Emergency Medicine (2002) 14, 2434

Suicide Prevention Series

Blackwell Science, Ltd

A global view of suicidal behaviour

Robert D Goldney Department of Psychiatry, Adelaide University, The Adelaide Clinic, Adelaide, South Australia, Australia

Abstract
Suicidal behaviour is a major public health problem. There is no one explanatory theory of suicidal behaviour, and various combinations of sociological and biological / medical interventions are required to reduce associated mortality and morbidity. The importance of primary prevention varies from community to community, and may have an impact at the population level. However, individual suicidal persons always require optimum assessment and management and that is usually provided by primary care and emergency physicians. This paper provides an overview of issues to be addressed in the assessment and management of suicidal patients. See Commentary, page 8.
Key words:

attempted suicide, suicide, epidemiology, management.

illness in suicide. Morselli published his Suicide. An Essay on Comparative Moral Statistics in Italy in 18796 (translated in 1881), shortly before the English work Suicide: Its history, literature, jurisprudence, causation and prevention by Westcott in 1885.7 All these works and others were published before Durkheims Le Suicide in 1897,8 although their contribution has sometimes been neglected. In the 20th century, research in the area burgeoned, so much so that over 20 years ago it was noted that it is probable that suicide is the most unremittingly studied human behaviour.9 It is unlikely that this will change, as suicide represents not only an increasingly recognized public health problem, but also challenges our individual philosophical sense of being.

Extent of the problem

In the year 2000 approximately one million people died by suicide and between 10 and 20 times that number attempted suicide.1 At least ve or six people are affected by an individuals suicidal behaviour2 and therefore at least one hundred million people worldwide have direct contact with suicidal behaviour each year. The most recently available ofcial gures for Australia and New Zealand indicate that there were 2492 suicides in Australia in 19993 and 574 suicides in New Zealand in 1998.4 Accurate gures for attempted suicide are not collated, but it is generally recognized that the management of suicidal behaviour represents a signicant proportion of emergency department work. Suicide has occurred since recorded history, but it is only in the last 200 years that intensive studies have evolved from a number of different perspectives. In 1790 Moore in England published two volumes entitled A full enquiry into the subject of suicide,5 and in the early 19th century Esquirol of France was probably the rst to place emphasis on psychiatric
Correspondence:

Epidemiology
In most countries suicide is more common in males, with the exception of China, where females predominate. 10 Because of the enormous population

Professor Robert D Goldney, The Adelaide Clinic, 33 Park Tce, Gilberton, SA 5081, Australia. Email: robert.goldney@adelaide.edu.au

Robert D Goldney, MD, FRCPsych, FRANZCP.

Global view of suicidal behaviour

of China, this represents at least 100 000 deaths of women per year in China alone. Suicide usually increases with age, although in developed countries there has been a signicant increase in younger males, particularly in Australia and New Zealand, where there has been a threefold increase in younger males in the last 30 years.11 For example, for those males aged 2534 years in New Zealand in 1996, the suicide rate was 44 per 100 000 and in Australia for the same ages it was 31 per 100 000.11 Marriage and strong religious faith appear to be protective. There are marked differences between some ethnic groups and individual countries, and also within different areas of the one country. For example, African Americans have a lower rate (7.0 per 100 000) compared with white Americans (13.1 per 100 000); in Europe suicide rates vary from as low as 3.5 per 100 000 in Greece to as high as 45.6 per 100 000 in Lithuania. and in the USA there is up to a threefold variation among States, with New Jersey and Nevada having rates of 7.3 per 100 000 and 24.5 per 100 000, respectively.12 The quality of suicide statistics collected varies from country to country, and it is difcult to compare gures. Nevertheless, the most recently available suicide statistics for a number of different countries demonstrate high rates in the Baltic States and countries of the Russian Federation, as well as in Sri Lanka (Table 1). Low rates are evident in some Mediterranean countries and elsewhere in the world, but the reliability of these statistics is questionable. There are also marked differences in method of suicide among countries. For example, the four most common methods in Sweden are poisoning, hanging, rearms use and drowning; in Hungary, they are hanging, poisoning, jumping from a height and drowning; in the USA, they are rearms use, hanging, poisoning and cutting or piercing; in India they are poisoning, hanging, self-immolation by re and drowning; in China they are hanging, drowning, poisoning and jumping from a height; and in Australia and New Zealand they are hanging, carbon monoxide poisoning from motor vehicles, poisoning by solid/ liquid substances and rearms use.

nature, challenges our ability to provide a cohesive conceptual hypothesis within which to work. One model which has some face validity is the threshold and trigger model, synonymous with a stressvulnerability model. The vulnerability of longitudinal issues which may lower or raise the threshold to engage in suicidal behaviour is impinged on by stressors or a trigger, which precipitates the behaviour. Factors related to the threshold include genetic predisposition, biochemical factors in a persons metabolism, personality traits, the emotional state of hopelessness, and the presence of ongoing support systems. Triggers can include mental disorders or physical illnesses, alcohol and/or other substance abuse, and interpersonal loss or rejection.13 Clearly these issues are not independent or mutually exclusive. There is mounting evidence that contributing factors are cumulative14,15 with an association between the number of such factors and the likelihood of suicidal behaviour. Even biological markers such as serotonin are inuenced by other factors such as diet (cholesterol), drugs (including alcohol), gender and age.16 There is no one simple cause of suicide.

Approaches to prevention
In 1993 the World Health Organization (WHO) presented six broad approaches to the prevention of suicidal behaviour.17 These were: (i) the treatment of those with mental disorders; (ii) gun possession control; (iii) detoxication of domestic gas; (iv) detoxication of car emissions; (v) control of availability of toxic substances; (vi) and a toning down of reports of suicide in the press. Although WHO delineated the treatment of mental disorders as the rst of the six, the others are referred to rst as they, more so than the treatment of mental disorders, can vary from country to country. For example, those countries where suicide by rearms predominates (such as the US) should focus more on that issue, as opposed to countries where this is not a major issue. In Australia the use of rearms as a means of suicide has been decreasing over the last 20 years. In fact, the reduction preceded Australia-wide legislation.18 Hard evidence for the effectiveness of restrictive rearms legislation is equivocal, both in Australia19 and New Zealand.20 A similar debate applies to several of the other WHO steps. Detoxication of domestic gas in some countries such as the UK, Japan and Switzerland has correlated with a decrease in suicide, but this is not 25

Theories of suicide
Despite the intense study of suicidal behaviour, there is no universally accepted theory of suicide. Indeed, there may never be, as suicidal behaviour, by its very

RD Goldney

Table 1.

Suicide rates (per 100 000) as of June 19991

Country Lithuania Russian Fedn Estonia Latvia Finland Hungary Sri Lanka Kazakhstan Belarus Slovenia Ukraine Austria Switzerland France Cuba Denmark Belgium Rep. Moldova Croatia Slovakia Czech Rep. Bulgaria Japan China (mainland) Germany Luxembourg Sweden Poland Kyrgyzstan Mauritius Canada Singapore New Zealand Australia Romania Norway Suriname USA China (SAR Hong Kong) El Salvador Trinidad and Tobago Guyana Uruguay Netherlands India Republic of Korea Iceland Italy

Year 1995 1995 1995 1995 1995 1995 1985 1995 1993 1995 1992 1995 1994 1994 1995 1995 1992 1995 1995 1995 1995 1994 1994 1994 1995 1995 1995 1995 1995 1995 1995 1995 1993 1994 1995 1994 1992 1994 1995 1990 1994 1994 1990 1995 1995 1994 1994 1993

Total rate 45.6 41.5 40.1 40.7 33.8 32.9 31.0 28.6 28.0 26.6 22.6 22.2 21.4 20.7 20.2 18.9 18.7 18.5 18.5 18.4 17.8 17.3 16.8 16.1 15.8 15.4 15.3 14.3 13.5 13.5 13.4 13.4 12.8 12.8 12.3 12.2 11.9 11.9 11.8 11.6 11.6 10.5 10.3 9.8 9.7 9.5 9.4 9.3

Men 79.1 72.9 67.6 70.8 43.4 50.6 44.6 48.9 48.7 45.3 38.2 34.2 30.9 31.5 25.6 24.2 26.7 29.7 29.7 23.4 25.6 25.3 23.1 14.3 23.2 22.4 21.5 24.3 21.2 21.1 21.5 16.3 20.5 21.0 20.3 17.7 16.6 19.8 14.3 15.6 17.4 14.6 16.6 13.1 11.4 12.8 15.8 12.7

Women 15.6 13.7 16.0 14.7 11.8 16.7 16.8 9.4 9.6 12.6 9.2 11.0 12.2 10.7 14.9 11.2 11.0 8.3 9.8 4.6 8.5 9.7 10.9 17.9 8.7 8.6 9.2 4.7 6.1 5.5 5.4 10.5 5.4 4.7 4.6 6.9 7.2 4.5 9.2 7.7 5.0 6.5 4.2 6.5 8.0 6.1 3.0 4.0

26

Global view of suicidal behaviour

Table 1.

continued

Country Ireland Puerto Rico Portugal Spain Zimbabwe United Kingdom Saint Lucia Argentina Barbados Israel Belize Uzbekistan Seychelles Turkmenistan Chile Venezuela Costa Rica Ecuador Thailand Malta Tajikistan Georgia Brazil Colombia Greece Nicaragua Bahrain Honduras Mexico Sao Tome and Principe Panama Saint Kitts and Nevis Albania Armenia Dominican Republic Paraguay Philippines Kuwait Bahamas StVincent and Grenadines Azerbaijan Guatemala Peru Syrian Arab Republic Jamaica Jordan Iran Egypt Qatar

Year 1993 1992 1995 1994 1990 1995 19861988 1993 1995 1995 1995 1993 19851987 1994 1994 1994 1994 1995 1994 1994 1992 1990 1992 1994 1995 1994 1988 1955 1995 19841985 1985 1986 1993 1992 1982 1994 1993 1994 1995 19821985 1995 1984 1989 1981 1985 1965 1991 1987 1995

Total rate 9.1 8.7 8.2 8.1 7.9 7.4 6.9 6.6 6.5 6.5 6.5 6.2 6.1 5.8 5.7 5.1 4.9 4.8 4.4 4.1 3.7 3.6 3.5 3.5 3.5 3.4 3.1 3.1 3.1 2.8 2.6 2.3 2.3 2.3 2.3 2.3 2.1 1.8 1.1 1.0 0.7 0.5 0.5 0.3 0.3 0.2 0.2 0 0

Men 14.6 16.1 12.2 12.7 10.6 11.7 11.0 10.6 9.5 9.4 12.0 9.3 12.2 8.1 10.2 8.3 8.0 6.4 5.6 6.6 5.1 5.4 5.6 5.5 5.9 4.7 4.9 4.4 5.4 3.7 4.0 5.0 2.9 3.6 3.7 3.4 2.5 1.8 2.2 2.0 1.1 0.9 0.6 0.5 0.5 0.2 0.3 0.1 0

Women 3.7 1.9 4.4 3.7 5.2 3.2 3.0 2.9 3.7 3.6 0.9 3.2 0.0 3.4 1.4 1.9 1.8 3.2 2.4 1.4 2.3 2.0 1.6 1.5 1.2 2.2 0.5 1.7 1.0 0.0 1.1 0.0 1.7 1.0 0.9 1.2 1.7 1.9 0.0 0.0 0.2 0.1 0.4 0.1 0.2 0.1 0.1 0.0 0

27

RD Goldney

an issue in some other countries. This is also true for the detoxication of car emissions, as in some developing countries the availability of motor vehicles as a method of suicide is not an issue. However, for those countries where the use of carbon monoxide from vehicles is prevalent, the provision of catalytic converters to detoxify emissions or cabin sensors to automatically disengage engines is technically feasible.21 In a number of countries, such as Sri Lanka, India and some of the Pacic nations (e.g. Western Samoa), other toxic substances such as pesticides predominate, and legislation as well as educational programs for safe storage are required. In countries where prescribed drugs are the most prominent cause of suicide, stricter legislation in prescribing such medication and education of physicians to prescribe the least toxic medication should be encouraged.21 The role of the media is important in a small proportion of those who suicide and again the relative importance of this will vary between different countries. Studies in Austria, Canada, the Netherlands, the UK and the USA have supported the view that if the media behave responsibly by minimizing sensational depictions about suicide, there will probably be fewer suicides by imitation.22 The importance of the media in contributing to suicide has probably been overestimated, because even among young women, the group most likely to be inuenced by such publicity, no more than 56% of suicides could be attributed to such publicity. It is doubtful whether the inuence of the media could be considered responsible for more than 12% of suicides.23 Considering the lost opportunities for intervention elsewhere, for example in the treatment of mental illness in the suicidal,2426 it is more important to focus on important clinical issues, rather than scapegoating the media.23 The implementation of these non-clinical WHO approaches may require rm advocacy from professionals, volunteers and those with suicidal impulses. Indeed, although suicidal persons are often in situations which lack autonomy and inuence, by enhancing their coping skills through environmental change it is probable that suicidal behaviour will be diminished. This may involve advocacy at the legislative level, for example in decriminalizing suicidal behaviour in those countries where this has not yet been achieved.

Psychiatric illness
Psychiatric illness is an important factor in suicide. Psychological autopsy studies, in which a careful 28

examination of factors leading up to a suicide have been examined in a manner analogous to the traditional autopsy, have been published from a number of different countries including USA, Sweden, Finland, Australia, New Zealand, Taiwan, Hungary, England, and India. These have demonstrated that over 90% of suicides had recognizable psychiatric illness at the time of their death.27 Major depression occurs in 6070% of suicides. Schizophrenia is less common, although it has been reported in up to 19% of suicides in those under the age of 35.28 The vast majority of psychiatric illnesses have an increased risk of suicide, as illustrated by a meta-analysis of outcome studies showing a signicantly raised standardized mortality ratio for suicide for 36 of 42 mental disorders examined, with only one of the remaining conditions, mental retardation, not having any increase.29 Co-morbidity is also frequent, particularly with substance dependence, usually alcohol. With regard to depression, although denitions vary from country to country, careful analysis of symptoms in those who have suicided has demonstrated that depression appears universal across countries, rather than simply being a construct of Western psychiatric practice. This has been shown particularly by Cheng in Taiwan30 and Vijayakumar in India.31 There is often a window of opportunity for preventing suicide, as many who engage in suicidal behaviour have had recent contact with the helping professions. This is so even for younger age groups, where for suicides under the age of 20 years, only 5% have symptoms indicative of psychiatric illness for less than 3 months.32 However, it is of concern that such contact has not always resulted in adequate management, as some studies have revealed that not all of those who have suicided have had the potential benet of standard treatments.2426 This is important, because careful assessment, diagnosis and management of depression and schizophrenia, conditions in which up to 12% die by suicide, can reduce suicidal behaviour.33 These ndings emphasize the importance of the treatment of psychiatric illness in the prevention of suicide. However, it does not necessarily follow that all who are suicidal require psychiatric treatment, because a number of interventions, including sensitive assessment and management in the ED setting, as well as the support of volunteers, can alleviate much of the distress associated with psychiatric illness.

Global view of suicidal behaviour

Other risk factors

In addition to psychiatric illness, certain signs signal the possibility of suicide. The expression of suicidal intent with agitation, guilt, hopelessness and constriction of interests with self-absorption are particularly ominous indicators.34 So too is malignant alienation35 where the therapists patience has been exhausted, sometimes with resulting disparaging comments being made to those who are suicidal. Certain groups are particularly at risk for suicidal behaviour. These include those with a past history of attempted suicide, alcohol and other substance dependent persons, young males, the elderly, the bereaved, indigenous groups, those with sexual identity conicts, migrants, those living in rural areas, those in prison custody, and those with debilitating physical illness.
Past history of attempted suicide

such as Japan. Contributing factors include a break down in family relationships, unemployment and a change in social roles in young men. Mental disorders are important even in the younger age groups, although less so in those few children under the age of 15 years who commit suicide.38 Seeking treatment for emotional illness is not easy for young men, and a changed community attitude is necessary. The community must acknowledge that there are effective treatments so that young men, who have traditionally rejected treatment for emotional conditions, feel free to pursue assessment and management.
The elderly

Those who attempt suicide are more likely to complete suicide in the future than other groups.36 About 1% per year of those who attempt suicide go on to complete suicide, and the risk is particularly high in the rst year after an attempt. This is clearly a highrisk group. Full assessment is required, with attention to socio-cultural factors, optimum management of mental disorders, and promotion of more appropriate problem solving methods.
Alcohol and other substance abuse

Alcohol and other substance dependence is associated with an increased risk of suicide.37 Such abuse may be related to the individual attempting to treat him or herself with that substance, with underlying depressive or other psychiatric illness present. That is not always so, and assessment of any underlying emotional condition is only possible when the person is abstinent. The relative importance of alcohol and other substance dependence varies greatly from country to country. For example, alcohol abuse is not ofcially considered to be a problem in Islamic countries, whereas in other countries, such as the Eastern European block, alcohol is a potent contributing factor to suicidal behaviour.
Young males

In most countries the suicide rate is greatest in the elderly. However, that is not so in Australia and New Zealand, where there has been a decrease in the last 20 years. This is probably related to better recognition and treatment of illness in older age groups, and better social security safety nets.39 Depression is often understated in the elderly, and cognitive functioning can deteriorate with associated diminution in social functioning. Sometimes mental deterioration in the elderly is accepted as inevitable, but this attitude should be challenged. There is no reason why emotional illness in the elderly should not be treated vigorously. Sometimes the apparent memory disturbance can be seen in retrospect to have been pseudo dementia, with the presenting picture clouded by mental disorder. Requests for euthanasia or assisted suicide in the elderly should not be taken at face value, and treatable mental disorders should be carefully sought.40 Alcohol and other substance abuse is also prevalent in the elderly, and may be a pointer towards an underlying disorder. Physical illness is also more common, and clinicians may explain away emotional symptoms as being associated with physical illness, when emotional symptoms may need vigorous treatment in their own right. Many drugs in general medicine can also produce unwanted emotional side-effects. In treating the elderly it is important to be cautious about doses of psychotropic medication, as impaired renal and hepatic function may lead to elevated serum levels of antidepressants and other psychotropics.
The bereaved

In a number of countries, particularly Australia and New Zealand, there has been an increase in suicide in young males.9 This has not been seen in some societies

Those who have experienced the death of others, particularly by suicide, appear more vulnerable to 29

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suicidal impulses, 41 particularly at the anniversary of the deaths. An expression of a wish to join somebody who has died should be interpreted as of grave signicance. Careful judgement is required to decide when a bereavement process should be considered part of a depressive disorder. Grief is usually focused on the lost object, whereas clinical depression has symptoms which are more self-centred, with feelings of guilt. However, it can be challenging to distinguish these. Guidelines vary from country to country, but it is considered that depressive symptomatology persisting for longer than 6 months after bereavement should be treated in its own right, rather than being considered part of a grief and mourning process which will resolve spontaneously.
Indigenous groups

should not minimize the importance of mental disorders when they are present.
Those in rural areas

Indigenous groups in many parts of the world have increased rates of suicide. This is so in the Inuit in Canada, in the American Indians, in the New Zealand Maori42 and in Australian Aborigines.43 The reasons are complex and involve socio-cultural factors and associated mental disorders. Socio-cultural factors probably predominate, as those groups have often suffered quite extreme social, environmental and emotional deprivation, with disruption of traditional values. Often this leads to alcohol and substance abuse. Although the main aim in inuencing the overall suicide rate of such communities involves political/ social action rather than specic individual treatment, the prevention of individual suicide is essentially a personal matter and emotional suffering must be addressed along the usual lines.
Sexual identity conicts

In some countries there is a particular problem in regard to suicide in rural areas. This is so in Australia where the suicide rate in small communities is two or three times that of major population centres.46 Social change with the amalgamation of small farms into larger holdings, and the resultant increase in unemployment in the rural sector, leads to a breakdown in family relationships. With the ready availability of rearms and agricultural poisons in rural areas, there is a potent amalgam of factors leading to suicide. This is compounded by the paucity of social and health services in rural areas and overall management is not simple. However, in addition to social and political action, individual therapists still have the responsibility of assessing, detecting and managing the mental disorders which result from the diverse factors affecting those living in rural areas.
Those in prison/custody

Those in custody have a higher rate of suicide47 particularly during the initial phases of custody, and for those who have committed more serious offences, such as murder. This is not unexpected because the sometimes antisocial or impulsive behaviour may be associated with mental disorders, and also with alcohol and substance abuse. The loss of social supports and rejection from others that imprisonment entails are also potent stressors. Every community has a considerable responsibility to those in custody, and this involves the provision of readily available assessment and treatment services.
Persons with debilitating physical illness

Those with conicts about their sexual identity are more at risk for suicidal behaviour.44 Although sensitivity to these issues is required in establishing any suicide prevention programme, it is important not to miss any associated mental disorder, and to address the varying degrees of societal acceptance, depending on the cultural views of individual countries.
Migrants

Migration can be between countries, or within a country, for example from rural areas to the city.45 Persons who migrate are deprived of stable social supports, the provision of which can reduce overall suicide potential. However, the fact of migration 30

The presence of severe physical illness is associated with an increased rate of suicide, particularly when it involves chronic pain.48 Adequate control of pain and care of the dependency needs of those with physical illness are essential. A sensitive understanding is required of the emotional effects of the threat of physical illness, a threat which can be anxiety provoking, in addition to loss and potential loss, which leads to depression. It is the individual patients perception of the condition that is important, and caution is urged in the treatment of those who focus intently with hypochondriacal delusions on their illness.

Global view of suicidal behaviour

There may be a tendency to consider emotional distress associated with debilitating illness to be understandable and not in need of specic treatment. This issue requires careful clinical judgement, the judicious use of non-pharmacological support and encouragement of coping procedures, as well as the occasional use of psychotropic medication.

The individual approach

Although psychiatric illness is commonly associated with suicidal behaviour, a broad biopsychosocial approach is essential. A careful and comprehensive assessment of a persons needs is required before formulation of an overall management programme. The following guidelines for assessment and management of suicidal individuals from the International Association for Suicide Prevention49 can be used in conjunction with others such as those of the ACEM and the Royal Australian and New Zealand College of Psychiatrists.50

professional, differing questions will be asked. Challenging or direct questions which could be interpreted as critical rarely help. Rather, comments such as things seem to have got on top of you or you must have been pretty upset are often sufcient to allow persons to talk about their difculties, and the open ended comment Can you tell me more about it? is often useful. Some may remain resistant, but by stressing that it is important to understand what is happening and by the use of silence, which further indicates a willingness to listen, most will respond and rapport will be achieved.

Degree of suicidal intent

More direct questions may be necessary to elucidate the degree of suicidal intent. Suicidal thoughts and behaviour usually revolve around interpersonal phenomena and the role of people of signicance to the person should be sought. This may necessitate a systematic enquiry about relationships with family members and friends. More specically, suicidal intent can be determined on the basis of the degree of planning, knowledge of the lethality of the intended suicidal act, the degree of isolation of the person, and also by asking open ended questions such as What are your feelings about living and dying?. Such a question permits those with suicidal thoughts to express their feelings in a way that is not provided for by direct questions such as Do you really want to kill yourself?, which does not allow for almost invariably present ambivalent feelings.

First Contact
People with suicidal thoughts or actions evoke mixed feelings in other people. Volunteer workers and health professionals such as social workers, psychologists and psychiatrists are not immune to antitherapeutic thoughts and feelings. Not everybody should assume responsibility for treating those with suicidal thoughts and actions, but those in situations where such persons may present, such as hospital ED, should have the skills to make a general assessment, despite not continuing management. Indeed, potential therapists should be aware of their limitations and seek the assistance of colleagues with appropriate referral. Initial contact with suicidal persons is particularly important, but often occurs in less than ideal circumstances, such as a busy ED, the persons home, or on the telephone. In some countries this causes difculties with privacy and condentiality. Suicidal persons have often recently perceived rejection, and considerable expertise and patience may be required to establish rapport. This can be achieved by indicating a wish to understand what is happening to that person and that time has been set aside to do so. Having established a reasonable environment in which to assess the person, that person should be allowed to present a full history. Depending on whether the assessing person is a volunteer or a health

Initial management
The most important initial decision is based on assessment of the safety of the suicidal person. The classication of immediate, serious and lesser risks delineated in the Guidelines endorsed by the Colleges of Emergency Medicine and Psychiatrists is of practical value.50 For those at immediate risk with severe psychiatric illness and marked suicidal ideation, hospitalization is necessary. Sometimes compulsory detention is required to reduce the likelihood of danger to the person or to others. In that case, it must be emphasized that it is to protect the person, rather than to punish them for their suicidality. For those at serious risk, hospitalization may still be appropriate, and full psychiatric assessment should be provided as well as initial emergency care. 31

RD Goldney

For those at lesser risk the opportunity of ventilating thoughts and feelings to a concerned person may be sufcient therapy. In the absence of psychiatric illness, and if suicidal thoughts and actions have resulted in positive changes in personal relationships, further contact may appear to be unnecessary. However, the opportunity for follow up should be left open, particularly if there are inadequate social supports.

Subsequent management
Most people benet from some ongoing contact. This should be structured to meet individual needs, and clearly delineated follow-up appointments, preferably with the same therapist, should be scheduled. Few require support for longer than 2 or 3 months. This can involve 36 sessions, each of sufcient duration to allow the person to deal with current interpersonal difculties. Signicant other people, such as the persons partner, should be involved, because the presence of a neutral therapist allows the expression of mixed feelings in a controlled manner. Such feelings may have been expressed in the past by suicidal threats and actions. Those who care for persons who are suicidal must listen to their demands. However, such demands cannot be met unconditionally, and tact is required in pointing out responsibility for actions. It is useful to insist that they clearly describe their options, other than suicidal behaviour, should they nd themselves in a similar crisis in the future.

that the drugs could be used in a suicide attempt. However, if the signs and symptoms warrant the use of antidepressant, antianxiety or antipsychotic medication, there is no reason why the potential benets of such medication should be denied to the suicidal person. This is so for a number of different conditions, particularly major depression and schizophrenia. The most commonly prescribed medications are antidepressants, which are particularly useful for patients with the classic biological features of depression, including agitation, insomnia, loss of weight, poor concentration and lowered libido, as well as suicidal ideation. It is imperative to use an adequate dose of antidepressants, and to be aware of the potential risk of suicide with such drugs because of their toxicity. The newer antidepressants are less toxic in overdose and should be used if there is any concern about suicidal behaviour.

Longer-term care
Suicidal ideation and behaviour tend to recur, depending on the nature of ongoing interpersonal stressors and any associated psychiatric illness. Although the aim of management should be to treat existing psychiatric illness and enhance the coping skills and independence of patients, ne clinical judgement is required in assessing the need for ongoing contact. There is increasing evidence that some patients require ongoing care, and that reductions in care can be associated with suicide.51 Therapists and those who have been suicidal should be aware of the warning signs of relapse, and that some people need maintenance medication and emotional support, either of a professional or volunteer nature, in the longer term. This is particularly so in recurrent depressive and schizophrenic disorders.

Encouraging independence and coping skills

There is a ne line between fostering independence and appearing to reject the suicidal. It should be made quite clear that the therapists involvement is time limited and that condence can be expressed in the persons ability to cope in a more adaptive manner when future crises arise, despite them not felling completely at ease. Although an aim of the intervention is to encourage the person to live independently of helping professionals, some persons, such as young single parents with few family and social supports and patients with borderline personalities and chronic mental disorders, require longer-term supportive contact.

Conclusion
There are a number of ways in which suicidal behaviour can be managed and prevented. An increasing awareness of this has resulted in National programmes such as those in Finland 52 Australia 53 and New Zealand.54 Such programmes have two broad themes: the social and individual. Broad social issues can be inuenced by rm advocacy for change in appropriate areas in different countries, such as by restricting

Use of physical treatments

There is always concern about prescribing drugs when persons are suicidal, because there is some risk 32

Global view of suicidal behaviour

access to specic means of suicide and by enhancing health and social services in general. At the individual level, after the establishment of rapport, there should be screening for the presence of specic mental disorders, which, if present, should be treated vigorously. If medication is indicated, the safest drug should be prescribed, although even if drugs are utilized, non-drug treatment is important in every suicidal person. The focus of supportive therapy, which can be provided by both the helping professions and volunteer organizations, is the provision of hope for the future, the enhancement of independence, and the learning of different ways of coping with the inevitable stressors of everyday life. Rather than the sense of pessimism which pervaded some of the literature a decade ago, there is now a sense of optimism that with attention addressed to these issues, inroads into the unacceptable world wide levels of suicidal behaviour can be made.

12. Hoyert DL, Kochanek KD, Murphy SL. Deaths: Final data for 1997. National Vital Statistics Report, 47 (19). Hyattsville: National Centre for Health Statistics, 1999. 13. van Heeringen K, Hawton K, Williams JMG. Pathways to suicide: an integrated approach. In: Hawton K, van Heeringen K, (eds). The International Handbook of Suicide and Attempted Suicide. Chichester: John Wiley and Sons, 2000; 223 34. 14. Beautrais AL, Joyce PR, Mulder RT, Fergusson DM, Deavoll BJ, Nightingale SK. Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a casecontrol study. Am. J. Psychiatry 1996; 153: 8. 15. Beautrais AL. risk factors for suicide and attempted suicide among young people. In: Commonwealth Department of Health and Aged Care, National Youth Suicide Prevention Strategy Setting the evidence-based research agenda for Australia. Canberra: Commonwealth of Australia, 1999. 16. Traskman-Bendz L, Mann JJ. Biological aspects of suicidal behaviour. In: Hawton K, van Heeringen K (eds). The International Handbook of Suicide and Attempted Suicide . Chichester: John Wiley and Sons, 2000; 65 78. 17. World Health Organisation. Guidelines for the Primary Prevention of Mental, Neurological and Psychosocial Disorders . Geneva: WHO, 1993. 18. Cantor CH, Baume PJ. Changing methods of suicide by young Australians 19711994. Arch. Suicide Res. 1998; 4: 4150. 19. Martin GD, Goldney RD. Guns and Suicide in Australia. Med. J. Aust. 1997; 166: 5. 20. Beautrais AL, Joyce PR, Mulder RT. Access to rearms and risks of suicide: a case-control study. Aust. N. Z. J. Psychiatry 1996; 30: 741 8. 21. Jenkins R, Singh B. General population strategies of suicide prevention. In: Hawton K, van Heeringen K (eds). The International Handbook of Suicide and Attempted Suicide . Chichester: John Wiley and Sons, 2000: 597 616. 22. Schmidtke A, Schaller S. The role of mass media in suicide prevention. In: Hawton K, van Heeringen K (eds). The International Handbook of Suicide and Attempted Suicide . Chichester: John Wiley and Sons, 2000: 675 98. 23. Goldney RD. The privilege and responsibility of suicide prevention. Crisis 2000; 21: 8 15. 24. Hulten A, Wasserman D. Lack of continuity A problem in the care of young suicides. Acta Psychiatr Scand. 1998; 97: 326 33. 25. Waern M, Beskow J, Runeson B, Skoog I. Suicidal feelings in the last years of life in elderly people who commit suicide. Lancet 1999; 99: 407 11. 26. Isacsson G, Holmgren P, Wasserman D, Bergman U. Use of antidepressants among people committing suicide in Sweden. BMJ 1994; 308: 506 9. 27. Tanney BL. Psychiatric diagnoses and suicidal acts. In: Maris RW, Berman AL, Silverman MM (eds). Comprehensive Textbook of Suicidology. New York: Guilford, 2000; 311 41. 28. Appleby L, Cooper J, Amos T, Faragher B. Psychological autopsy study of suicides by people aged under 35. Br. J. Psychiatry 1999; 175: 168 74. 29. Harris EC, Barraclough B. Suicide as an outcome for mental disorders. Br. J. Psychiatry 1997; 170: 205 28. 30. Cheng ATA. Mental illness and suicide: a case-control study in East Taiwan. Arch. Gen. Psychiatry 1995; 52: 594 603.

Acknowledgements
This paper has been adapted from International Association for Suicide Prevention Guidelines which were formulated with the assistance of an unrestricted educational grant from H. Lundbeck A/S Denmark.

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