A public health approach to suicide prevention

Introduction Suicide has become a public health concern worldwide. According to the World Health Organization (WHO), an estimated 1 million people died from suicides in 2000--in other words, 1 suicide occurred every 40 seconds. (1) In 2001, the global death toll from suicide far exceeded the number of deaths by homicide (500,000) and war (230,000). (2) Suicide is also a particularly serious problem in the Western Pacific region: this region alone accounts for 38% of the world's suicides. (1) In Hong Kong, too, suicides have cost our community dearly. According to the Hong Kong Jockey Club (HKJC) Centre for Suicide Research and Prevention, (3) the total number of suicide deaths reached 1264 in 2003--equivalent to 18.6 per 100,000, which is 28% higher than the world average of 14.5 per 100,000. Moreover, suicide is the leading cause of death among the 15- to 24-year age group, and the rate has surged by more than 70% since 1997. The estimated loss of labour productivity of suicide in 2003 was HK$1.4 billion. In addition, the number of suicides overtook the number of 'natural' deaths from infectious and parasitic diseases (1047); endocrine, nutritional and metabolic diseases (885); and traffic accidents (175) in 2003. (3) A Public Health Approach to Suicide Prevention The burden of suicide to our community can no longer be ignored. Unfortunately, the majority of the suicidal people are reluctant to seek help from health care professionals, (3) probably because of the stigma towards treatment and uncertainty about treatment effectiveness. Suicide has traditionally been viewed as a mental health issue that is addressed primarily through clinical intervention, especially the treatment of depression. (4) Nevertheless, it is also well known that approximately two-thirds of all people who committed suicide did not receive any specialist psychiatric care in the year before death. (5) On the basis of rigorous calculations, Lewis et al showed that high-risk strategies would have only a modest effect on population suicide rates, even if effective interventions were developed, and that the UK government's target for suicide reduction was more likely to be achieved using population-based strategies that aimed at actively reducing risk among the whole population. (6) Furthermore, all research has pointed out that suicide can be the tragic endpoint of an interplay of a wide array of factors, including biological, genetic, social, cultural, psychological, and behavioural factors. (7) For these reasons, it is imperative that multiple avenues be taken for suicide prevention and intervention. As the eminent psychiatrist Keith Hawton, from the Centre for Suicide Research at the University of Oxford, UK, put it, "Suicide rates are unlikely to decline as long as we confine our prevention efforts only to those who are at immediate risk of attempting suicide. " Flooding is a useful metaphor for the problem of suicide. When a flood occurs, rescue teams work hard to save those affected, focusing attention mainly on the victims who are swept downstream. However, the cause of the flood, including upstream conditions such as deforestation, are seldom dealt with or considered. What lies 'upstream' of the increasing number of suicides is often a malfunctioning society. A public health approach to suicide prevention has therefore been widely advocated by governments, international organisations, and professional bodies worldwide (e.g., the USA Department of Health and Human Services, the WHO, and the International Association of Suicide Prevention). (2,8,9) This approach acknowledges the importance of both the high-risk and the population-based strategies to suicide prevention, and requires a multi-sector effort to tackle the problem at multiple levels: in the community (universal strategies), among specific population subgroups (selective strategies), and among those at a particularly high risk of suicidal behaviour (indicated strategies) [Table 1]. …