Last chances

This year, I spent a long Easter weekend in California. Flying in from rainy Seattle, I was pleased to see the brilliant blue of the Pacific Ocean lazing under a cloudless sky. The hills, typically a sere and muted gold, were brilliantly green after a late season rain and the landscape was ablaze with wildflowers. It should have been a happier arrival, but I was heading back to my childhood home for a funeral. A friend I had known for over 30 years was dead by suicide, leaving her husband, children and a huge circle of friends to grapple with unanswerable questions. Given the ubiquity of the phenomena we study, I suspect that most of our readers will know the pain of injury or violence in some personal as well as professional capacity. Globally, violence kills at least 1.6 million people each year, with as many as 870 000 of these deaths attributed to suicide. It is both humbling and unnerving to be broadsided by the emotional impact of such a tragedy. We feel we know something about injury until we are exposed, again, to its violence, its indiscriminate toll, and the raw immediacy of its aftermath. Sometimes there is just too much to fix. The prevention of suicide is nevertheless a difficult concept to sell. The Cold Spring Arch Bridge from which my friend threw herself is over 120 m high. It is well known in the area as a site for suicide, and, each year, two or three people climb over the short safety rail to jump to their deaths. Leaping from the bridge is both an act of self-directed violence and a statement that taps into local memory and the very palpable meaning of this bridge in this community. Unfortunately, those drawn to this span have made a lethal choice; to date, the case fatality rate is 100%. To me, the utility of a suicide barrier at that site is self-evident. Others will argue, however, that because the bridge itself doesn’t cause suicidality it is just a means to an end. If we restrict access to this means, won’t a desperate individual just find another method? This is an empirically testable question, and it seems that the answer is no, not always. If a particular means (such as firearms or pesticide ingestion) is a common method of suicide in a region, restricting access to that method decreases overall suicide mortality. More specifically, restricting access to bridges that have become suicide hotspots does not inevitably result in compensatory jumping from other locations. Elsewhere in this issue, Miller and colleague explore the association between suicide and gun ownership. While it may seem obvious that access to a firearm increases the potential lethality of impulsive or ill-considered acts, some have questioned whether the increased risk of fatal suicide among gun owners reflects a higher prevalence of psychopathology in that population. The authors show, convincingly, that it does not. From a prevention standpoint, however, this observation does not change our message. Restricting access to lethal means should work whether suicide is impulsive, the end result of an alcohol-induced depression and disinhibition, or the outcome of a longstanding psychopathology. Suicide barriers work. There is no doubt that safety fences reduce suicide on the bridge or building to which they are installed. 7 For many suicidal individuals, the added effort of getting over or around the barrier seems to dissuade them, perhaps just long enough to question their decision or to imagine an alterative. Our failure to design such safeguards into more bridges and buildings has caused us to forego our last, best chance to intervene with a fellow human being in existential pain. The sad outcome is determined by the context we present, indeed the message we send, to the desperate individual faced with her last choice. I believe we have an obligation to do better. In most communities, it is possible to identify these high-risk, high-yield locations and to advocate for the installation of barriers. The Bloor Street Viaduct in Toronto was one such suicide magnet. The architectural award-winning ‘‘luminous veil’’ safety barrier was added to the bridge in 2003. In addition to its functionality, the attractive installation memorialises those who died at the site and symbolises the city’s commitment to do more for those among us who suffer. Such a barrier on the Cold Spring Arch Bridge would not only stop the impulsive plunge, it would—over time—disentangle the stunningly beautiful structure from the meaning it has acquired in collective memory as an epicentre of hopelessness and despair. In this manner, we honour those we could not save through a strategy that encompasses both prevention and healing.