DEVELOPING COMMUNITY NETWORKS FOR SUICIDE PREVENTION
SHAHUL AMEEN, M. D., Senior Resident, & S. HAQUE NIZAMIE, D.P.M., M.D., Professor of Psychiatry & Director, Central Institute of Psychiatry, Ranchi, India

INTRODUCTION

According to the World Health Organization (WHO), approximately 850,000 people died of suicide in 2001. This gives a suicide rate of about 14 per 100,000 people, and works out to about one death in every 40 seconds. This is almost four times the number of people who died in wars in 2001. More alarmingly, for every suicide, more than twenty others have made an attempt to take their own lives. In the last 45 years suicide rates have increased by 60% worldwide. According to the statistics provided by the National Crime Records Bureau in 2003, 108,593 Indians committed suicide in year 2000; and during the decade 1990 to 2000, while the population grew by 21 per cent, the rate of suicide increased by 21.2 per cent.

Suicide is the result of many complex medical and socio-cultural factors, and it is preventable by control of these factors. Before discussing the prevention strategies, it will be useful to look at the etiologies of suicide. Suicide is typically seen as the fatal outcome of a long-term process shaped by a number of interacting cultural, social, situational, psychological and biological factors. Following sociodemographic variables have been associated with a higher risk for suicide (1).

Various clinical determinants of suicide are listed below (1).

Factors within a community that appear to contribute to overall risk of suicide in that community include war, economic change, unemployment, availability of particularly lethal methods of suicide, cultural and religious values, and changes to social structures and supports.

Suicide prevention necessitates an integrated and multi-sectoral approach, pooling together, amongst others, the efforts of the public and private healthcare sectors, governmental agencies, business corporations, the media, non-governmental organizations (NGOs), the schools and institutions of higher learning. In rural areas, community development approaches have the capacity to provide support to the limited number of trained professionals by empowering communities to act on their own behalf. A comprehensive, community-wide approach to suicide prevention that recognizes the complexity of the problem and capitalizes on the skills and talents of a broad range of community partners has the greatest likelihood of success. While each community is unique and each will be at a different stage of organizational readiness for developing a community-wide approach to suicide prevention, there are some key broad level considerations that can guide program development and community organization in this area. The steps in developing a community network for suicide prevention are (2):

1. Assessing the current status of the community

2. Consulting the community

3. Setting up an interagency planning body

4. Developing an interagency action plan

5. Evaluating the suicide prevention efforts

1. ASSESSING THE CURRENT STATUS OF THE COMMUNITY

1. Population for City/Town/County according to 2001 census

2. Median household income for City/Town/County

3. Unemployment rate

4. Percentage and number of the following age groups in City/Town/County:

• Children/Youth (0.19 years)

• Adults (20-44 years)

• Adults (45-64 years)

• Seniors (65-84 years

• Seniors (85 and over)

5. Medical care service providers (i.e. hospitals, health care centers, medical centers) in the City/Town/County

6. Mental health service providers (i.e. hospitals with psychiatric units, mental health clinics) in the City/Town/County

7. Local media which reach the City/Town/County (includes newspapers, cable television etc)

8. Number and type of organizations that serve:

• Pre-kindergarten children

•  Youth

• Homeless people/families

• Seniors

• Victims of domestic violence

9. Estimate of suicides (attempts or completed) in past year

10.  Suicide prevention services/activities/programs/plans presently taking place within the target community

Community Suicide Risk Factors and Prevention Resources

In the next step, consider the risk factors for suicide and resources for suicide prevention for the target community. The resources may be classified by their level of prevention - universal (target and benefit everyone in the community irrespective of their suicide risk), selective (benefit specific groups whose members have a significantly higher risk of developing suicidal behaviors), indicated (target and benefit identified high-risk individuals or those who already exhibit suicidal behavior) and postvention (includes all measures that would prevent further suicide attempts in the aftermath of a suicide). It will be useful to identify the connection between risk factors and the resources. Circumstances surrounding recent suicides in the target population may be considered to identify the population-based risk factors. Another consideration should be the strengthening of the protective factors in individuals and populations to counteract the prevalent risk factors.

Assets of the Community

1. Identify the available assets for suicide prevention in the target population 

2. Prevention network members’ individual skills/Capacities

3. Social betterment groups

4. Faith-based Organizations

5. Cultural events/Organizations

6. Local Institutions (schools/faith)

7. Personal Economic Resources

8. Space (open and gathering space)

9. Businesses (formal and informal)

10. Others

2. CONSULTING THE COMMUNITY

The next step would be to hold a community consultation including the members and caregivers in the community to know their perceptions about the suicide problem in the particular community and the potential solutions to the problem. These meetings will also help to build their further commitment and to fill in the potential gaps in the information already gathered. An opportunity should be provided for broad public input, and the opinions and perceptions of a broad range of community members should be solicited. Various methods like public meetings, small focus groups, telephone survey, etc. could be used to receive feedback from a variety of groups within the community. Questions that could be considered in these interactions include (2):

• Do they perceive that suicide and self-destructive behaviour is a significant problem in the community?

• If so, what leads them to believe this, or according to them, what's the evidence?

• If it is not perceived to be a problem for this community, what is a more pressing or urgent problem that needs to be addressed?

• Can the issue of suicide be approached from another perspective or through the efforts of other prevention initiatives? (E.g. youth violence, injury prevention, substance abuse prevention, health and well-being promotion).

• What are community members' perceptions about what needs to be done?

• What are the strengths/capacities of the community in responding to this problem or issue?

• What gets in the way?

• Can some consensus be reached regarding what are perceived to be community priorities?

If the issue of suicide it is not viewed as a priority area for the community at present, and cannot be integrated with other current initiatives, then it is not advisable to "force the issue." This does not mean, however, that the work of suicide prevention needs to be abandoned altogether. Work on those areas that the community perceives to be the most salient and pressing concern. Meanwhile, continue to be strategic by taking advantage of opportunities to educate and heighten awareness about the issue of suicide; by helping others to make the links between suicide prevention and other prevention/health promotion efforts; and by lending your explicit support to community-based efforts that seek to enhance the protective conditions within the community, including increasing social support and reducing isolation; strengthening families; and creating supportive school and work environments.

3. Setting up an interagency planning body

Reducing suicides and suicidal behavior is not something that can be achieved overnight, nor will one single strategy suffice. It is therefore ideal to establish an interagency body that can coordinate specific results-oriented suicide prevention strategies, which are designed to be implemented across an array of settings and maintained over time. For communities interested in establishing a formal interagency body for suicide prevention, some key consideration should be kept in mind (2):

Build on the existing structure

Build on the existing community infrastructure wherever possible. It is neither necessary nor efficient to create a new organizational structure for every particular for every particular problem or issue, including suicide. Rather, create suicide prevention sub committee from an existing intersectoral body.

Work with the local governing bodies

The community- wide approach to suicide prevention is more likely to be successful if it is part of an established and legitimate body that has been given and explicit mandate to promote the well-being of the community and reduce risks to their overall health. Furthermore, by including the work or suicide prevention in broader community health promotion and prevention efforts, some important links between community suicide prevention and other related issues will be fostered, for example substance abuse prevention.

Advocate and coordinate

The role and corresponding duties of the local suicide prevention interagency group include:

• Providing a strong voice for suicide prevention

• Spearheading key initiatives

• Ensuring the coordination of various suicide prevention efforts

• Sharing and collecting key information

• Establishing functional links across agencies

• Advocating for service & community approaches that are known to reduce suicide

• Monitoring the effectiveness of the combined community efforts

Facilitate key linkages

Individual agencies, hospitals, and mental health professionals will clearly be contributing to the overall goal of reduced suicidal behaviour through the provision of assessment, crisis intervention, and treatment services. While it will be up to each of these organizations/ practitioners to monitor the effectiveness of their own individual efforts, the interagency body can facilitate important linkages, assist with identifying community priorities, and coordinate/aggregate information across organizations.

4. DEVELOPING AN INTERAGENCY ACTION PLAN

1. It is wise for the interagency planning body to set some long-range goals as well as some more intermediate targets; always keeping in mind that the ultimate goal is the reduction of fatal and non-fatal suicidal behaviour.

2. Try to plot out your work plan according to a timeline (e.g. one to three year work plan).

3. Whatever strategy does get implemented, ensure that it is results-oriented. For example, what would you expect to change as a result of your intervention: individual attitudes, knowledge, behaviors; agency practices; level of community coordination; media reporting; policies, etc.

4. Identify who is going to take responsibility for what, by agency and/or by individual.

5. Monitor your results based on previously identified indicators of success

6. Share your findings with a broad range of community partners and stakeholders as well as those implementing suicide prevention strategies in other areas of the state.

7. Refine and build on previous efforts, based on the results achieved.

8. Celebrate your successes and learn from those things that did not work.

Keep in mind that these ideas are meant to serve as broad planning guidelines only. Be aware that there is no one single approach that will work best for every community. Draw on the expertise of your community to determine what will be the best course of action or "best fit."

The roles of each of the component groups should be defined as clearly as possible in the response plan before any crisis occurs. These roles should be agreed upon and reviewed by persons representing those groups. Most of those involved in the response will already know how to perform their particular duties. However, appropriate training for the staff of these groups should be provided as necessary.

The following example illustrates the need for inclusion of and cooperation among many community organizations. Suppose that two high school students from the same school commit suicide in separate incidents on a weekend during the regular school year. The coordinating committee decides that these two deaths may increase the risk of suicide or attempted suicide among other students. The responsibilities of some of the relevant community resources might be as follows: School officials might be responsible for announcing the deaths to the students in an appropriate manner. School counselors and teachers might assist in identifying any students whom they think are at high risk; students in the school might also help in this regard. The local mental health agency might provide counselors to work with troubled students, as well as supply training and support for the teachers. Emergency departments of community hospitals might set up a suicide-attempt surveillance system that would increase the sensitivity with which suicide attempters were identified and would ensure proper referral of the attempters for counseling. Hotlines might help identify potential suicide attempters, and police might assist in locating such persons when appropriate. Police may also help by identifying and maintaining contact with such high-risk persons as high school dropouts and those with a history of delinquency. Local government or public health authorities might help coordinate these various efforts, if so designated by the coordinating committee.

Strategies that can be used by the community network for suicide prevention

Major strategies that can be used by the various components of suicide prevention network are described below.

a) Reducing the availability of means for suicide

This is the most widely discussed population strategy for suicide prevention. It is based on the evidence that changes in the availability and/or danger of a popular method for suicide have an impact on suicide rates. The common adage that if people are intent on committing suicide they will find a means is not entirely correct. The most cited evidence for the effectiveness of this approach is the reduction in suicides in the United Kingdom which occurred in the 1960s and early 1970s when toxic coal gas supplies were gradually replaced with non-toxic North Sea gas.

Given the very strong link between suicide and depression, and the risk of death from overdose of some of the older antidepressants, there has been much debate about whether more extensive use of less toxic newer antidepressants would prevent suicides. This is not a simple question, since some patients respond better to the older tricyclic anti-depressants. Another consideration concerns the cost of the newer antidepressants compared with the older varieties. Also it is very important to remember that most people who are taking antidepressants do not kill themselves with their antidepressants but use other methods. This and the probable selective prescribing of SSRIs to people judged to be at risk probably accounts for the finding that suicide rates were higher in patients taking fluoxetine than patients taking other and in some cases more toxic antidepressants. Nevertheless, common sense dictates that patients known to be at risk, and especially those with a history of suicidal behavior, should be prescribed the less toxic preparations (1).

b) Education of primary care physicians

Much of the attention regarding improved detection of individuals at risk for suicide has concerned the management of depression in general practice. This was stimulated by findings that showed that many people who died by suicide or who attempted suicide had seen their general practitioners shortly before these acts. Psychiatrists involved in designing suicide prevention strategies might ensure that there are effective local educational programmes for clinicians in primary care and other settings regarding detection and treatment of people with mental disorders. Primary care physicians should also be informed about the following indications for referral to specialist care and immediate hospitalization for their patients (4)

When to refer:

Patients should be referred to a psychiatrist when they have:

• A psychiatric disorder

• A history of a previous suicide attempt

• A family history of suicide, alcoholism and psychiatric disorder

• Physical ill-health

• No social support

How to refer:

After deciding to refer a patient, the physician should:

• Take the time to explain to the patient the reason for the referral

• Allay anxiety about stigma and about psychotropic medication

• Make clear that pharmacological and psychological therapies are effective

• Emphasize that referral does not mean "abandonment"

• Arrange an appointment with the psychiatrist

• Allocate a time for the patient after his or her appointment with the psychiatrist

• Ensure that the relationship with the patient continues

When to hospitalize:

These are some of the indications for immediate hospitalization:

• Recurrent thoughts of suicide

• High level of intent to die in the immediate future (the next few hours or days)

• Agitation or panic

• Existence of a plan to use a violent and immediate method

How to hospitalize:

• Do not leave the patient alone

• Arrange for hospitalization

• Arrange for transfer to the hospital by ambulance or the police

• Inform the concerned authorities and family

c) Educational approaches in schools and institutions of higher learning

These institutions can be encouraged to introduce programmes that would help to reduce suicidal tendencies among school children and students, such as courses on crisis management, enhancement of self-esteem and development of healthy coping skills. Teachers and other school staff should be aware that the following risk situations and events that may trigger suicide attempts or suicide (5).

• Situations that may be experienced as injurious (without necessarily being so when evaluated objectively): vulnerable children and adolescents may perceive even trivial occurrences as deeply injurious and react with anxiety and chaotic behavior, while suicidal young people perceive such situations as threats directed against their self- image and suffer from a sense of wounded personal dignity

• Family disturbances

• Separation from friends, girl-/boyfriends, classmates, etc.

• Death of a loved one or other significant person

• Termination of a love relationship

• Interpersonal conflicts or losses

• Legal or disciplinary problems

• Bullying and victimization

• Disappointment with school results and failure in studies

• High demands at school during examination periods

• Unemployment and poor finances

• Unwanted pregnancy, abortion

• Serious physical illness

They should also be sensitized to take any sudden or dramatic change affecting a child’s or adolescent’s performance, attendance or behavior seriously, such as:

• Lack of interest in usual activities

• An overall decline in grades

• Decrease in effort

• Misconduct in the classroom

• Unexplained or repeated absence or truancy

• Excessive tobacco smoking or drinking, or drug (including cannabis) misuse

• Incidents leading to police involvement and student violence

Once a suicide risk is identified, various forms of supervision and removal or locking-up of dangerous medicines and weapons in schools, parental homes and other premises should be undertaken. Since these measures alone are not enough to prevent suicide in the long run, psychological support should be offered at the same time, and if necessary, the student should be referred for treatment of their psychiatric disorders or substance abuse.

d) Sensitizing the media

It is particularly important that representatives of the local media be included in developing and implementing the suicide prevention plan. Although frequently perceived to be part of the problem, the media can be part of the solution. If representatives of the media are included in developing the plan, it is far more likely that their legitimate need for information can be satisfied without the sensationalism and confusion that has often been associated with suicide. Keith Hawton had pointed out three key points that the media should bear in mind when reporting on suicides:

1. Reports and portrayals of suicide in the media can lead to an increase in suicidal behaviour, particularly if those reports or portrayals are given prominence, repeated, or describe in detail the method of suicide. Young and elderly people are particularly vulnerable to this type of media influence.

2. Providing information about crisis lines and encouraging suicidal people to seek help can have positive benefits

3. It is often not apparent from media reports and portrayals that the vast majority of people who kill themselves have a significant psychiatric illness at the time of their death. Reports and portrayals of suicide consistently under-report this important fact.

Media professionals should be sensitized to the follow the following instructions on reporting suicide or suicide attempts (6).

What to do:

• Work closely with health authorities in presenting the facts

• Refer to suicide as a completed suicide, not a successful one

• Present only relevant data, on the inside pages

• Highlight alternatives to suicide

• Provide information on helplines and community resources

• Publicize risk indicators and warning signs

What not to do:

• Don’t publish photographs or suicide notes

• Don’t report specific details of the method used

• Don’t give simplistic reasons

• Don’t glorify or sensationalize suicide

• Don’t use religious or cultural stereotypes

• Don’t apportion blame

e) Education of the public about mental illness and its treatment

In view of the very strong link between suicide and mental illness, effective treatment of psychiatric disorders must be a central theme in suicide prevention. However, detection of people with mental disorders will depend on the awareness that they and those around them have regarding the signs and symptoms of disorder, and their willingness to seek appropriate help. These important stages in receiving effective help will depend on attitudes towards mental illness and knowledge of its nature and the feasibility of treatment. The method of education of public will clearly depend on local factors, and potential strategies include leaflets in hospitals and doctors' waiting rooms, workshops for the public, and articles in the local press or other media.

f) Educating public to deal with a suicidal individual

The public should be sensitized to the things that should and should not be done on encountering a suicidal person in the community (modified from 7).

Things to do:

• Listen, show empathy, and be calm

• Be supportive and caring

• Take the situation seriously

• Ask about previous attempts

• Explore possibilities other than suicide

• Ask about suicide plan

• Identify other supports

• Remove the means, if possible

• Take action, tell others, get help

• If the risk is high, stay with the person

Things not to do:

• Ignore the situation

• Be shocked or embarrassed and panic

• Say that everything will be all right

• Challenge the person to go ahead

• Make the problem appear trivial

• Give false assurances

• Swear to secrecy

• Leave the person alone

g) Befriending agencies and telephone help-lines

A very important component of suicide prevention policy in many countries is the support provided by largely volunteer staffed befriending agencies and especially telephone help-lines. Volunteer-run telephone helpline and similar services benefit greatly from the support and advice of local clinicians, who should regard them as a potentially valuable element in a local suicide prevention strategy (1).

5. EVALUATING THE SUICIDE PREVENTION EFFORTS

Community-wide efforts that have as their ultimate goal the prevention of suicide and suicidal behavior are difficult to evaluate for a number of reasons. Completed suicides are fairly infrequent events when considered at the local or community level, which makes it difficult to detect changes that may be due to specific program. It is very difficult to measure the suicidal behavior. Suicide and suicidal behavior are not outcomes that follow a straight line or simple path, with specific markers leading predictably to a suicidal crisis or death. This makes it challenging to identify the appropriate intermediate targets for change and the corresponding outcome measures that would be most suitable for evaluation purposes.

Despite these limitations, various short, medium and long-term indicators of success have been suggested to be useful for evaluation of the suicide prevention programmes. Short term indicators are those changes that the strategy itself is designed to produce, for example, increased knowledge. Medium term indicators of success capture changes that you might come to expect further down the road, for example, increased help seeking among adolescents or referrals of their at-risk peers. The ultimate outcome or long-term indicator of success is a reduction in the suicidal behavior and completed suicides (2).

Conclusion

Suicide is a serious problem in many contemporary societies. The pathways to suicidal behavior are long and complex, and the prevention of suicidal behavior require attention to a range of broad and specific strategies. This presentation covered some general strategies for suicide prevention which are probably relevant to most communities. Development of suicide prevention networks that modify the presented strategies according to the local cultural factors of a particular community is likely to help in amelioration of the rising suicide rates.