, especially improved detection and treatment of depression, even if general practitioners rarely experience suicide in one of their patients. Moreover, it is directly relevant to social health and economic policy. Lastly, it is a solid target that will keep mental health in the forefront of planning about health care and prevention of ill health. The difficulty of measuring the third Health of the Nation mental health target—namely, improvement in the health and social functioning of the mentally ill (and indeed the second suicide target2)—should warn against having another target that lacks hard longitudinal data. While a target related to effective detection and treatment of depression might seem ideal, given the incidence of depression and its consequent disability, it is difficult to imagine what this might be. An unmeasurable target could harm mental health strategy.
If the suicide target is retained in the forthcoming white paper how might it be achieved? Pinpointing factors that have contributed to the recent decline in the suicide rate is not easy. Nevertheless, the management of patients with psychiatric disorders has improved in terms of clinicians maintaining continuity of care through the care planning approach and in the development of more effective medication for schizophrenia and safer antidepressants. The presence of a suicide target has certainly helped keep risk assessment at the forefront of clinicians' minds. One way of refining prevention efforts would be to target specific groups of individuals at risk.
Three immediately come to mind. Firstly, the rate of suicide in young men is nearly double what it was 10-15 years ago. Creative strategic planning is necessary to tackle the anomie and substance abuse that afflict many young men today, especially in socioeconomically deprived groups. Secondly, patients who deliberately harm themselves have a risk of suicide some 100 times that of the general population,5 and 20-25% of people who die by suicide have presented to a general hospital after episodes of self harm in the year before death.4 Yet despite the availability of guidelines,6 the quality of general hospital psychiatric services for these patients remains variable and often inadequate.7 When many people who will commit suicide are presenting to clinical services this must be a focus for improvement, even if demonstrating effectiveness in terms of suicide prevention is difficult.3 The third group comprises patients with mental illness: virtually every psychiatric disorder carries a raised risk of suicide. Further developments in mental health services must, however, be introduced in ways that encourage clinical creativity and competence without adding to the stifling sense of medicolegal liability that afflicts many clinicians in psychiatry today.
Effective suicide prevention should combine population strategies with those aimed at high risk groups.8 Population strategies should include restricting the availability of means of suicide, since reducing availability does seem to reduce risk3;standards for media reporting and fictional portrayal of suicides; and, possibly, school programmes for equipping youngsters with effective problem solving skills and helping staff to detect those at risk of mental health problems and self harming behaviour.9 Finally, while showing the effectiveness of crisis intervention helplines such as the Samaritans is difficult, the Samaritans should continue to receive support. Recent efforts to extend the availability of Samaritan befriending to reach those at risk, including in prisons, rural areas, and via email, deserve praise.
Abandonment of a suicide target at a time when other countries are establishing suicide prevention programmes10 would be a backward step, not only for future potential suicides. Absence of a clear and measurable mental health target, for which suicide seems the only realistic candidate, could have negative consequences for overall mental health strategy and is likely to result in the needs of those with mental ill health slipping backwards in the league of health priorities.