Strategies to prevent suicideBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3054 (Published 06 July 2010) Cite this as: BMJ 2010;341:c3054
All rapid responses
In response to Gunnell D, Miller M: Strategies to prevent suicide,
BMJ 2010, 340:c3054, doi:10.1136/bmjc3054.
We would support Gunnell and colleagues' suggestions that the targeting of
Hot-Spots per-se may not significantly impact on suicide rates given the
relatively small numbers of deaths that occur from methods such as jumping
and that a focus on methods, accessibility and restriction is most likely
to have the biggest impact.
However such strategies can have additional benefits for organisations.
As part of a local NHS mental health trust initiative in partnership with
multi-agencies in the North East of England (Newcastle, Gateshead, South
Tyneside, North Tyneside and Northumberland ); signage with the Samaritans
contact number "In Despair please contact" was erected at a number of
These landmarks in particularly bridges were identified by Northumbria
Police as being associated not only with actual suicides but also with
individuals threatening suicide. Newcastle city for example has 7 bridges
spanning the River Tyne over a small geographical area.
There is evidence based on hard data from Northumbria police that
since the erection of the signage in 2007/8, calls to the police
negotiators from incidents involving suicidal individuals at recognised
landmarks have reduced overall. The most significant change has involved
the Tyne Bridge in Newcastle where from a baseline of 131 calls made to
the negotiators in 2007, year end to year end in 2008 negotiators were
called to 47 incidents, this fell in 2009 to 30 and to August 2010 there
have been 19 calls.
Unfortunately it is not possible to determine whether calls to the
Samaritans have increased due to the way the calls are disseminated.
Of the 173 police negotiator incidents, 89 incidents involved people
who were previously known to mental health services or who were
subsequently involved with services. Of these there were 24 individuals
who were involved in more than one suicidal incident and two individuals
accounted for 10 incidents over the 3 years.
The collaboration between Northumberland, Tyne and Wear NHS
Foundation Trust and Northumbria police has led to formal information
sharing agreements being ratified by both legal departments. This
agreement allows for key risk information to be shared with on-scene
police at high risk situations for those individuals known to mental
health services locally (most commonly the 24 hour Crisis Teams are the
police first point of contact for this information).
As a reciprocal arrangement the police negotiators supply copies of their
negotiator de-briefs to the Trust for those individuals in contact with
services. This ensures that treating psychiatric or community teams are
aware of any high risk incidents and are able to adapt risk minimisation
plans accordingly. In some cases particularly for those individuals who
are considered to be repeat attendees strategy meetings involving other
services such as the police can be arranged. It has also broadened the
police awareness of mental health and the premise that individuals can
remain unpredictable despite the best efforts of all services.
It must also be acknowledged that when an incident occurs at a high
profile location such as a busy traffic thoroughfare it can have
significant economic and social costs including disruption to the public
and the closing of roads. Data supplied by Northumbria police suggests
that Fire service call out alone is based on a cost of ?1000/hour - at an
incident on the Tyne Bridge, fire tenders , police, ambulance, river
police and police negotiators will be called. The cost of such incidents
inevitably falling to the tax payer.
Hard data from this initiative suggests that there may be a process in
action that is leading to a change in behaviours and at the very least it
has improved overall risk sharing information and treatment strategies for
suicidal individuals. There is a need for further study and this
information sharing could be copied elsewhere.
Competing interests: No competing interests
We thank Dr Verberne for his interest in our editorial (BMJ
2010;340:c3054, p.157). We disagree with his interpretation of Norman
Kreitman's paper (British Journal of Preventive and Social Medicine
1976 June; 30(2): 86-93.). Verberne has overlooked the impact of
declines in coal gas suicides on OVERALL suicide rates. As Table 1 and
Figure 4 of Kreitman's paper clearly show, between 1962-3 and 1970-
71, overall suicides declined by around 30% in both males and females. We
agree there is evidence of a (limited) increase in suicide by other
methods, as might be expected, but the far
greater reduction in suicide by carbon monoxide poisoning over the period
studied result in a dramatic decline in overall suicide rates for both men
and women (carbon monoxide poisoning was the single most frequently used
method of suicide in England and Wales in the late 1950s/early 1960s). To
quote Kreitman (page 88) referring to male suicide: "Thus the
decrease in CO suicide has been sufficiently large to lower the total
suicide rate at all ages, but in doing so it conceals an appreciable
increase in young men of suicides by other means" and to
female suicide (page 89) " ... the CO suicide decline has been great
enough to reduce the total suicide rate at all ages".
professor of epidemiology,
Department of Social Medicine,
University of Bristol, Bristol BS8 2PR
associate professor of health policy and injury prevention,
Harvard School of Public Health, 677 Huntington Avenue, Boston,
Massachusetts 02115, USA
Competing interests: DG is a member of the National Suicide Prevention Advisory Group (England) and supported the campaign to construct barriers on the Bloor Street Viaduct. MM none.
Gunnell and Miller (1) identify strategies to prevent suicide
attempts as an important public health measure to reduce premature
mortality. We report a new association of suicide attempts with long term
sequelae of childhood intrafamilial sexual abuse or incest.
Incest is not rare: 15% of US college students surveyed in 1991
reported an unwanted sexual experience in childhood (2), and a 1992
Scandinavian study showed that children suffering incest (intrafamilial
abuse, by a trusted family member) experience more comorbidity (3).
Recent US and European studies consistently show a similarly high proportion of
children reporting unwanted sexual experiences (4),(5) . Despite this,
identification of the sequelae of incest is not routinely taught in
medical schools, even though epidemiological studies have begun to
identify its long term consequences (6).
In 2009 the International Association of Incest Victims (AIVI3),
initiated an epidemiological survey in France. IPSOS surveyed 931
individuals sampled from the general population and showed that 3% of the
adult population have been subjected to incest.(7) A further IPSOS survey
assessed the impact of incest on health and daily life, by comparing
samples of those who had been subjected to incest (n=341 AIVI members)
(Association International des Victimes de l'Inceste)with non abused
individuals, using 12 questions derived from the Adverse Childhood
Experience study (8) and the Trauma Screening Questionnaire (9). The
internal consistency of the questionnaire as constructed was adequate
(Cronbach's alpha 0.79)
A multivariate logistic regression was applied to the 1287
individuals of this survey. This showed 91% [95% CI, 87-95] of women and
76% [71-81] of men who answered "yes" (current or past) to three questions had experienced incest. These three questions relate to presence of:
- eating disorder (Q1),
- suicidal ideation and impulses (Q6),
- social phobia (afraid of others or of saying no) (Q9).
A "yes" response to all these three questions gave a positive predictive
value of identifying past incest (PPV) of 91% for women and of 76% for
men, and a negative predictive value of 82% for women and 97% for men. (In
other words, when at least one response to the three questions is "no",
82% of women and 97% of men have not experienced incest.)
Responses to an additional 24 self-reported questions were gathered
from the 341 respondents who had experienced incest. This revealed that
chronic health symptoms related to incest remained unexplained for an
average of 16 years until spontaneous disclosure (7).
The US based ACE study demonstrated a strong graduated relationship
between the accumulation of adverse childhood experiences and multiple
risk factors for public health problems.(10) Our French study is much
smaller, however our results were unexpected and they appear significant.
Suicidal ideation has not previously been systematically identified in
relation to incest, but this triad of features (suicidal ideation, social
phobia and eating disorder) represents a potentially simple and cheap
clinical screening test to identify individuals at risk of mental health
problems following experiences of incest, allowing appropriate
intervention. Disclosure of incest may occur spontaneously, but unless
physicians ask these three simple questions , the hidden risk is likely
to last an average of 16 years.
To increase the chances of identifying suicide risk (and eating
disorders) related to incest experiences we suggest that primary and
emergency room carers use the presence of one of the triad as a prompt to
ask these three simple questions (11). Early identification of this "triad" may be a valuable tool for screening for mental health trauma
Dr Louis Jehel MD, PhD, APHP, Psychiatrie, INSERM U669, Paris, France; Dr Pierre Levy MD, APHP, INSERM UMR-S 707; Dr Heather Payne MB, BS, FRCPCH; Isabelle Aubry President of AIVI; Dr Catherine Bonnet MD, consultant in child and adolescence psychiatry, Chevalier dans l'Ordre de la Legion d'honneur
1. Editorial: D Gunnell and M Miller Strategies to prevent suicide
BMJ 2010; 341: c3054 (6 July)
2. Erickson PI and Rapkin AJ Unwanted sexual experiences among middle
and high school youth Journal of Adolescent Health 12 (4 ) 319-325 (June
1991 ) http://www.jahonline.org/article/0197-0070(91)90007-9/abstract
3. J. A. Bushnell , J. E. Wells, M. A. Oakley-Browne Long-term
effects of intrafamilial sexual abuse in childhood, Acta Psychiatrica
Scandinavia 85 (2) 136-142 Feb 1992 (published online 23 AUG 2007) DOI:
4. Finkelhor D The international epidemiology of child sexual abuse
Child Abuse and neglect May 1994 18(5) 409-417 Available online 22 June
5. May-Chahel C, Hercoz M. Child sexual abuse in Europe. Strasbourg
2003. Council of Europe Publishing.
6. Darves Bornoz JM, Berger C, Degiovanni A, Gaillard P, Lapine JP.
Similarities and differences between incestuous and non-incestuous rape in
a French follow-up study. Journal of Traumatic Stress 1999;12:4, 613-623.
7. IPSOS. Etat des lieux de la situation des personnes victimes
d'inceste: vecu, etat de sante et impact sur la vie quotidienne. Sondage
aupres des victimes d'inceste et des francais. 2010. www.aivi.org
9. Serre L, Jehel L, Le depistage de l'etat de stress post-
traumatique en consultation de medecine generale. evaluation de la version
francaise du trauma screening questionnaire, Medical Thesis, Rennes
10. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM,
Edwards V, Koss MP, Marks JS. Relationship of Childhood Abuse and
Household Dysfunction to Many of the Leading Causes of Death in Adults:
The adverse childhood experiences (ACE) study. American Journal of
Preventive Medicine. 1998;14:245-258.
11. Edwards VJ, Dube SR, Felitti VJ, Anda RF. It's ok to ask about
past abuse. Am Psychol. 2007-Jun; 62 (4):327-8
Isabelle Aubry is President and Dr Bonnet is a membe of AIVI (Association of Incest Victims International)
Heather Payne and Catherine Bonnet are members of PACA (Professionals against Child Abuse)
Competing interests: No competing interests
While I am a GP much of my work is taken up with nutritional
treatment of mental illness involving in particular trying to find
biochemical imbalances and using nutrients where possible. The standard
medication is used of course although one hopes to get them off medication
in most cases after some months by using nutrients only and not having
I have learned a great deal from the work of Dr William Walsh PhD, a
scientist who studied the biochemistry of 3000 depressed patients at the
Pfeiffer Center, Chicago (www.hriptc.org). Dr Walsh came to Dublin
recently and gave 5 hours of lectures on the biochemistry of mental health
and the nutrients that help.
Dr Walsh agreed to allow his slides to be made public and you can access
them via the first page my website at www.omega3.20megsfree.com.
I believe that if nutrient therapy was widely available mental health in
the community would improve greatly, the number of admissions to
psychiatric units would drop significantly as mine have, and suicide would
be far less common than it is now.
Competing interests: No competing interests
Gunnell and Miller (BMJ 2010;340:c3054, p.157) state that the
of the domestic gas supply in the UK, was followed by a marked reduction
the overall suicide rate.
The statement is made despite Norman Kreitman’s article (British
Preventive and Social Medicine 1976 June; 30(2): 86–93.), in which the
evidence was reviewed, giving no support for it. The following three
from the article make this very clear:
“Suicide due to non‑gas methods has in general increased,
markedly so in
some groups.” (p. 86)
“Far from any improvement the non-CO suicide rate has been shown to
increasing, especially in Scotland, among women in both regions, and among
the young and middle-aged.” (p. 92)
“Among men below 45 years of age in the same region a fall in CO
has been counteracted by an increase in other forms.” (p. 92)
Clinical Neuropsychologist (ret.)
Rosanna, Victoria, Australia
Competing interests: No competing interests