Suicide prevention: keeping the momentum
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2017)

Every year on Sept 10, World Suicide Prevention Day is an opportunity to raise awareness and increase literacy on a highly complex and wide-reaching global health problem. WHO estimates that around 800 000 people die by suicide every year, but this number is likely to be just the tip of the iceberg: for reasons that include the stigma shrouding suicide in many cultures, the lack of adequate vital registration systems, or even the arduous administrative steps that go with the registration of a self-inflicted death, many suicides remain undetected or are routinely misclassified. Regardless of the limitations in the available data, suicides are without doubt among the top 20 causes of death worldwide, and the second leading cause of mortality among people aged 15–29 years, with great variations by region and population group. Perhaps surprisingly but also worryingly, close to 80% of suicides are thought to occur in low-income and middle-income countries (LMICs), where fewer public health resources and reduced access to mental health services limit prevention efforts. And yet, as mental health slowly establishes its rightful place among global health issues, suicide prevention is seemingly gaining ground. World Health Day this year was dedicated to depression, a major risk factor for suicide. WHO has had a global Mental Health Action Plan since 2013, which includes reducing the rate of suicide in countries by 10% by 2020. And although somewhat lost amid other non-communicable diseases in a very vague target, mental health is included in Sustainable Development Goal 3, which features the suicide mortality rate as an indicator. Obviously, monitoring these targets will require a drastic improvement in surveillance. In a 2013 survey done by the International Association for Suicide Prevention (IASP) and WHO, only 16 (18%) of 89 respondent countries reported the presence of a registry for suicide. So increasingly in LMICs, research studies are providing much needed data—on the magnitude of the problem, on the risk factors of suicide, which are so culturally sensitive that they require high levels of granularity, and on the means used for self-harm, which are the cornerstone of prevention. A good example is the study by Olakunle Alonge and colleagues published in last month's issue, which details the burden of injuries in rural Bangladesh. Suicide was found to be the leading cause of death due to injury in people aged 15–24 years, and more than 50% of these suicides occurred in women. The results pointed to the modifying effects of age and sex on suicide in that context, providing vital input for prevention programmes at the local level. In the 2014 “Preventing suicide: a global imperative” report, WHO outlined the bases for defining a national prevention strategy, a first step that an increasing number of countries are attempting to take. The diversity of risk factors underscores the complexity of prevention: they include difficulties in accessing health care, access to means of self-harm, stressors such as disasters and conflict, lack of social support, or mental disorders. Prevention is also complicated by the variety of methods, which vary by setting and population group and evolve over time. Pesticides and firearms are among the most common methods globally, and efforts to limit their access has been the focus of some strategies. For example, in south and southeast Asia, where pesticide self-poisoning is a major public health problem, restricting access by locking the pesticides in storage boxes has been promoted. However, the results of a cluster-randomised controlled trial in rural Asia published in The Lancet this week show no reduction in pesticide self-poisoning as a result of improved pesticide storage. Another more promising option is restricting access through legislation. A recent Article by David Gunnell and colleagues in The Lancet Global Health presents a systematic review of the international evidence and concludes that national bans could be effective in reducing both pesticide-specific and overall rates of suicide. Indeed such bans have shown beneficial effects on suicide rates in Asia. An example is that of Sri Lanka, which, as Duleeka Knipe and colleagues highlight in a Comment published in the July issue, achieved a striking 70% reduction in the total suicide rate—exceeding by far the 2020 WHO goal—by improving its pesticide regulation. Increased global awareness and better data have improved countries' commitment to suicide prevention. This momentum must be maintained to overcome the remaining hurdles. For the sake of those who are at risk and for the bereaved who are too often forced to manage a mixture of shame, guilt, and stigma on their own, stopping suicide must be a global priority. Prevention of suicide with regulations aimed at restricting access to highly hazardous pesticides: a systematic review of the international evidenceNational bans on highly hazardous pesticides, which are commonly ingested in acts of self-poisoning, seem to be effective in reducing pesticide-specific and overall suicide rates. Evidence is less consistent for sales restrictions. A worldwide ban on the use of highly hazardous pesticides is likely to prevent tens of thousands of deaths every year. Full-Text PDF Open AccessEffectiveness of household lockable pesticide storage to reduce pesticide self-poisoning in rural Asia: a community-based, cluster-randomised controlled trialWe found no evidence that means reduction through improved household pesticide storage reduces pesticide self-poisoning. Other approaches, particularly removal of highly hazardous pesticides from agricultural practice, are likely to be more effective for suicide prevention in rural Asia. Full-Text PDF Open AccessFatal and non-fatal injury outcomes: results from a purposively sampled census of seven rural subdistricts in BangladeshThe burden of fatal and non-fatal injuries in rural Bangladesh is substantial, accounting for 44 050 deaths and 21 million people suffering major events annually. Targeted approaches addressing drowning in children (especially those aged 1–4 years), falls among the elderly, and suicide among young female adults are urgently needed to reduce injury deaths and morbidity in Bangladesh. Full-Text PDF Open Access