The British Journal of Psychiatry
Preventing suicide
S. Pridmore

In his editorial, De Leo ( 2002) cites important papers of the past 8 years. He does not mention that over 100 years ago the great sociologist, Emile Durkheim ( 1897), stated that the suicide rate reflected patterns of social relationships within communities and that individual mental disorder had little bearing on this behaviour. His view has never been effectively refuted.

De Leo does, however, observe that ‘socio-economic events’ such as wars and economic fluctuations may ‘provoke effects’ that ‘ would be incomparably bigger than any well-targeted anti-suicide initiative’. He recognised that in most Western countries, there is currently a ‘remarkable decline’ in youth suicide, which cannot be attributed to suicide prevention activities. Over the past 50 years, there have been synchronous, international trends in suicide ( La Vecchia et al, 1994). All of these events are probably due to sociocultural influences rather than fluctuations in the prevalence of mental disorders, and substantiate Durkheim's view.

De Leo states that suicidal behaviour attracts little interest among contemporary psychiatrists, as judged by the low number of contributions to suicidology journals. But this would seem to be the wrong yardstick. If Durkheim's view is accepted, the most profitable approach to the prevention of suicide would be the creation of full employment and supportive environments, and the reduction of family breakdown and drug misuse. Such an approach would call for increased attention from sociologists, economists, clergy, educators and governments. In the defence of psychiatrists, in the psychiatric literature there is considerable interest in suicide prevention among people with mental illnesses.

De Leo sees promise for suicide prevention in antidepressants, functional neuroimaging and psychometric testing, but surely this would apply only in the clinical setting. It is important to reveal the alternative to identifying and intervening with people at high risk (which has been described as ineffective and even wasteful), that is, the public health approach, in which efforts are made to reduce the risk of suicide across the community ( Rosenman, 1998).


Author's reply

Sociocultural factors are of great importance in suicide, and the deliberate manipulation of the sociocultural milieu (social engineering?) would evoke a meaningful change in suicide mortality. However, this concept is theoretical and, like most approaches to suicide prevention among high-risk individuals, lacks rigorous scientific evidence. It is important to point out that while Emile Durkheim's theories have never been effectively refuted, neither have they been supported by convincing empirical evidence.

My main contention is that the prevention of suicide, like other types of preventable death, requires a multifaceted approach that should incorporate interventions specific to high-risk individuals as well as public health approaches. As far as I am aware, this principle guides all existing national strategies, including the recently launched National Plan in England (September 2002). There is little doubt that strategies exclusively targeting high-risk subjects would produce only minimal reductions in mortality rates. Dr Pridmore maintains that counteracting unemployment and drug misuse, and improving community cohesiveness, would be profitable approaches to population-based suicide-prevention tactics. Once more, although shareable on the basis of common sense, convincing evidence for the effectiveness of these interventions is non-existent. For example, I recently reported in this journal on the impact of a telephone support service on suicide mortality among the elderly ( De Leo et al, 2002). The supportive environment provided by that service had a significant impact only among female clients. Elderly men, who suffer from far higher rates of suicide than women, reported very little benefit. Similarly, full employment would surely positively affect suicide attempt rates, but maybe not suicide mortality.

The multi-disciplinary approach to suicide seems to me the conditio sine qua non under which prevention of this human tragedy can be effectively pursued. Given their professional exposure to suicidal individuals, psychiatrists are often in a privileged position to positively interfere with a suicidal process. To do it more consistently and on a larger scale, they should contribute more to suicide research, particularly within multi-disciplinary teams in collaboration with psychologists and sociologists, demographers and anthropologists. Complexity of causes requires complexity of remedies; there are no short cuts.