PREVENTION OF SUICIDE WORLD HEALTH ORGANIZATION GENEVA 1968© World Health Organization 1968 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Con. vention. Nevertheless governmental agencies or learned and professional societies Imay reproduce data or excerpts or illustrations from thea without requesting an ‘euthorization from the World Health Organization, For rights of reproduction or translation of WHO publications in roto, applica tion should be made to the Division of Editorial und! Reference Services, World Health Orgenization, Geneva, Switzerland, The World Health Organization wel- comes such applications. Authors alone are responsible for views expressed in Publie Health Papers. ‘The designations employed and the presentation of the material in this publica: tion do not imply the expression of any opinion whatsoever on the part of the Director-General of the World Health Organization concerning the legal stats of any country oF territory or of its authorities, or concerning the delimitation of its frontiers,CONTENTS Preface 2... Introduction. . Preventive measures ‘i Prevention of fatal outcome of suicidal nets + Prevention of repetition of suicidal acis Prevention of first suicidal attempt Provention of desire to attempt suicide Ientifiation and care of high-risk grours Organization of suicide-prevention services Existing services... Steps in development of services Education and training programmes . Content and presentation . Programmes for the general public Programmes for medical. personnel Programmes for mental health personnel Programmes for nurses and social workers Programmes for other professional groups... Programmes for personel in specialized ‘suicide presen Hon servi ee Statistics and research . ‘Statistics currently available. Methods used to collect data on sticide’ Statistical tabulations Reliability of available suicide statistics Improving value of statistics Enidemiologieal and. ecological research Clinical research ses Annex 1, Annotations to text Annex 2. Tables on factors related to suicide and attempted suicide Annex 3. Data on death rates from suicide in selec ted countries by selected variables References 5 ae eae 68 1”PREFACE The main purpose of this publication is to draw the attention of national and local health authorities to the extent and nature of the problem of suicide and the possibilities of suicide prevention. During the latter part of 1966, WHO began gathering information on suicide prevention in various countries, mainly through informal dis- ‘cussions with experts who had experience in the organization of services for suicide prevention and in research on this subject. The following took part in these discussions :* Dr, Asuni, Neuropsychiatric Centre, Aro Hospital, Absokuta, Western Nigeria Dr N. L. Parberow, Suicide Provention Center, Los’ Angeles, Cal., USA Professor P. Kietholz, Psychiatrischo Universtitslinik, Basle, Switzerland Dr E. Ringel, Poychiatrisch-Neurologische Universititsklinik, Vienna, Anstria Dr P. Ssinsbury, Director of Research, Medical Research Council Clinical Paychiatry Research Group, Graylingwell Hospital, Chichester, England Professor E. Stengel, University Department of Psychiatry, Sheffield, England Dr P. M. Yap, Senior Payehisttic Specialist, Medical Department, Hong Kong Paychiatric Centre, Hong Kong. Secretariat : Dr P. Baan, Chief Medical Officer, Mental Health, WHO, Geneva Mrs Joy Moser, Scientist, Mental Health, WHO, Geneva Dr Farberow and Dr Sainsbury prepared a drajt report of the discussions and later the WHO Secretariat reviewed the literature on the subject and made a selection of material to illustrate and reinforce the main arguments, The present publication is a synthesis of the report, in an expanded form, together with the literature review. The original draft underwent several revisions, faking into account sugges- tions and new material provided by the experts listed above and by Time ob ie epee ted ae anc at Side esensee: th fcbiens sebys ft Bexctve Coneiten of the Inpaionsl PEGE SUSI ee meena se Wile8 PREVENTION OF SUICIDE others to whom the text was submitted for comment. Grateful acknowledgement is made to the following for their assistance : Professor N. Kessel, University Department of Psychiatry, Manchester, England Sir Aubrey Lewis, formerly Professor of Payehiatry, Institute of Puychiatry, Maudsley Hospital, London, England Dr P. Prokupek, Postgraduate Medical Institute, Department of Psychiatry, Prague, Czechoslovakia Dr E. S. Shneidmen, Chief, Center for Studies of Suicide Prevention, National Institute of Mental Health, Md, USA. Dr A. Stoller, Chief Clinical Officer, Mental Health Authority, Vietori, ‘Avsialia In the following pages, consideration is given to preventive measures, ‘he organization of suicide-prevention services, education and training programmes jor suicide prevention, and statistics and research. Supple ‘mentary notes and literature references are given in Annex 1. Data from studies on suicide and attempted suicide are reproduced in tabular or graphic form in Annexes 2 and 3. The data are presented in such @ way as to facilitate reference to investigations on particular aspects of suicide ; they also indicate the range of the findings and some of the reasons for the differences. However, attention is drawn 10 the fact that the data are not statistically comparable, because of variations between types of population studied and methods of investigation. It is hoped that the detailed information given in the annexes will provide 4 starting point for the much needed further research on the prevention of suicide.INTRODUCTION EXTENT OF THE PROBLEM Prevention of suicide (1)* is an important public health responsibility. Although reliable figures are not available for many areas, it has been estimated that an average of at least 1000 persons a day commit suicide in the world, The figure of about half a million persons a year dying by their own hand represents only a small part of the total problem connected with suicide. It has been estimated conservatively that the ratio of attempted suicide to suicide is eight to one (2). Thus, there are likely to be several million people attempting suicide in the world in any one year. As a cause of death, suicide has ranked among the first five to ten in most European countries and North America for many years. More- over, the improvement over the years in mortality rates for many phy- sical diseases is not reflected in suicide rates. Investigations have shown that suicide in developing countries is 2 more important problem than was formerly suspected. ‘The most recent figures for 21 countries (1951-63) show annual average suicide rates varying from 7.1 to 33.9 per 100000 of the Population from 15 years of age.* Several investigators consider that the actual rates are likely to be considerably higher than those reported. @). Gross under-reporting may be due to a combination of factors, such as unwillingness to report a death as suicide owing to the legal and social repercussions on the survivors, and in some cases the equiv- ‘cal nature of the mode of death. Although in general the rates for males are much higher than for females at all ages, the rates for the latter are showing a tendency to rise in many countries, whereas the male rate is dectining. National rates are seen to rise to a maximum in old age but, because of the concomitant high death rate from all causes, suicide is propor- 910 PREVENTION OF SUICIDE tionately not conspicuous as a cause of death in the aged. Moreover, in several areas the rate declines after about 65-75 years of age, especially among females. In a few countries a secondary, though much lower, peak occurs in the age groups 15-24 where, because of the low general death-rate, suicide may appear as a prominent cause of death, ‘There is evidence that the suicide rate is rising among the ‘younger age groups in some parts of the world, Increasing attention is being given to the study of attempted suicide. Despite the difficulty of securing reliable statistics, it appears certain that the rates are much higher than for suicide and have shown considerable increase in recent years in some areas (4). In general the female rate for attempted suicide is much higher than the male and the incidence is much greater in the younger age-groups than in the aged. § OF PREVENTION Whatever the local conditions, measures taken to lower the inci- dence of suicide would have the fourfold aim of preventing : (a) fatal outcome of suicidal acts ; (6) repetition of suicidal acts ; (¢) the first suicidal attempt ; and (d) the desire to attempt suicide, In each case, success would depend largely on early identification and adequate treatment of high-risk populations. Where emergency medical services exist, they are usually well equipped for the employment of life-saving techniques, but once the patient’ life is out of danger, he is all too often discharged to face the same situation that led to the suicidal act. Follow-up studies have shown the greatly increased risk of suicide among persons who have previously made suicidal attempts or threatened to do so. Preventive programmes would therefore do well to focus initially on such identified groups. ‘An important finding is that suicidal act is committed frequently a “cry for help” rather than with a clear desire to dic. It would appear that where this ery for help can be answered, and the help can be continued in an attempt to solve the outstanding. problems leading to the act, much suffering may be relieved and renewed attempts may be prevented. This has been the impression of a number of ser- vices set up in recent years. Further inquiry is needed into the working ‘of such services. Attempts at evaluation should lead to increase in efficacy. Publication of the findings could be expected to result in ‘more widespread organization of suicide prevention. Such activities, however, presuppose an increase in public understanding of suicide. Programmes of public education need to emphasize the importance ofINTRODUCTION rt taking suicidal threats and attempts seriously. At the same time, special training courses are required for volunteer and professional personnel to assist in early recognition of high-risk cases and treatment or referral and after-care. Improved training of doctors is required in the recognition, assessment and management of high-risk clinical groups. Of particular importance are the group with depressive illness and alcoholics. STATISTICS AND RESEARCH From information already collected and analysed, valuable indica- tions for suicide prevention have been derived. An examination of available data suggests, however, that improved methods of collecting, compiting and analysing statistics are needed asa basis for further research on the incidence, causes and prevention of suicide. Many investigations have been carried out on the relationship between suicide rates and various socio-economic factors and individual charac- teristics. Although certain similarities are found in rates and associated conditions between the areas studied, important differences are appar- ent. It would therefore be inappropriate to generalize findings and adopt uniform solutions. What is now required is the careful compil- ation and analysis of evidence on a community level as a foundation on Which to establish preventive services consonant with local requirements, This is an urgent task facing public health authorities, ‘TERMINOLOGY The terms “suicide” and “attempted suicide” have been used to cover a wide range of self-damaging acts undertaken with varying degrees of lethal intent and with varying degrees of awareness of the possible consequences. It is not always possible to decide whether the intention was self-destruction or whether the act was meant merely as @ gesture. The possibility of an accident has also to be considered (5) Since there is no general agreement on the connotation of the above terms, the expression “suicidal act” is used in this publication to denote the self-infliction of injury with varying degrees of fethal intent and awareness of motive, For the purposes of this paper, “suicide” means a suicidsl act with fatal outcome, ‘attempted suicide ” one with non-fatal outcome, For a variety of reasons, the two are treated as separate categories (6).PREVENTIVE MEASURES PREVENTION OF FATAL OUTCOME OF SUICIDAL ACTS Dissemination of knowledge on life-saving techniques is important in the prevention of a fatal outcome of suicidal acts. The proportion of deaths averted depends not only on the efficiency of the techniques employed but also on the speed with which the patient can be identified and brought under care. In some areas of the world, special facilities have been established for provision of specific emergency information and treatment, As mentioned above, an important increase in cases of selt-poisoning has been observed in recent years in several countries A percentage of the deaths resulting from the unpremeditated usc of drugs lying about the house might be prevented by improved control of prescribing and sale of drugs, identification of drugs by individuat marking and the removal of unnecessary and dangerous drugs from the home. Toxicological research has improved the prognosis in cases of self- poisoning. In many countries poison-information bureaux are avail- able to supply details of treatment {o doctors in emergencies and in some areas specific poison-control centres (often attached to the inform. ation bureaux) carry out treatment. ‘Training in artificial respiration, including newer methods such as ‘mouth-to-mouth breathing, has become widespread in some countries The availability of special resuscitation apparatus through the police force and fire services can help to prevent the fatal outcome of attempts at self-asphyxiation. Preferred methods of committing suicide vary considerably from place to place and show changes over time, the choice depending partly on availability of means and fashion (see Annex 2, Table 1). Even in the same area, the preferred methods may show variation according to ethnic origin (7). In many developed countries, the commonest me- thods are poisoning with domestic gas, barbiturates or analgesics and use of fire-arms and explosives. Hanging and drowning top the list in some areas. Regularly repeated analyses of statistics on methods used 2pPREVENTIVE MEASURES 13 should assist in organizing services for the speedy use of life-saving techniques. It is not certain that reducing the availability of a common ‘method of committing suicide will necessarily lower the suicide rate. Tt may merely result in a change of preferred method (8). PREVENTION OF REPETINION OF SUICIDAL ACTS All studies carried out indicate that a person who has made a previous attempt is more likely to die through suicide than one who has no history of suicide attempt. Tf there have been two previous attempts, the subsequent risk of suicide is considerably increased. Table 2 (Annex 2) shows that in the studies analysed, when the period of follow- up observation has been less than five years, 5% or fewer of the suicidal patients on the average have killed themselves. Where the follow-up has been longer, the proportion of the patients found to have committed suicide has been higher — up to 10 % (9). ‘The data in Table 3 (Annex 2), showing the incidence of previous suicidal attempts, are probably less reliable. For the cases of suicide, the information is extracted from coroners’ inquests where information is often very limited, whereas for attempted suicide the information may be obtained from the patients themselves or their relatives, or may be based on long-standing acquaintance with the patients. The same applies to many of the other data in the tables. ‘Attention has been drawn to the fact that the danger of repetition of a suicidal attempt depends on whether the act has brought about a ‘change in the life situation and mental state. For many, the attempt ‘may have a cathartic effect, through release of aggression (10). ‘A number of workers have tried to assess the “seriousness ” of suicide attempts. Some have divided those who attempt suicide into three groups : those who follow a strong impulse to die and leave little to chance — males being represented in excess ; those who are mainly crying for help and who would appear anxious to ensure survival ; and an intermediate group who are confused and undecided and act, ‘on impulse, leaving the chance of survival to fate (11). It has been suggested that i( may become possible to assess “ suicide potential ” by certain indicators (12). However, as has been pointed out (13), many social, ecological and personality factors that appear related to the setiousness of attempts in large-scale studies may not be useful for prediction with small samples or individual patients. ‘Two probable exceptions are that (a) a suicidal attempt in the elderly is more likely to be followed up by a subsequent suicide than it is in the young, and (©) the suicidal attempt in manic-depressives (depressive phase) is more likely to be serious than in non-depressives (14).14 PREVENTION OF SUICIDE Recently it has been stressed that there is considerable advantage in making a thorough psychiatric assessment of all suicidal cases ad- mitted to emergency medical services within a few hours of admission. At that time inquiries are made into the situation while its impact is still very strong and before the family and patient attempt to cover up the underlying factors. During their brief stay in the emergency ser- vice, such patients can be screened and their further care discussed with the family and other persons most closely concerned and with the therapeutic team, which could profitably include the general medical practitioner (family doctor), a psychiatrist and a social worker (15). Once such contact has been established with psychiatric services, the patient may be induced to apply voluntarily for help in times of distress instead of resorting again to suicidal behaviour. The family or other persons in contact with the patient can be warmed in certain cases of the danger of recurrence and advised to apply for help in good time. Wherever possible, it would appear advisable to arrange for follow- up at intervals of persons who have made a suicidal attempt. Long- ‘tudinal studies of all reported cases of self-poisoning and self-injury in defined populations should throw light on some of the factors involved in high risk of suicide (16). PREVENTION OF FIRST SUICIDAL ATTEMPT In the earlier stages of prevention, much might be done by recognition of suicidal intent and provision of support. Several studies have shown that a high percentage of persons com- mitting or attempting suicide had given previous warning of their intent, Some investigators consider that in practically all eases some verbal or behavioural clues as to the intent are given. Frequently these may be interpreted as conscious or unconscious appeals for help before the suicidal act occurs. All too often, however, even when such warnings are noted, they are not acted upon (17). In some areas it has been found that more than half the persons committing suicide had seen a physician within three months of the event, and studies have shown that tup to a quarter had had psychiatric contact (see Annex 2, Table 4). It is, therefore, highly desirable that increased attention be given in medical training to the recognition of indices of suicidal intent. Care- fully prepared information on this matter and on initiation of appropri- ate procedures for help could be presented also to other professional groups (see p. 30).PREVENTIVE MEASURES 15 PREVENTION OF DESIRE TO ATTEMPT SUICIDE Measures leading to development of sound mental health and a well adjusted personality are likely to be conducive to prevention of suicide : ‘unfortunately, all too little is known about the nature and application of such measures. Research on parental deprivation in childhood and its possible sequelae have indicated that measures can be — and often are — taken to minimize adverse effects. Certain studies suggest that differences in methods of child rearing may account for some differences in suicide rates between countries (18). Studies of relationships between morbid hostility, suicide and hom- icide have shed some light on the cultural influences predisposing 10 these manifestations, which might possibly be manipulated in long-term. efforts at prevention (19). However, the results cannot be used for general application, Many investigations have pointed to a disry relations as being a main precipitating factor in st There is now some evidence that the recently instituted 24-hour telephone services, giving isolated, lonely or desperate persons a possi- bility to communicate, may help to avert suicidal acts (21). IDENTIFICATION AND CARE OF HIGH-RISK GROUPS Epidemiological studies have thrown light on the groups of persons with a high risk of suicide. In planning suicide-prevention services for a particular community, carefully designed epidemiological and ecolo- gical studies of the defined area to be served can be of great value for identification of the factors associated with high risk of suicidal behaviour. These factors are not necessarily the same from one community to another, although a number are found to recur in similar combinations in very different parts of the world, Reference to some of the more recent investigations is made in Annex 1. The aged In most areas of the world there is a particularly high tisk of fatal outcome of suicidal acts in the older age-groups. Female suicide rates, tend to show considerably less increase with age than do male rates, (ee Annex 3), Physical and mental ill-health, social isolation, death of a loved one, break in routine and loss of occupation and social role, particularly among men on retirement, together with a sudden lowering16 PREVENTION OF SUICIDE of income, are frequently associated with high suicide rates in the aging and aged (22). Possibilities of prevention of suicide in later life would appear to depend largely on the scale and efficiency of the economic, social, welfare and medical services available to the aged. The decline in the rates after age 65-75 in some countries may be a reflection of such preventive effects together, possibly, with change in the social status of females (23). Younger age-groups In the younger age-groups, where the suicide rates are in general ‘much lower, a comparatively high risk of suicide has been found among some university student populations (24). Extension of university psychiatric services has been indicated as a preventive measure. The risk of attempted suicide with non-fatal outcome has been found to be very high in the younger age-groups in some areas, particularly among. females. In contrast with the older age-groups, personal and domestic problems appear to predominate as causes and many studies reveal a high incidence of broken homes in early youth (25). Tn a considerable proportion of cases, the suicidal act appears to have been not premedi- tated but carried out impulsively. Many studies have indicated that the majority of persons who attempt suicide have no clear-cut wish to die, but find themselves trapped and desperate and resort to suicidal beha- viour in an attempt, conscious or otherwise, to alter their life-situation, Tt would appear that, in a percentage of cases, resort to such action may be avoided where facilities for emergency and continued consultation, advice and help are available (see p. 22). As it is, however, the members of this high-risk group are usually not identified until after their first suicidal act, The mentally ill Statistics on deaths among mental patients (26) indicate that suicide rates in these groups are higher, in some institutions much higher, than in the general population (see Annex 2, Table 7). Moreover, it appears that excessive measures taken to prevent suicide in such patients, often entailing severe curtailment of liberty, are not necessarily successful. In fact, suicide rates in mental hospitals appear to have declined in certain areas with increasing liberalization of hospital policy (27). Many investigators have pointed to the relatively high percentage of persons attempting or committing suicide who were found to have been suffering from a mental disorder (see Annex 2, Tables 9 and 10). The discrepancies in these tables are probably due largely to differences in coneepts of normality and in standards of diagnosis. Some investi-PREVENTIVE MEASURES 7 gators include only the affective and other psychoses and the psycho- neuroses, while others diagnose reactive, neurotic or psychogeni depression or psychopathic reaction when a person reacts to a stressful situation with a suicidal act. These depressions are regarded as abnor- ‘mal and included in the mental disorders. It is, of course, generally easier to obtain evidence of mental disturbance among the group who survive a suicidal act than among those who die. Among the latter group, lower rates are often based mainly on information obtained from non-medical records. Much higher rates have been found when the home of the person who committed suicide has been visited and a history obtained from persons who had been in close contact with him. ‘The mental disorder most frequently found as a background to suicidal acts is depressive illness, notably endogenous and involutional depression. Some illustrative figures are given in Annex 2, Tables 8 and 11, ‘The data in Table 12 suggest that about 15 % of persons found suffering from depressive illness may ultimately die by suicide. Several authors point to a greatly increased tisk of suicide over the age of 40 among persons with manic-depressive psychosis (28), the rate being particularly high among males (29). Although it was formeriy considered that depressive illness was rare in the developing areas of the world, recent studies tend to prove the contrary (30). Improved and enlightened use of electroconvulsive therapy and the advent of a range of antidepressant drugs have made the prognosis for depressive illness more hopeful. Extensive research is at present being carried out on identification of the most appropriate type of anti- depressant, depending on the special features of the depressive condition G1). The successful outcome of such therapy, however, depends not only on the drug but also on the physician who prescribes it and his use of appropriate psychotherapy. ‘The danger of increasing the risk of suicidal acts through drug therapy needs to be more widely investigated and the results dissemi- nated so that noxious effects can be counteracted, Certain pharmaceutical preparations, for instance those used in the treatment of high blood pressure, have been found to provoke or cause deterioration in depressive states, apparently leading in some cases to suicidal acts (32). Several investigators have noted this danger when psychomotor retardation and stupor in depressed states are treated psychopharmacologically (33). Schizophrenies treated over a long period with neuroleptics have been found to develop symptoms indistinguishable from endogenous depression and leading also to suicidal acts (34). The onset and decline of depressive illness are the stages when suicidal acts are most likely to occur (35). Special eare is therefore18 PREVENTION OF SUICIDE needed at these times, especially as the patient may frequently appear Persons with depressive illness appear everywhere to constitute a high-risk group. In suicide-prevention programmes, high priority should therefore be given to improvement in recognition and treatment of these conditions and organization of after-care for treated cases. In ‘undergraduate and postgraduate medical education, special stress should be laid on the recognition, assessment and management of depression. Other common mental disorders reported fairly frequently as under~ lying suicidal behaviour are arteriosclerotic and senile psychoses and psychoneuroses (36). ‘Some investigators consider that suicidal acts by schizophrenics ate relatively rare. In the USA, however, where the diagnosis schizophrenia is used in a higher proportion of case than in most other parts of the world (often including cases diagnosed as manic-depressive elsewhere), schizophrenics appear to contribute heavily to suicide rates (37). ‘Comparatively high rates are found in some other countries. Certain personality disorders commonly encountered in records of suicides include the hysterical, the “ antisocial” and the compulsive personalities. It has been claimed that the complexity of the relationship of suicide to mental disorder is due to the fact that both are ultimately determined by the same order of social, psychological and biological causes, com- bining in one individual to dispose to suicide, in another to mental illness, and in a third to both (38). Persons dependent on alcohol and other drugs ‘Numerous studies have reported a high frequency of suicide among alcoholics (sec Annex 2, Table 13) and of alcoholics among samples of persons who have committed or attempted suicide (see Annex 2, Table 14), Types and definitions of alcoholism show considerable variation from place to place and are likely to affect rates. In any case, there is general agreement that in many countries heavy drinkers are strongly represented among persons who attempt ot commit suicide (39). A high frequency of alcoholic parents has been found among young people attempting suicide (40). Tt has been suggested that dependence on other drugs, particularly narcotics, may be an alternative to suicide (41). As among alcoholics, there appears to be a high risk of suicide during withdrawal from drags (42). Many persons dependent on alcohol or other drugs could also be diagnosed as suffering {rom depressive illness. ‘There is a dearth of information on suicide in many populations with a high prevalence of[PREVENTIVE MEASURES 19 dependence on narcotics. Further research is needed on the relation between suicide and some of the newer dependence-producing drugs, such as the central nervous system depressants and stimulants and the hallucinogens, which are sometimes used in conjunction with alcohol or as an alternative, A tecent report of the WHO Expert Committee on Mental Health? discusses these problems more fully and makes recommendations on services for prevention and treatment of the conditions involved. As for the other high-risk groups, programmes aiming at suicide prevention among drug-dependent persons would rely heavily on provision of adequate social and medical — including psychiatric — services, Persons from socially disorganized areas Many investigators studying suicide rates according to the social characteristics of areas of residence have found higher rates in areas with high indices of social disorganization, such as overcrowding, 12 high proportion of persons living alone, mostly in boarding houses and cheap hotels, a high incidence of alcoholism, drug dependence and criminality and a high population mobility (43). Findings in reletion to attempted suicide have been similar (44). In many parts of the world, suicide rates have been higher in cities than in rural areas, and particularly high rates have been noted in the larger cities. However, this picture seems to be changing in some countries, possibly as a result of the improvement in medical and social care and standard of living in urban as compared with rural areas (45), Studies of the geographical distribution of residence of persons ‘committing or attempting suicide could obviously be of value in planning the location of preventive services, Specific occupational groups In some parts of the world specific professional groups, especially physicians, dentists and lawyers, have shown particularly high suicide rates (46). Considerable variation between countries is found in the relative rates for occupational groups (47). For farmers and agricul- tural workers the rates are particularly high in some areas and parti- cularly low in others (48). A few studies have pointed to a significantly higher percentage of persons unemployed among those committing or attempting suicide compared with the general population (49). Further TWIT Hh Ore, sei, Rey Sery 308% 3620 PREVENTION OF SUICIDE research on the relation between occupation and suicide rates might assist in the strategic organization of preventive services. Socially isolated groups Migrants to a district, foreign-born (50), those living alone, and the divorced and separated (51) have distinctively high suicide rates accor- ding to most studies. Specific attention may need to be directed to these high-risk indices. Offspring from broken homes (52) Numerous studies have found a more frequent history of broken ‘homes in childhood in cases of suicide and attempted suicide than in the general population (see Annex 2, Table 6). Various definitions of “broken home” are given, but they usually include loss, or absence for at least 6-12 months, of one or both parents during childhood,ORGANIZATION OF SUICIDE-PREVENTION SERVICES Tn countries with highly developed and well co-ordinated health and welfare services readily available to the population, structures already exist for the prevention of suicide. The outstanding need isto link these structures into a network of services which will go as far as possible to meet estimated needs for the community to be served. EXISTING SERVICES The range of such services differs considerably between countries. In the USSR, for instance, all hospitals of all types have instructions on how to deal with emergency suicide attempts, and psychiatric examination is compulsory in these cases. When suicidal behaviour is observed in any individual, he can immediately be referred to the local psychiatric dispensary (mainly outpatients) for psychiatric care, referral and follow-up. ‘The seme is true in Czechoslovakia, where psychiatric examination is compulsory in all cases of suicide and attempted suicide and all physicians have the duty to report such cases to the local psychiatric facility (53). In the United Kingdom, everyone is registered with a general medical practitioner who is often approached by suici- dal persons or their families, According to the circumstances, the general practitioner will send the person who has made a suicidal attempt either to a Casualty Department (these are now beginning to deal systematically with self-injury and poisoning in collaboration with the mental health services) or direct to psychiatric services, such as outpatient clinics, or he will arrange for a domiciliary visit to be made by a social worker or specialized psychiatric personnel (54), Similar services are available in other areas where medical services are not nationalized, through collaboration with private and commonity resources. In the USA, for example, locally operated community ‘mental health centres are being established to serve catchment areas of 21 —22 PREVENTION OF SUICIDE 120 000 to 200 000 persons. ‘The emergency services in these centres will also cover suicide-prevention activities. In 1966, the Federal Government established a national center for studies of suicide preven- tion within the National Institute of Mental Health (55). In some parts of the world, specialized institutions have been estab- lished to deal with suicidal patients and those who have already attempted suicide (56). A notable example is the Los Angeles Suicide Prevention Center (57), run with the co-operation of the available ‘community resources : medical, psychological, social, welfare, pastoral, etc. Referral to them may be through medical or lay sources or the patient may come of his own accord In certain other countries, such as Austria, France, Germany and Switzerland, suicide-prevention centres have also been established, often in close collaboration with a university psychiatric clinic or with a poison-control centre, as in the Lebensmiidentfiirsorgen’ of Vienna (58), referral being made by a family doctor ot by the family of the suicidal person. Lay organizations offer help to suicidal persons who either do not regard their difficulties as medical problems or refuse to seek ‘medical help. ‘The best known is the Samaritans (59), which started in London but has become international. In countries where there is no ready access to family doctors, where the psychiatric clinies are over ‘burdened, and where it is not the tradition for ministers of indigenous religions to provide psychological counselling, such voluntary organi zations give useful advice and support, and help by referral to medical and welfare agencies. ‘They can form the basis for further development into suicide-prevention centres properly integrated into the medical and psychiatric service. [STEPS IN DEVELOPMENT OF SERVICES Emergency services ‘As discussed earlier, a primary role of a suicide-prevention pro- gramme is the prevention of fatal outcome of suicidal acts. For this purpose, local emergency services are required, accessible at all times, ‘with skilled medical and nursing staff available. In many countries, such services are provided in emergency hospitals or emergency (casualty) departments of general hospitals. However, in many parts of the world attention is required to improvement in organization of emergency treatment and particularly in the training of personnel in TT Fosaoe for pense tied ofORGANIZATION OP SUICIDE-PREVENTION SERVICES 23 the use of the most up-to-date techniques. Existing treatment facilities ray also serve as centres for collection and dissemination of information ‘on emergency life-saving measures such as resuscitation and on the choice of appropriate antidotes. It is of great importance that adequate psychiatric consultation be available to such treatment centres. It has, in fact, been proposed that all persons who have attempted suicide should be seen by a psychiatrist Gee p. 14). The question arises as to whether this would be practical, in view of the amount of time that would be involved per psychiatrist. Certainly it would not be possible in the many countries of the world where there is a dearth of such trained staff, Greater reliance would have to be placed on the preparation of other personnel to deal with suicidal patients In many countries, however, it would appear feasible to provide reasonably adequate psychiatric consultation through careful organi- zation of services. In Edinburgh, for example, more than 90% of cases of self-poisoning coming to any hospital are dealt with in a special ward for acute cases where medical and psychiatric treatment is available. Just over 500 cases were seen in one year out of @ population of about 470 000. It was estimated that to deal with 500 instances of self-poisoning a year in the ward and to provide subsequent outpatient care required weekly : a consultant psychiatrist for approxi- mately three half-days, junior hospital psychiatrists for eight half-days and a psychiatric social worker full ime. ‘This includes time for report- writing and home visiting. It was pointed out that many patients would in any case have been referred for psychiatric care (60). Since there is a rapid turnover of patients in medical emergency services, it is important that where possible the psychiatric consultation be available within a few hours, as discussed on p. 14, In this con- xexion, it should be pointed out that the degree of physical harm infic- ted by the patient on himself is no index of the need for psychiatric care and should not be used to determine whether a psychiatric evaluation is required. ‘The same difficulties arise in estimating the seriousness of suicidal intent as apparent from gestures, threats or the acquisition of means of self-destruction. thas been proposed that wards in certain hospitals in each large city should be equipped to serve a specific district, so that suicidal persons in need of help can be taken there at once, whether for medical rescue, for emergency psychiatric help or for after-care, Emergency psychiatric services should also be available where there is no other medical emergency service. They may function within existing community mental health centres, outpatient psychiatric clines, psychiatric wards in general hospitals or24 PREVENTION OF SUICIDE psychiatric hospitals. The importance of continuous availability of help and easy access to care is again emphasized. Despite the difficulty of evaluation of effectiveness, experience now indicates that emergency services should desirably include facilities for immediate response to telephone calls or to patients who are referred or come of their own accord. Trained workers should be available to man the telephones or to interview the patients without waiting, Such services would focus on the handling of the crisis with which the person is immediately concerned, attempting to evaluate the suicidal poten- tiality and to work out a treatment plan for the patient. Attention needs to be given to the naming of such services and the way they are listed in directories. In some areas, they are listed in the daily papers along with other emergency services. In the experience of several countries, such screening can most expeditiously be cartied out in an existing treatment centre within the psychiatric or general medical ser- vices. Where separate suicide-prevention centres are established, care should be taken to maintain the links with existing social and medical services. Follow-up care ‘As already noted, a percentage of patients showing suicidal behaviour are suffering from mental disorders and the risk of repetition is high in patients who have already attempted suicide, Follow-up psychiatric care is therefore highly desirable for many of the cases seen in emer gency services as well as for others identified as high-risk patients. Tt is likely to be advantageous to the patients, and economical of time, for members of the same psychiatric team to work in both emergency and follow-up care. It has been pointed out that not only patients diagnosed as having a psychiatric illness can benefit from treatment. Nearly half the patients, stated to be without psychiatric illness in one reported sample, for instance, were referred for further care, which included aid by social ‘workers as well as psychotherapy (61). Tt should also be Kept in mind that many persons who have made suicidal attempts are found not to need special psychiatric treatment after screening but may require other help. Various social welfare agencies may need to be involved in the further assistance of suicidal patients. Voluntary help can be invaluable in providing the Jong-term support often required to prevent suicidal acts. The co-operation of the family and of certain professional groups, particularly general medical practitioners, educators and the clergy, is often required. Specialized suicide-prevention centres can play a usefulORGANIZATION OF SUICIDE-PREVENTION SERVICES 25 part in co-ordinating the lielp provided from various sources and seeing that there is continuity of cate for patients in need of help. Careful attention should be given to the problems of those closely connected with a person who has committed suicide. Professional help ‘may be of value in averting possible subsequent suicidal bebaviour in those affected by such a death, Early identification and support of high-risk groups In establishing suicide-prevention services, an important step is to develop education and training programmes. These will involve dissemination of information about suicidal behaviour, as well as training in the early identification of suicidal persons and the initiation of appropriate procedures for dealing with them. In the first place, these programmes would be directed especially to key groups within the community such as general medical practitioners, community health and welfare workers, the clergy, educators and the police. In some communities, medical assistants, “ dressers ”, tradic tional healers and tribal chiefs would be included. ‘These gronps often constitute a first line of contact for emotionally disturbed persons and can provide continuing support. ‘A suicide-prevention service ean be effective in so far as the nature of its work is recognized by the general public, Public education pro- ‘grammes about suicide and the kind of services available are necessary. Provided appropriate information is available, the family can play an important role in early identification of a potentially suicidal mem- ber, can assist in getting the patient to the help he needs, and in providing continued support and after-care. However, caution must be exercised when involving the family in treatment of the suicidal patient. tis sometimes the relationship within the family which has contributed to the suicidal behaviour. The positive elements within the family relationship have to be used and the negative ones counteracted. Role of public health services In view of the magnitude of problems associated with suicidal beha- viour and the existing possibilities for control, national and local healt! services are faced with a responsibility for development of suicide- prevention services. In assuming this role they have in many areas bbeen preceded by voluntary and private initiative. ‘The results of such enterprise will require careful study by the public health authorities and in many cases may’ be found suitable as models for more extensive services to provide greater coverage for the community.26 PREVENTION OF SUICIDE The public health services are in a particulacly good position to collect statistical and other epidemiological information on problems of suicide in each community (see p. 31). In carrying out these inves- tigations, the assistance should be sought not only of demographers, statisticians, the medical professions — including psychiatrists — and psychologists but also of sociologists and economists. ‘The pattern of services to be provided can then be better geared to the local require- ‘ments and possibilities. In the further development of suicide prevention in the community, careful consideration will have to be given to the economical use of existing public, private and voluntary facilities and the choice or estab- lishment of a suitable centre to co-ordinate and extend the various suicide-prevention activities. Such a centre could maintain records of all cases seen and ensure follow-up care, Tt would serve as an excellent source of research data. ‘The local public health or mental health authority could well initiate such a programme by calling a conference of all the groups in the area who serve the suicide-prone. Responsibility for co-operation in educational and training program- mes on suicide problems will often devolve upon the public health services.EDUCATION AND TRAINING PROGRAMMES ‘CONTENT AND PRESENTATION The information to be given on suicide problems will inevitably vary in the amount of detail according to the groups to be reached, but in ‘general the contents of education and training programmes on this topic could be included under the following headings : importance and widespread nature of problems connected with suicide underlying and precipitating factors in suicidal behaviour ; identification of high-risk groups ; significance of symptoms, warnings and threats ; preventive measures ; availability of preventive, treatment, and after-care facilities ; ‘methods of referral to care ; methods of treatment of suicidal patients ; requirements for after-care. Obviously, the emphasis and method of presentation will vary also according to the audience, ‘The material should, however, always be presented in a non-sensational manner. Facts should be presented where possible : for instance, illustrative statistics on incidence of sui- cide and suicidal attempts for the area concerned. It should be clearly stated, though, that much is still not known about causes of suicidal behaviour. PROGRAMMES FOR THE GENERAL PUBLIC Objectives ‘A programme of public information on suicide problems would aim at reducing taboos surrounding the topic and making it possible and permissible for suicidal persons to reach out for help. Another objec- tive is to secure early recognition of suicidal risk and co-operation in supporting the persons aifected. Such education should lead to reali- zation that certain information about suicide-prevention measures is28 PREVENTION OF SUICIDE already available and that its successful application depends to a con siderable extent on the co-operation of society. Mass media Much information on suicide is given through the press, radio, tele- vision and cinema, Of recent years there have been some excellent examples of close co-operation between experts in the preparation of ‘material for these mass media and specialists in suicide problems, In ‘many countries much might still be done to inform the communication ‘media professions and to provide undistorted facts for specific material, It would appear necessary in particular to point to possible damage caused by undue publicity and dramatization of suicidal acts. Families of high-risk groups Special provision is required for informing families of persons iden- tified as having a high risk of suicide. Discussion with the therapeutic team can do much to help the family view the situation more objecti- vely, to seek adequate help when required, and to co-operate in a therapeutic programme. Discussion groups led by adequately trained personnel can assist in achieving the above goals and enable the family to feel less stigmatized because of the situation. PROGRAMMES FOR MEDICAL PERSONNEL In the training of medical undergraduates, information on suicide and training in dealing with the suicidal patient could well be a res- ponsibility shared by the department of social and preventive medicine with the department of psychiatry, where these exist. Provision should bbe made for acquiring experience in the various facilites availuble locally for dealing with suicidal patients and their families, such as an emergency psychiatric service or suicide-prevention centre. It should include, where possible, domiciliary visiting with a social ‘worker ot other member of the therapeutic team. Information should be given on the role played by social-welfare services. Working with an emergency telephone service would provide valuable experience. Discussion groups with general medical practitioners could give insight into the role that these physicians can play in suicide prevention. Some specially interested students could be encouraged to participate in the work with families and in the follow-up of suicidal patients and may choose suicide prevention as a topic for a thesis as well as assisting in research projects,EDUCATION AND TRAINING PROGRAMMES 29 More detailed courses would be required for those specializing in general practice and for doctors already working as general medical practitioners. They could include group training in dealing with the suicidal patient and his family, possibly as part of courses on psychiatry in general practice as given in some countries (62). PROGRAMMES FOR MENTAL HEALTH PERSONNEL, Tt may be assumed that psychiatrists, psychologists, psychiatric nurses and psychiatric social workers receive training in suicide preven- tion in their professional preparation. In some cases, however, there ‘may be insufficient integration of the parts played by cach. It may therefore be desirable to organize local meetings and round-table dis- cussions where information can be exchanged on the role of the various ‘members of suicide-prevention teams, of other professional groups in the community, of social and welfare organizations, of voluntary wor- kkers and of the families of suicidal persons. Special programmes are likely to be required for professional and non-professional personnel working in mental hospitals, where suicide rates are frequently much higher than elsewhere, Particular attention would be given to such matters as evaluation of suicidal risk in patients about to be discharged or released on trial visit. Much of this in- service training might be carried out by case conferences and could be linked with research. PROGRAMMES FOR NURSES AND SOCIAT, WORKERS Patients are frequently admitted to general hospital wards after sui- cidal attempts. General nurses lacking psychiatric experience tend to wish to be relieved of such patients as soon as possible and their attitude may add to the patient’s misery (63). Public health nurses and social workers are also likely to be in close contact with suicidal persons. Tt would be desirable to organize pre-diploma training for these professions, possibly in conjunction with courses given to medical students, and further training for more experienced groups with general medical practitioners. Nurses and social workers can play a very important role in identifying pre-suicidal and suicidal behaviour and in early referral of patients to suitable care. ‘They can also do much to assist the family in understanding and sup- porting the patient and can reveal to the therapeutic team many of the family and environmental problems underlying the situation. Training30 PREVENTION OF SUICIDE for these tasks might well include group discussion on specific cases with other members of the therapeutic team (64). PROGRAMMES FOR OTHER PROFESSIONAL GROUPS Undergraduate and refresher courses should also be available to other professional groups likely to play an important role in suicide prevention, such as educators, the clergy, the police and the legal profession. Because of the high incidence of suicide among persons living alone, it would appear important for suicide-prevention services to contact hotel directors and boarding-house owners and provide st table information on facilities available for providing assistance in case of need. PROGRAMMES FOR PERSONNEL IN SPECIALIZED 'SUICIDE-PREVENTION SERVICES ‘The training programmes for personnel in stich centres should, where possible, be “on the job” experience. The contribution of additional staff such as “ semi-professional ” ‘graduate students in mental health professions and non-professional volunteers may be effective. Criteria are being developed to assess selection procedures. According to some programme organizers, non- professional volunteers can give valuable help, under supervision, during suicidal crises, and more generally in psychiatric emergencies. In the initial stages careful training is required. In some areas, specialized suicide-prevention centres may undertake to provide programmes of education and training for the general public and specialized personnel. In this case particular attention will have to be given to the preparation of certain staff for their teaching role, for example through courses in the psychology of education and methods of presentation of teaching material.STATISTICS AND RESEARCH STATISTICS CURRENTLY AVAILABLE Suicide ‘The principal source of international comparisons of suicide statistics are the tables published by WHO (65 and Annex 3). These, however, are a compilation of national statistics provided by about $2 nations out of apossible 125. ‘The available national statistics are in some instances broken down by region, by smaller administrative districts and even by census tracts or enumeration districts. Other sources of suicide statisties are local surveys undertaken by agencies or individuals for specific purposes, often research projects, and cumulative psychiatric cease registers (66). ‘The reasons for non-reporting of certain vital sta- tistics should be investigated. It is to be hoped that in the near future it will be possible to include in the international tabulations of suicide data an item describing the procedures used in each country for re- cording suicides. Altempted suicide Reliable national statistics on attempted suicide are probably no- where collected (67), Systematic surveys carried out in some centres in England, Switzerland and the USA showed that the ratio of attempted to committed suicides was 8:1 and 10:1. Where co-ordinated suicide- prevention services exist, it may be feasible for them to keep a cont dential register of persons attempting suicide. Notification could be made through physicians and possibly other persons who had received special training in recognition of cases. It would be necessary to avoid any discriminatory implications, METHODS USED TO COLLECT DATA ON SUICIDE Whether a sudden or violent death is due to suicide may be estab- lished either by official agencies, such as police departments, or by —u—32 PREVENTION OF SUICIDE police surgeons, by the coroner or other egal official, or by medical personnel, such as the general medical practitioner or other doctor. There is need to define more precisely the functions of these various official recorders, Much-needed investigations comparing the present procedures in different countries for ascertaining that death is due to suicide are currently being made by the International Asso- jon for the Prevention of Suicide. ‘The criteria used to decide whether death is due to suicide differ between countries. For example, Post-mortem examinations are mandatory in some and not in others ; medical evidence is more often sought to corroborate that death is due to suicide in some countries than in others. ‘The final decision whether the death will be recorded as a suicide may be made by a person other than the official investigating the cause of death: for instance, in Scotland. ‘The formal and official instructions for completing the death certificate may obscure the fact that death was due to suicide: eg., “immediate cause of death : bronchopneumonia, due to second cause : overdose of barbiturates ". STATISTICAL TABULATIONS, Countries differ in the extent to which they break down their suicide figures according to demographic or social groups. Rates are obtainable from certain countries under one or more of the following headings : ‘age, sex, marital status, urban-rural, administrative districts down to the smallest ones, occupation, social class, unemployed or retired, race, place of birth, month of the year, method used. Tabulations could be ‘made showing which of these variables are reported by which countries and the sources of the suicide data (coroners’ reports, police dossiers, ctc.). Rates of attempted suicides need to be broken down in the same way. [RELIABILITY OF AVAILABLE SUICIDE STATISTICS Suicide is almost certainly under-reported everywhere, and therefore the available statisties do not reflect true incidence. Knowledge of true ineidence is most important when the problem is one of preventing sui- cide, It is of less consequence when the problem is one of making comparisons between the suicide rates of different groups in the same community in order to explore factors related to or predisposing to suicide, Sources of error making for unreliability in the latter instance, particularly when international comparisons are sought, are :[STATISTICS AND RESEARCH 33 (@ _ National differences in methods of defining, ascertaining and recording suicide. For example, in developing countries where a post- ‘mortem examination is difficult to perform, and there are few adequate Jaboratory facilities, suicides by poisoning may be missed. (®) Social, cultural and personal pressures acting on the agency ascertaining the suicide, e.g., cultural attitudes toward suicide, religious or legal condemnation of suicide, economic situation, social class of persons committing suicide. (Differences in efficiency with which the population census is carried out. Suicide rates are related to this source. It useful comparisons are to be made between suicide rates for ‘various nations, great attention will have to be paid to improving the value of the statistics, as pointed out above. At present, such compa- risons should be made with caution and appropriate reservations. If, however, the above limitations are kept in mind and methods of cixeum- venting them are employed, critical comparisons can provide valuable information (68). A careful study is required of national differences in methods of case-finding and recording as well as derivation of suicide rates. ‘Comparisons made within one country are likely to be particularly valuable, provided the registration sysiem has remained the same. Under these conditions, fluctuations in rates over the years, for example, may signify important trends (69) and persistent differences in rates between ethnic groups can be considered genuine. Where research is carried out in areas with comparable populations and identical methods of registration, comparison of suicide rates by demographic and other variables is likely to provide valuable clues for suicide prevention (70). Attempted suicides ‘The problems of defining and finding cases and recording attempted suicides are even more dificult. There is a need for groups of investi- gators in the same and in different countries to agree on criteria and procedures for reporting, IMPROVING VALUE OF STATISTICS ‘The reliability of a country’s suicide rates will depend on the efficiency with which the population census is carried out and the suicides recognized and reported (71). Coverage will depend on the range of items included in the census. There is a particular need to increase the coverage of attempted suicide statistics either by: (a) statutory notification of attempted suicide to health authorities, at least34 PREVENTION OF SUICIDE in a sample area ; or (b) including in the returns ordinarily made to the central registry of the country’s health departments cases of attempted suicide admitted to emergency treatment centres or wards. ‘Additional questions that might be included in the census so that the fie suicide rates can be calculated arc: whether a student ; mode of living — whether alone ; family size ; work status of old people ; whether retired. Improved methods of collection and compilation Checks should be made on consistency of procedures, such as preparation of coroners’ reports, to ensure that standards are consistently Efforts should be made to secure uniformity in procedures In Los Angeles, experis skilled in the evalu- ation of suicide assist the medical examiner (coroner) (72). ‘These procedures should be explored further. For example, skilled social scientists or psychiatric social workers might assist coroners’ officers in taking evidence from witnesses. These procedures are important from the point of view both of prevention and of obtaining statistics. ‘Another check of validity of ascertainment procedures would be provided by studies in which independent observers also assessed the data presented and categorized their findings as suicide, accident, or open verdict. EPIDEMIOLOGICAL AND ECOLOGICAL RESEARCH Many of the methodological problems involved in epidemiological investigations — finding the cases, defining them and sampling — are simplified with regard to suicide because of existing statutory procedures for ascertaining and recording of violent deaths. Moreover, ecological studies of the social factors affecting suicide may very well suggest hypotheses about the importance and the application of these factors, in other disturbances of behaviour. The epidemiological approach can be profitably employed to explore the effect on the incidence of suicide of the following factors : (@ urbanization and the decreasing influence of rel tions, especially in developing countries : the breakdown of tribal social structure ; (®) the changing social status and role of women in countries undergoing rapid social change ; (© social mobility, particularly loss of social or occupational status and feeling of belonging to @ group : it is probable that these are more important than poverty per se in determining suicide ;STATISTICS AND RESEARCH 35 (@ social isolation and loss of social role, particularly in the aged on retirement (¢.g., the usual increase in suicide in the aged was not ‘observed in some countries in which the status of the old person in the community was high) ; (e) outlets for aggression, ‘The epidemiological approach could be used also to study the relation between social and cultural characteristics and the incidence of methods of suicide. Epidemiological studies are required to identify high-risk social and demographic groups. A high suicide rate in a large heterogenous group may be further analysed to identify the component responsible for the high rate. If one subgroup has consistently shown a higher rate than another (eg, males higher than females) and then an exception is found, a further inquiry may produce valuable clues. Factors associated with change in suicide rates that have been identified epidemiologically include economic depression, social upheaval, and the months of early summer. War, on the other hand, is stated to be associated with a decreased incidence of suicide. ‘There is need for long-term follow-up investigations of both unselee- ted and selected samples of people who make suicidal attempts, not only for the purpose of finding out how many of them die through suicide but also for the study of the short- and long-term social and ‘other effects of the suicidal act Improving methodology Assuming that the methods of recording suicide and the census are accurate, then the main methodological problems in studies of this kind are those of defining and measuring the social variables. For example, how may social isolation be more precisely defined and whet indices should be employed to measure it? Furthermore, to be of value, corre- lation studies require hypotheses from which predictions may be made and then tested. Their significance for prevention has been to draw attention to the importance of social factors aficting suicide thet may be remedied by social action, One must beware of generalizing findings obtained on one culture. CLINICAL RESEARCH Case studies of suicide are based on the perusal of coroners’ records, police files, the case histories and records of patients who were in psychiatric or general hospitals shortly before or at the time of death by suicide (73), the clinical examination of psychiatric patients with36 PREVENTION OF SUICIDE suicidal ideas, and investigation of persons who attempt suicide. It would be desirable to standardize these procedures. ‘As has been seen (page 16), the recognition of mental disorders in persons who have committed or attempted suicide depends partly on the intensity of the search, partly on the definition of mental disorder. Since definitions of mental illness and of specific mental disorders vary widely, the definition employed in each investigation should be clearly stated, Intensive study of individuals who manifest suicidal behaviour is to be recommended. ‘The personality attributes of suicide ceases need to be investigated. Emotional and situational erises pre~ ceding the suicide, the previous psychiatric history and social circu stances might also be studied, as well as the psychological and soci sequelae of suicidal attempts in individual cases. ‘The main methodological requirement in studies designed to identify the environmental characteristics predisposing to suicide is to compare ‘a group having committed suicide with the general population. ‘The clinical symptoms associated with suicide may be investigated by following up a cohort within a diagnostic category to see in what clinical respects those who do and do not commit suicide differ.Annex 1 ANNOTATIONS TO TEXT (1) An important source of references is the bibliography covering the yours 1897-1957 in Farberow & Sbneidman (1961), @) Parkin & Stengel (1965) made a careful study of incidence of attempted suicide in Sheffield, England, using records of castlties in general hospitals, ‘menfal hospital records and a questionnaire distributed to general medical practitioners. The estimated ratio of such reported attempted suicides to suicides was 9.7 to 1 for the two years 1960, 1961. This estimate does not include cases not coming to the notice of a doctor. Shneidman & Farberow (1961) ‘estimated that in Los Angeles, USA, the mumber of attempted suicides was seven fo eight times that of suicides. Prokupek (1967) on the other hand, found only two cases of atlempted suicide for each one of suicide in the records collected in Czechoslovakia for 1963-1966, (@) Dublin (1963) reports a study by statisticians of the New York City Health Department of deaths from berbiturate poisoning, inhalation of gas, and falls from high places, all under unspecified circumstances, which suggested that the recorded suicide figures are understated by as much’ as one-fourth (0 ‘one-third, Stengel (1964) gives further desails of reasons for under-reporting and quotes Kessel (personal communication), who checked az untelected sample of Known eases of sucide in Scotland and found only half of them recorded (4) Several investigators ave noted increases particularly in numbers of cases of self-poisoning coming to attention, Bappert (1968), for example, found 8 fourfold ineresse in the number of ‘such cases seen sanually in 1961 compared with 1947 in a medicsl department, whercas the total mimber of patients seen bad only doubled, He estimated from health insurance statistics that in Germany as a whole an average of 0.45 persons per 1000 insured persons ‘made suicidal attempts or injured themselves in 1985 and 1956, compares with 20 per thousand in 1960. Ringel (1965) found that, wherees the number of persons aitempting suicide in Vienna acd seen by the Lebensmidentlrsorge had risen only slightly between 1948 and 1957, the fraction aged 1420 years had risen from one-twelfth to one-sixth, Evans (1967) found a 63% increase in the annual prevalence rates of acute deliberate self-poisoning from 1962 to 1965. Kessel (1966) determined the anaual number of cases of deliberate self-poisoning admitted to the main treatment centre in Edinburgh. Between 1928 and 1950 the figures fluctuated between about $0 and 100 per year, but rose thereafter precipitously, reaching 600 i 1960. So38 PREVENTION OF SUICIDE (3) Stengel & Cook (1958), p. 129, view suicidal acts as incidents in the strugele for adjustment. Their outcome depends not only on the relationship between self-destructive and ife-preserving tendencies in the individual but also on the immediate reactions of the environment. (© Stengel (1967) states: “The fact that many acts of self-damage are harmless to life that suicidal intent is often denied, and that the purpose of manipulation of the environment is often admitted, makes it doubtful whether it is. justified to decribe such acts as “attempted suicide’. ...On the other ‘hand, “attempted suicide” has the advantage of directing attention to the self destructive component, Which may be latent, and to the suicide proneness of those people which is evidenced by their excessive suicide rate.” ‘Kessel (1966) considers the terms “ slf-poisoning™ and “ self injury ” more appropriate than “attempted suicide” for characterizing. deliberately harmful facts against the self, Tn his later studies of case material his definition of the ‘act contained three components: it must have been deliberate; the quantity of drug or any other substance taken must have been known to be excessive ; fand it must have boea intended to be barmful, The difficulty here lies in the objective measurement of the intentions. Several investigators, including the two above, have pointed out that the patients intentions are often ambivalent and that frequently the recovered patient appears to have had no conscious reason for his act or is unable or unwilling to communicate the reason (See also Shneidman, 1963). 'No widespread agreement has been reached on the definition of terms. ‘Stengel (1963) considers that Dociors should assame that if a person behaved fas if he had intended suicide, this intention actually existed, whatever the subject's explanation", Kessel (1966), however, states that to approach patients who have poisoned or injured themcelves, already convinced that there ‘was some degree of lethal intent in their acts isnot only unreasonable ; it prevents fone ever ascertaining the opposite.” ‘As regards the use of the term “ suicide, Litman (1966) probably represents ‘a body of opinion in his statement : “I do not feel that the community is ready for a new taxonomy of death, Rather we should encourage the lezal profession, coroners, and police officals to use the customary and accepted classifications ‘more consistently and conscientiously.” Consideration is required of means of reaching more widely acceptable definitions, as pointed out ia the section on satistis aad research, (@) Dublin (1963, p. 43) gives a table showing the percentage distribution cof death from suicide, by means, among Negroes, Indians, Chinese and Fapanese in the USA in 1959. "In the frst two groups the preferred method is by firearms ‘and explosives ; in the other two, by hanging and strangulation, He also refers to the urban and rural differences in method. (8) Stengel (1964, p. 34) points out, for instance, that the city of Basle ‘Switzerland, had for’a long time a high incidence of suicide, the chief method used being domestic gas. Detonfication of the gas was followed by a brief reduction in the suicide rate which, howover, reverted 10 the previous high level after a year, drowning having become the method used most frequently. (©) Stengel & Cook (1958, p. 19 on), review the literature on research into attempted sbicide and show that it has aimed at contributing to the knowledge of suicide by investigating problems which cannot satisfactorily be studied after ‘the death of the subject, Their own contention is, however, that attempted suicide presents problems peculiar fo itself in addition to those it has in commonANNEX 1 39 with suicide, ‘They discuss the special character of the available samples of suicidal attempts (p, 33) and draw attention to the diversity of the case material (on-representative of total, unknown, number of attempts and of sex ratio; difference in cri nosis and disposal of patients). This warning should be kept in mind when consulting the tables in Annex 2. (10) Stengel & Cook (1958) point out that the attempters life situation may bbe changed in a variety of ways, e.g, the suicidal act may lead to dingnosis and ‘treatment of undetected physical or mental iliness; it may also have profound long-term effects on human relations and modes of life. “The authors investigated not only the person who committed the suicidal act but also individuals and ‘roups forming his social environment to whom the act is often quite openly, reaction to the act will affect the risk of repetition. Prokupek, in an unpublished report on studies in Prague, states that the repeated suicidal attempts speared only in perions in whom psychiatric ‘diagnoses were found after a careful medical examination (mostly melancholia ‘oF unbalanced psychopathic personality). In casss of sudden reections to stress stations in persons otherwise healthy, the repetition did not ovcur. (1D Dublin (4963, p. 11), quoting Ringel (1953), Stengel (1962) and Shneidman (1963), makes this division and considers that about one-third of apparently suicidal acs fall into each group. “Hendin (1950) evaluated a series of 100 cases as to the degree of intent, ‘on an arbitrary scale of 1 to 3. The evaluation was based mainly on the statements of the patient and on the circumstances and method employed. Schmidt et al. (1954) evaluated the suicidal attempt in 109 cases ax serious or not serious ; after an average follow-up of eight months, two had committed suleide, both from the original “serious” category. Stengel & Cook (1958) related dangerousness of attempts to manifest intention and found that the two were often inversely related. Kessel (1965) devised an “index of endangering life" by which to characterize each act from the patient's point of view. (12) Litman et al. (1961) enumerate such indicators and suggest thet it might bbe possible to construct formulae for reducing these data to a few comprehensive indices for suicidal danger. (13) Weiss et al. (4961) nevertheless found some statistically significant positive findings, including: (1) attempts where the psychological intent was ferious tended to produce dangerous medical consequences ; 2) the attempts most likely to be psychologically serious and medically dangerous were made by persons over the age of 45, those who expressed concern about their own mental Hlness and those diagnosed as suffering from a clinical psychotic process ; (G) the attempts of persons under age 30, of those whose method involved solely the ingestion of poisons, and of those who atiributed the acts to the pre- cipitating stress of “family trouble” were generally not psychologically serious for medically dangerous. (14) Schmidt et al. (1954) note that, by omitting the patients with manic. depressive depression and dementia, it was found that the average ages of patients in their “serious and “ natserious™ groups did not differ significant, Suggesting that seriousness of attempt may be correlated with occurrence of manic-depressive depressions and dementias in the older uge-eroup. (15) These poinis are made by, eg, Kessel (1965). Stengel & Cook (1958), ..130, in a discussion of the implications of their research for preveation of ‘Suicidal acts, point out thst “The recognition of the appeal function of the40 PREVENTION OF SUICIDE suicidal attempt implies that warnings of suicide have to be taken seriously ; the individual's life situation has to be explored with a view to helping him towards a new adjustment. ‘The same applies to the situation after a suicidal attempt, which carries a message to the human environment. This message, fof whose meaning the person is frequently unaware, has to be deciphered and formulated. An understanding of the individual significance of the appeal inherent in the suicidal attempt would enable those who want to help to do so rationally and effectively and thus prevent repetition. The exploration envisaged hhere would not necessarily require much time and would usually be possible with the help of the psychiatric interview”. (16) Kessel & McCulloch (1966) report on a one: to two-year follow-up oof the 511 patients admitted to hospital in one year (1962-63) for deliberate selt-poisoning or selGinjury. Of this number, 97 (19 9%) bad repeated the act within the year, 20 of them twice, seven three times and two four times. Eight (1.6 %) had Killed themselves. “By 1965, 20 (4%) hud committed: suicide (McCulloch et a., 1967). In the latter study of the ecology of suicidal behaviour, the highest correlations with suicide were overcrowding and acts of self poisoning ‘and self-injury. Much fuller information was available for the 20 suicides io the follow-up cohort than for the others. Evans (1967) used data from the Oxford Record Linkage Study for epidemiological follow-up of patients admitted to hospital for deliberate eelf-poisoning. (1) Gorceix & Zimbacea (1965) showed that 41% of 148 cases of suicide investigated had given warning, Kessel (1965) found that 34% of 511 patients fdmited for selfpoisoning had given warnings, of which 62 % were noted but not acted upon, Motto & Greene (1958) discovered, from records of 175 eases of suicide and 197 attempts, that 25% had been in touch with a medical doctor within one month before the act. Half of the 134 cases of suicide studied by Robins et al, (1959) had given warning, the percentages being particularly high among the manic depressives and alcoholics, (18) Hendin (1968), for example, suggests thatthe low suicide rate in Norway {in contrast to the high rates ia Denmark und Sweden may be largely accounted for by differences in child-rearing practices. He considers the prevalent type of suicide in Sweden to be based on rigid performance expectations and a strong sel-hatred for failure, with a background of early mother-child separation, In Denmark, suicide appears to Hendin to be primarily of a “ dependency loss" type and resulting partly from a tendency to suppress aggression and to arouse sulle feelings in others, all based on family patterns, He ascribes the lower ‘Norwegian suicide rate to child-rearing practices that develop a greater indopen- dence and give a greater freedom to express aggression and other emotions than in Denmark and Sweden, Tga (1966) found high levels of dependency, self-assertion and insecurity ‘among suicidal Japanese youths and related these personality components (0 factors in Japanese eocial structure and child-rearing which may be responsible for high suicide rates in the young, (19) Yap (1958a) shows that running amok, which is certainly not rare in some parts of South-East Asia, is an example of homicide merging into sui the aggrieved person strikes out blindly and attempts to kil all in his way until be himself is killed or otherwise overpowered. “This pattern of behaviour tends to become habitual where aggressiveness is idealized and rewarded, resulting in 1 lowering of frustration tolerance. The case studies carried out in various parts of Africa are of interest im this connexion (Bohannan, 1960), FallerANNEX 1 4 & Follers (1960), fcr instance, state that “in presentday Busoga, the breaking ‘down of taditiozal institutions appears to reduce the frequency of homicide and suicide rather than to increase it”. (20) This point is illustrated by the study of Murphy & Robins (1967) in which they comparo recent bereavement or loss ia 31 alcoholic suicides and 660 manic depressves : 15 5% of the former had been bereaved within » year and 48.% of the latter, 21) Bagley (1968) has attempted to evaluate the effectiveness of the ‘Samaritan schemes (See also note $9) in the prevention of suicide. He used aa ecological method of research design which had been found valuable in previous sociological studies. The suicide rates for all 15 British cities in which © Samaritan scheme had been in operation for two years were compared with rates in 15 mached controls chosen from 157 British’ towns already. inves- tigated for demographic, health, social and economic variables. The. suicide tates in the control towns were significantly higher (at the 1% level of signfi- cance) than in the “Samaritan” towns. A second set of controls was selected for comparison of ratss adjusted by age, sex and social class. Again, the control cities showed higher suicide rates (at the 1% level of significance) in the “postSamaritan” years than the “Samaritan” towns. As pointed out by the author, it may be objected that persons coming to the notice of the Samaritans may resemble the groups that ailempt suicide rather than those that commit suicide, who may belong psychiatrically to a different category ; thus the effect of the Samaritan service may be prevention of atiempted suiciée which cond Inave been accidentally fatal. However, no systematic work on the characteristics of persons coming to such services has yet been published. ‘A second argument might be that some sipects of the community's dynamics say have led both to the setting up of the suicide prevention scheme and to the decline in suicide rates, This would be dileult (0 test (22) Sainsbury (1955) correlated the suicides notified in the 28 metropolitan boroughs of London and the City with indices of their social characteristics ; hhe also investizated these associations by examining case-records of all suicides (409) reported to the coroner for North London in 1936-38. Several of the statements in the text are taken from his work. Ssinsbury (1961) compared suicide rates in old age in 20 countries and found them unrelated to old age peusions : moreover, the introduction of such pension schemes in fen countries was not followed by a'decline in the suicide rates among the aged. However, as Stengel (1968) mentions, this might be interpreted a5, financial help alone being insuficient, and concomitant factors with a negative ‘effect may have been at work, Sainsbury (1961) found physical illness to be a precipitating factor for suicide in 35 % of the elderly patients he studied. Studies in Nigeris (Asuni, 1962), Korea (Kim, 1959 and 1963) and preavar ‘China (Yap, 1963) indicate the possiblity that where the old person bas a high status a5 a valued member of society, the sticide rates may not show such rise in old age. 23) Kruft (1960, p, 430), basiag bis concstoas on ike WHO ststistis, points out that this old-age regression was manifested most strongly ia Great Britain, Scandinavia and the white populations of the Commonvweslth42 PREVENTION OF SUICIDE Scandinavia is comparable to that in the USA, though this is not true of other Western European countries (24 At Oxford and Cambridge Universities (England), for instance, the suicide rate among male studeats was 3-5 times higher than for males of the Same age in the general population, although the increase was much less ‘marked in seven provincial universities (Rook, 1959). A suicide rate of 5.45 pet 100.000 vas found among 40.000 former male students of the University ‘of Pennsylvania and Harvard University (Paffenbarger & Asnes, 1966). Exie ‘mination of records of 15-40 years previously revealed that early loss or absence of the father was the dominant distinguishing characteristic of the persons who ‘committed suicide. (@5) Kessel (1965) found that more than one in $00 Edinburgh girls aged 15:19 attempted to poison herself in a single year. The precipitating cause was often a breaking of broken love affair. Ia a survey of hospital admissions for selfpoisoning in the Oxford area, England, Evans (1967) found a rate of 164 per 1000 in 4 years among married females under the age of 20. Otto (1965), ina study of 1727 cases of attempted suicide in persons under 21 years of lage in Sweden from 1985 to 1959, noted that 80 % were gitls. The motives ascribed were love problems in about a third of the total sample and home and parental problems in another third. Of 32% who attended school, only 18 9% ficsted schoo! problems as a precipitating cause, Weitbrecht (1963), reviewing the literature, also points to the high incidence of love and sexual problems pre ciitating suicidal acts in adolescence. Gaultier et al. (1965) noted that, of 2000 cases of non-accidental self-poisoning seen in a poison-control centre in France over a period of 43 years, 20 % wore aged 15-21, three-quarters of these being itis; in about 40 % of these adolescents, the father was absent, and there nad been long-standing poverty of affective tes or severe family confit. Many were found to have been living alone. Jacabziner (1960) found that, in the 8-19 age-group females accounted for three-quarters of the cases of atiempted self Poironing reported in New York City in 1955-58, In 8 % of the 299 cases the father was decsased. Yap (1988) noted among Chinese ia Hong Kong that many suicidal acts that faled to result in death had been precipitated by an acute inter- personal conflict leading to x manifest“ hypereridic” state (lem coined by Lindemann) marked by impulsivity, uncertainty of purpose, lack of planning tnd ineMfeient execution of the act. He notes that hypereridisma may be detected “in persons whose culture normally denies them opportunities of self-assetion, and who need not be suspected of having any anomaly of biologieal drive”. He Suggests thatthe relatively high percentage of young women among his sampie of Chinese attempting suicide in Hong Kong “was a reflection of their subordinate status in a traditional culture, with its patriarchal orientation and male domi- (26) Peshaps the most convincing studies are those by Helgason (1964) and Fremuming (1951) who traced large cohorts up to an advanced age. The deaths and suicides in individuals who had suffered specific psychiatric condi- tions are given in Annex 2, Table 8 7) Sainsbury (1963) cites evidence of considerable reduction in suicide rates among residents in mental hospitals in England following adoption of the ‘open-door policy. This reduction occurred despite an increased admission rate for depressive psychoses and a higher average age of the resident population. (28) Robins et al, (1959) found that, in a total group of suicides, 41 % of the ‘men and 58 % of the women were inthe depressive phase of manic-depressiveANNEX 1 43 illness. ‘They point out thet, in diagnosing manic-depressive illnes it is important to note that the onset is after the age of 40 in half the eases (see also Lundquist, 1945 and Stendstedt, 1952) — this differentiating them from other * functional ™ psychiatric disorders. (29) Pitts & Winokur (1964) found that, of the 422 deceased parents of 365 ‘manic-depressive patients, 31 (13 %) of the mothers had a diagnosis of probable affective disorder, of whom 2 committed suicide, and 25 (11 &) of the fathers ‘were £0 diagnosed, of whom 7 committed suicide, He quotes the findings of Langeliddeke (1941): of 110 male and 231 female menie-lepressive patients followed up for 40 years, 25 % of the 92 deceased males and 10% of the 176 deceased females had commited suicide. (30) Asuni (1962) notes that it is now generally accepted that depressive itlness snd depression complicating other psychiatric and physical illnesses are ‘more frequent in Africa than was formerly considered to be the ease, Of his sumple of cases of suicide in Western Nigeria, 24% were stated to have suffered from psychoses, of which he considered the majority 10 be depressive, In study of 29 persons who had atlempted suicide, Ascni (1967) and a colleague ‘examined 13 personally and found three to be suffering from depressive psychosis. Field (1960) points out that depression is the commonest mental ilness among ‘Akan rural women, 1) A number of authors, eg, Kietholz (1965), and Kielholz & Poldinger (1964) have pointed out that the most appropriate type of antidepressant drus ‘depends on the dominant symptom of the depressive syndrome, such as depres sion, anxiety and agitation, or psychomotor retardation, ince 1962 a joint research programme has been carried out in the five university psychiatric elinies in Switzerland for the esting af new antidepressants, using standardized methods of diagnosis and recording of symptoms and their course. This research is being coordinated with similar work in France, Ger- ‘many, the Netherlands and the USA. ‘The Clinical Psychiatry Committee (1965) in England carried out comparisons ‘of treatment of depressive ilness by elestroconvalsi FECT), imipramine, Pheuelzine and placebo, bora shorwecm (4 weeks) and long-term (6 months). ECT and imipramine ineressed the frequency cf recovery over and above the spontaneous rate shown on piacobo, The drug gave especielly favourable results in males and the ECT in females, (32) Faucett (1958), for example, noted depression appecring in 26% of 202 patients with essential hypertension treated with rauoifia preparations. (93) This is discussed, for instance, by Labherdt (1959) and Kielbolz & Paldinger (1968) (34) Hippius (1965, p. 243), refers to his studies with colleagues of such changes in schizophrenics, Bohatek (1968) found similar effects in 41 of 340, schizophrenics treated over a long period with phenothiazines. Of $00 female schizophrenics treated with piperazine phenothiazines, 11-12 % showed a change to depressive psychosis although previously free from such symptoms (Bohagek, 1965a, 1966). (85) Pokorny (1964) found that 30% of the manic depressives followed up who died by suicide did so Withia one month of leaving hospital. (26) These two categories were found in 10% of Sainsbury's (1955) cases.44 PREVENTION OF SUICIDE (37) Helgason (1964) gives a figure of 2.3% for Iceland (see 15. above). Sehneidman et al, (1962) found, in a large national hospital system in the USA. where schizophrenics make up approximately 71 % of the mental hospital po- ppulation, that this category accounted for 70 % of suicides committed in the ‘mental hospitals. The suicidal act occurred in most instances when the schizo- phrenic illness Was in remission ‘Osmond & Hoffer (1967) examined follow-up studies of 3521 patients wgnosed as schizophrenic in the last 25 years (ll but 76 in USA). In follow-up periods averaging more than § years, 62 had committed suicide (ie., about 20 times the general rate). (G8) This isthe conclusion of Sainsbury (1955, p. 87), who supports his view with reference to the ecological studies of Cavan, Schmid and Faris on suicide, and those of Faris & Dunham, Schroeder and Tietze et al. on mental disorder, in which both conditions were closely associated with social mobility, isolation and disorganization, (G9) Lederman (1952) found that @ high male suicide rate was closely related to a high average consumption of aleobol in the population studied (France). Kessel & Grossmann (1961) noted that the suicide rate in their sample of aleo- holies was some 75 to 85 times the expected figures for males in the same age- sroups in Greater Londen. (40) Szymanska & Zelazowska (1964) noted that, of 100 children and ado- lescents attempting suicide in Warsaw, 51% were children of alcoholic fathers: in only two eases were the mothers also alcoholis (41) Battegay (1965) investigated 58 drug addicts and 213 alcoholics. ‘During 5 years follow-up, 29 of the addicts had made a total of 74 suicidal attempts and one had committed suicide. In tho 18 to 24 years following treatment, 44 of the alcoholics had made a total of $5 suicidal attempts and 6 had committed suicide, (42) Yap (1958a, p. 42), found that the main precipitating cause of 8 out of 218 cases of suicide in Hong Kong was enforced narcotic withdrawal because of poverty (43) Sainsbury (1955) was able to separate London distticts of greatest poverty from those with greatest social disorganization and showed clearly that the latter was the paramount factor related to high suicide rates. ‘McCulloch et al, (1967) found suicides in Edinburgh to be drawn principally from two groups: (a) relatively old pessoas, often divorced or widowed, living alone ia aging tenement property ; (8) younger people in new houses, having high rates of suicidal behaviour (often repeated), overcrovided conditions, with low rates of psychiatric referral but high rates of delinguency as adolescents, and ‘having spent their early life in areas where grossly disturbed family settings are ‘Weiss (1954) made an epidemiological analysis of 278 suicides which occurred in New Haven, Conn, between 1936 and 1950, He found lower suicide rates among the lower socio-economic class than among the upper class, even when the data were adjusted for age, sex and country of origin. However, this trend. was reversed for males aged 65 and over. McCarthy & Walsh (1965) noted that 27.7 % of their sample (284) were living alone at the time they committed suicide, as compared with 3% of the ‘general population. Tae comparable rates in five London boroughs (Seinsbury, 1955) were 29.7 5 (Guides) and 3.5 % (general population of London),ANNEX 1 45 ‘Asuni (1962) on the other Hand found e higher incidence of suicide in Nigeria among those not living slone thax among those living alone (73.7 % and 8,6 %) ‘and among those Living with their families es compared with those living else- where ($39 % and 15.7 6) (44) Ettinger & Flordh (1958) found that 22 % of their sample of persons attempting suicide were living alone, Kessel (1965) found in Edinburgh a very significant association between solfpoisoning rates and indices of social disorganization such a8 overcrowding land the proportion of people living out of a normal family seting. There was no significant correlation with indices of social isolation, (43) Several authors have carried out investigations related to Durkheim's (1912) theory that periods of disintegration result in high suicide rates. Kruijt (1960), for example, noted that in the Netherlands, as in certain other highly industrialized countries, there has been a gradual process of adaptation to urban ‘patterns of life and industrial modes of production so that a petiod of reintegra~ tion is observed in the cities. In some rural areas, however, strong disintegrating forces are active and many rural communities are now passing through a stage of transition, “Few relible figures are available from developing countries, but several investigators have pointed to the need to study changes ia indices, such 8 snlelde rates, thot could bo expected to occur with rapid changes in industi zation and urbenizstion, (46) A striking example is observed in England and Wales, where one in 50 ‘medical doctors takes his own lie: over a five-year period, 6% of all deaths in physicians under the age of 65 were from suicide — about the sume rate as for tung cancer (British Medical Journal, 1964). "The same journal refers to reports of high suicide rates among doctors in Denmark, Ialy and the USA. Blachly et al, (1963) found high rates among physicians, dentists and attorneys. (47) Rates for persons engaged in the liquor trade are much above average in England and Wales, In France, the 195% suicide rato among occupational sroups connected with fishing and the navy was four times that for the total Working population (Candiotti ot el, 1948), (48) Agricultural workers fn che USA, farmers in the Netherlands (Krai, 1960) and persons engaged in agriculture, busting and fishing in Spain (Spain, Institmto Nacional de Estacistice, 1959) have signiticently high rates, whereat farmers end agricultural workers in Eogland ard Weles show low mortally from suicide. In Nigeria, the suicide rate among * adrsinistation, profesio ral and technical was Veo tines that for fh “agriculture and fishing" (Asuni, 1962). (49) Occupation and social status are closely related, Dublin (1962) points fo USA and United Kingdom data indicating that "suleide is an imporcent jem at the two extremes of the economic scale — at the top and the botiom of the socio-economic ladder" Kruijt (1960) shoved thst, at east in the Netherlands, the depression years had a differential influence on suleide rates according to social class and oe pation. The rates increased sharply among small tradespeople, seif-employed crafismen and manual workers, among whom there were accompanying wnem- ployment and tow income. White-collar workers were least affected, In England and Wales, however, the Registrar-General’s figures for suicide by class show that the highest inorease 'n sulside during the depression occurred in the ‘upper classes; in scius! fact the eroportion of deaths due to suicide decreased in46 PREVENTION OF SUICIDE classes IV and V (the lowest), so that those most likely to be unemployed were the ones among whom the suicide rate was least affected by the depression Swinscow (1951), however, found a close relation from 1923 to 1947 between ‘numbers of suicides and numbers unemployed among the male population of Great Britain, (50) Yap (1958) showed that the suicide rate for postwar iaxmigrants was four times that of the population comprising pre-war immigrants and persons born in Hong Kong. Pfister-Ammende (1955) found among just over 5000 refugees in Switzerland a snicide rate 54 times that of the Swiss population, whereas no suicide was recorded among over 3000 repatriates. In the USA, ‘Dublin (1963) noted that the suicide rate among foreign-born males was ice that of the total US male rate; the higher ratio was found for 11 out of 12 countries of origin. Sainsbury (1955) noted a significant correlation between Suicide rates and social mobility (daily turnover of population and proportion of immigrants), whereas Asuni (1962) found a higher suicide rate among those resident in their native places in Nigeria than among those who had moved cut (51) Higher suicide rates are customarily found among the widowed and divorced than among the general population in the same age-groups (see Annex 2, Table 5). Dublin (1963) noted suicide rates among widowed and divorced ‘males in the USA up to seven times those for married men of the same age for women, the ratio was 3-4 times the married rate, Sainsbury (1955) found that % of the London sample were separated or divoreed, compared with an incidence of divorce of 0.24% for the general population. Hartelius (1967) ‘established that, whereas divorced and widowed men comprised 6.04 % of the ‘male population aged over 15 in Sweden in 1941-50, the incidence of suicide in this category comprised 14,68 % of all suicides among men. Yap (1958) noted a particularly high suicide rate in Hong Kong among concubines. Among those who attempt suicide, an excessive proportion of divoreed persons is found. Kessel (1965) noted that among the persons in his Edinburgh sample aged 20-64 ‘who had ever been married, the marriage had terminated in separation or divorce or 30% of the males and 26% of tho females, McMahon & Pugh (1968) showed that suicide rates were higher in recently widowed persons than in controls (52) Greer (1966), for instance, followed up for six months 156 persons who had attempted suicide and compared them with two control groups of hospitalized patients, one of non-sucidal nonpeychiatric and the other of non- suicidal psychiatric patients. “Compared with the controls, the sample showed higher incidence of parental Joss (or continued ubsence of at least 12 months) before the age of 15, and more commonly loss at a younger age of both parents, the absence being more commonly permanent. In the 49% of the sample that hhad suffered parental loss, the ‘suicidal atlempt had more frequently been preceded by disruption of close interpersonal relations than in the 51 % of the ample that came from intact homes, The latter fraction showed a statistically higher occurrence of schizophrenia and psychotic depression and of patints cover 50 years old. "Tuckman ot al, (1966), studying 172 suicides so classified in 1961 in Phila- delphia, found that 46 % of the families (the suicide, his spouse, parents, children and siblings) had bad contact before the date of the suicide’ with health and welfare agencies. Tae Municipal Court of Domestic Relations had been in contact with 21% of the families for problems of support or marital incompa- tibility, and the protection agencies had been in contact with 20% concerning intervention for the welfare of & child,ANNEX 1 47 (33) Prokupek (1967) states that this provision has been in existence since 1960._ ‘The district psychiatrist takes the necessary steps for establishment of the pychiatic diagnosis and for the investigation of the causes and motives, (54) Stengel (1963) refers to circulars issued by the Ministry of Health of England & Wales to hospital boards, local authorities and general practitioners Advising them how to deal with cxses of attempted suicide, “Hospital authorities fare asked to do their best to s00 that all cases of attempted suicide brought to a hospital receive psychiatric investigation before discharge, (55) A Bulletin of Suicidology has been estsblished, prepared jointly by the Conter for Studies of Suicide Prevention and the National Clearinghouse for Mental Health Information, both in the United States National Tastitute of Mental Health. The first number (July 1967) describes the Center and its function, It also contains a directory of suicide prevention facilities in the USA and abstracts of fifty papers on suicide (56) Ringe! (1963), summarizing the results of the Second Intemational Working Conference for Suicide Prevention, stated that “ far more organizations than ate in existence now are desperately needed to deal exclusively with sticide prevention". (57) Sbneidman & Farberow (1968) state: “Our advocacy of a separate ide prevention center is consistent with our bolef that the suicidal eriss thos unique features, relating especially to the dramatically heightened intra- and interpersonal crisis in which life and death frequently hang in the balance, Focused resources are needed for these focused emergencies. ‘The suicide prevention center is conceived as an emergency psychosocial first aid center. With its special resources and specially trained personnel geared to mest the specific needs of both the individual and his significant others at the moments ‘of special ersis". (38) The work of this agency is described in Ringel (1953, and subsequently) ‘Dublin (1963, p. 181) gives an outline of its history and programme, All persons ‘knowa to have attempted suicide in Vienna are taken to the University neuto- psychiatric clinie, where « poison control centre has «iso been established, Te police and the voluntary Vienna Rescue Society alco report cases of attempted suicide to the Lebensmiidenfirsorge, which includes on its staff paychiatrsts of the clinic, peycholosists, psychotherapists, Iemyers, clergy and social workers, ‘The Lebensmiidenflrsorge has an emergency telephone and advisory service and its social workers visit the patients in the clinic and give followaup assistance, (59) This service is described in Varah (1965) and oollined in Dublin (1963), It relies mainly on volunteers, who help to maintain « full-time ‘phone service and offer friendship and advice on where (0 seek further help if needed. “Many persons who have received such sssistance aow eooperste in running the service. A similar organization is the FRIENDS in Miami. ‘Dublin (1963) also outlines the work of tue Lebensmidenbetreaing, in West Berlin, a branch of the Order of St Luke the Physician, wich has sections in ‘many ‘countries. Another agency under Church sponsorship is Reseve Tne, in Boston. (60) The working of the seriices is described in Kessel (1963, 1968), (61) This was roported by Kesicl (1965), who found that, in his sample of persons admitted for self-poisosing in one year in Edinburgh, 26 % of the males land 20 % of the females were not diagnosed as suffering’ from a psychiatric illness,48 PREVENTION OF SUICIDE (62) In the USA, a course on suicide prevention is now being offered at the University of Florida and special lectures are given at the University of Southern California and at the Johns Hopkins University, Baltimore, Mu. (63) Stengel (1963a) states that “Lack of understanding for psychiatric problems will be remedied only when every nurse in training fas 40 spend at Teast three months ina psychiatric department of a general hospital or in a ‘mental hospital... A period of psychiatric training will act as a corrective against the nurse's preoccupation with the technicalities of physical treatments". (64) Jacobziner (1960) found thet, of 299 children and adolescents attempting suicide in New York, few were referred for psychiatric care after treatment Of the self poisoning attempt, However, when public health nurses visited the homes later, they made such referrals in every instance, (63) See: Epidemtological and Vial Statistics Reports, 1956, 9, 243 ; 1958, AU, 342; 1961, 14, 145, 534 3 1962, 15, 519 ; 1963, 16, 590 ; 1964, 17, 5355 1965 18, 407. (66) Gardner et al, (1964) doseribe the value for suicide research of cumulative poychiatric case Tepister which compiles data on the population ‘coming to psychiatric attention within a geographically defined area. The case records may throw light on the factors in mental disorders leading to suicide ‘and persons who attempt suicide can be followed up. Sach a register was estab- lished in Monroe County, New York, in 1960 (population 600 000) and collects data on all patients seen by the paychiaeic fo-patient units, clinics, emergency services and all but three of $0 psychiatrists in private practice. Record linkage ‘possible, Psychiatrists are instructed to include “attempted suicide” as a iagnosis in their case histories. Records of an emergency department and two feneral hospitals are searched for cases of attempted suicide and these are followed up. All desth certificates for country residents are matched against the register, and records of additional eases of suicide are followed beck through ‘mental hospital reeords. (67) The Czechoslovakian Ministry of Health (1966) in its report on suicide (whieh contains summaries in Fglish, French and Russian) states that f recording system has been introduced under the Ministry of Health of all Cases of alempted and completed suicides (except soldiers in service and members of the staff of the Ministry of the Interior). Special forms are completed by the psychiatric department serving the area where the act Sccurted. The data noted include: sex, date of Dirt, place of residence, pro- fessional position, marital status, time and place of act and method, whether repeated attempt, motive, demonstrative attempt, psychiatric diagnosis, signs of ronkenness at time of act, prior psychiatric treatment, hospitalization in psy~ chiatric institution following attempt, The statistics collected are tabulated in ‘etail, However, the number of registered suicidal attempts is only double that fof the number of registered suicides, a8 noted by Prokupek (1967). In view of the much higher ratio found in special surveys, it would seem that as yet only ‘2 percentage of cases of attempted suieide are being recorded in Czechoslovaki (68) Sainsbury (1968) points out that the registration of suicide has been statutory in many countries for over a century and that a wealth of data is available for comparative studies, He correlated the suicide rates of immigrants to the USA with the rates of their countries of birth and found a significant correlation of 0.9, From this he concluded that the differences between national fide rates do not appear primarily to be due to the different procedures usedANNEX 1 49 in reporting deaths. He tested also the reliability of suicide reporting by coroners in $8 county borougas in Englaad and Wales during the six years 1950-52 and 1960.62, In 39 boroughs the coroner had been the same for both periods, and in 19 there had been one coroner ia the fist period and another in te second, No higher correlation was found between the suicide rates in the two periods in the 39 boroughs than in boroughs where the coroner was changed. Tt was therefore concluded that differences between suielde rates of districts in England and Wales could not be attributed to differences in either procedures or etileria of suicide that coroners use in arriving at a verdict, This evidence was taken as supporting the view that the differences in rates are dus to social phenomena. ‘An investigation comparing suicide acts using similar methodology and protocols has been carried out under the auspices of the International Astociation for Suicide Prevention by Farberow, Ringel, Stengel and others and will be published short. (69) An example of such a comparison can be found in Lin (1967), who, with the statistical assistance of E. Brooke, relates the changes in suicide rates among youth in Japan to the changing socio-economic conditions Hiartelius (1967) has studied changes in Sweden in suicide rates according to age-sroups during three 13-year periods and related them to changing con- ditions. Sainsbury (1963) has investigated suicide trends in various countries and shown how this type of epidemiological spproseh can contribute to the search for causes of suicidal behaviour. (10) The accuracy of suicide statistics is discussed more fully by Stengel (19642). He gives an example of two cities with comparable populations and identical registration methods, (71) Shneidman (personal communication) considers that the quality of statistical reporting and the improvement of its reliability will depend largely fon a redefinition of the concepts of death and suicide and of the role of the individual in the outcome of his suicidal act, "See slso Shneidman (1963). (72) A. procedure called “the peychological autopsy " was developed in the Los Angeles centre, Litman et al. (1963) report on. 100 consecutive cases of equivocal suicide referred by the medical examiner (who is aleo the coroner) for examination by a death investigation team, who interviewed relatives of the deceased and others likely to provide relevant information, After investigation, certification was changed from accident to suicide in 11 cases and from suicide to accident or natural death in 8 cases. Such studies would assist standardization of eertfication (73) This bas been the basis of several studies carried out by the Veterans ‘Administration (VA) Central Research Unit, USA. Farberow et al. (1963), for instance, studied 64 Dospital records of patients with diagnoses of malignant neoplasms, half of whom hud committed suicide, the other half being matched fs controls. “Clues were obiaized for identification and recognition of suicide potential, Records of the VA general medical and surgical patients with diag- noses of anxiety reaction or depressive reaction were analysed, A group that committed suicide compared with controls showed significant differences in twenty-three indices of fesling aad behaviour (Farberow & McEvoy, 1966). A similar study was carried out among patients with cardiorespiratory ‘ness (Farberow et al, 1966)50 PREVENTION OF SUICIDE Clinical research may be assisted by examination of suicide notes. A brief survey of such studice was made by Shneidman (personal communication) with ‘emphasis on work cartied out in Los Angeles as reported in Shneidman & Fa berow (1957) and later (Osgood & Walker, 1959; Shneidman, 1960). Suicide notes of 619 persons written in 1945-55 were classified: wishes to kill and be Killed were found to decrease with age and wish £0 die inereased with age. Com- parisons made between genuine and simulated suicide notes indicated that the fuicidal person was distinguished by hostility and self-blame. Notes from per- ons in the upper socio-economic classes spoke of “ being tired of life” and those from persons in the Tower category emphasized physical ines and the stress of living conditions, Wegner (1960) found that one-third of the authors of 60 notes studied manifested negative feelings towards their surroundings and one thin! towards themselves, Capstick (1960) found in 136 notes that waiters over 60 years old were moro likely to refer to physical iliness and the hereafter and to give instructions for management of their affairs. Those aged under twenty Were reproachful and seif-pitying This dffult to evaluate suck research, since usually only a small percentage ‘of persons committing suicide leave suicide notes and those writing notes may not be a representative sample of the total group.Table ‘Table ‘Table Table Table Table Table Table Table Table Table ‘Table Table Annex 2 TABLES ON FACTORS RELATED TO SUICIDE B us AND ATTEMPTED SUICIDE Preferred methods of committing suicide in selected countries Percentage of muds or repeated tempts following previous suleldal attempts Peeontge of previous attempts among persons who aiemst ‘or commit suicide a i Previous psychiatric contact of persons committing suicide Morty rates per 100000 from suicide, by mart states and sex ee a Offspring from broken homes among cases of suicide and attempted suicide a ag Incidence of suicide among patients with mental disorders . Cohort studies on relationship between psychiatric disorders ‘nd deaths from suicide « ae Mental disorders among persons who commit suicide ‘Mental disorders among persons who attempt suiside Incidence of depressive illness in persons who commit or attempt suicide. Percentage of ds depressive disorders bby suicide in patients with mar Percentage of alcoholics who commit or attempt suicide Percentage of alcoholics among samples of persons who ‘commit of atempt suicide 2 3 54 56 56 37 9 oo 6 6 63 64 6s 6652 TABLE 1 Bohannan, 1960 Barbosa & Ramos, "1966 Ramos & Barbosa, 968 Dublin, 1963 Prokapek, 1965 England and Wales, Registrar Goneral, 1964 Yap, 19588 MeCarthy & Walsh, ‘66 Dublin, 1968 ‘Asuni, 1962 Spain, Instituto nao. estadie- tica, 1958 Schneider, 1954 Dublin, 1963, PREVENTION OF SUICIDE ‘COUNTRIES [ata some | apo eine 8B erm snte ot [rosea | Set cao [ora capi | 104-02 canaca ws czochsovaba | 1863 Engieand | 100 |PRRaies Hons Keng [ana ss - basse rtd tesees |sow zane — fro Wgesa tss400 Spain tw0ess |entsrand [rasa veas0 |usa s589 Hanging Poisoning by solids or | tiguids | Poisoning 1 otide or | _ liquids Firearms end explosives Strangulation Domestic gas Hanging Domestic gas: Firearms and explosives Hanging Firearms, hanging Hanging and strangulation Hanging and strangulation] | cwhite mates) trearms and explosives PREFERRED METHODS OF COMMITTING SUICIDE IN SELECTED ‘uloiae | Poisoning by ‘ollds oF Tiquids Polsoning by sollds oF Tiquids Hanging and ‘strangulation ‘Strangulation Domestic gas Hanging Domestic gas Gas [Hanging Poisoning, hanging Drowning Domestic gas (White females) poisoning and asphyxiationANNEX 2 53 TABLE 2, PERCENTAGE OF SUICIDES OR REPEATED ATTEMPTS FOLLOWING PREVIOUS SUICIDE ATTEMPTS ke ] ‘Wot total eases eee | toe ama | oumens Te Nien] olbthlla | TEES" conan age suis | onto Batcnsor » | 200 | Consecutive | yoar 2 | ss apie 1850 intel to a semua pose. Stand Danigren, 1954 | 257 | ed. and psjcia. [2 yours | 10 Wding, Sweden| aan adele, wee Eiorthalgtal, | ot2|veterane Admin, [a years e | a ‘oo 8) pate Selon andy ou Bae abeanaton Ekblom & Fisk evens | 0 | 299 (tet, Fines Ettinger & 451 |peycia.cest, fez montte | 306 ioe, 15s en here {Steerbain, rime, Siegen) oss Garcnera ser | Poyoniat case | yoar 2 “0 onion sain Sit Can USS) Hove, 1088 seo |conteeutie laa yere | 5 | 10 "trac, cretatchs gen Sang Rooper neo Dotenes ameserai rota | 100 |aen,noop. average «| | ‘Wes ‘tintin (SSSR Australia) | ansson, 1962 zs eyes, cle {1 year 1 fe ‘Dancer mnt cine, | Kosso 1865 Ail setpoisoning {1 your te | as ‘Eanoush, | ase | Stand Megariny & Wales, | 158 casualty dopt, 208 menths| a1 350 thcbtn REM se Ireland) | Moito, 1965 | 193 | Gen, nosp. psychiat, 5-8 years ef ‘Sep Pancico, |S eameloe §3 ieee54 PREVENTION OF SUICIDE ‘TABLE 2. PERCENTAGE OF SUICIDES OR REPEATED ATTEMPTS: FOLLOWING PREVIOUS SUICIDE ATTEMPTS (Continued) total onto Type ot Duration repeating pateiaton Tollowtp jeommiing| "opeating site| ronal 618 |Veterans Admin. 34 psychiat. hosp, patients suicide fttempts, threats, Toa Rings!, 1959 2879 |Hosp. admissions |a-44 months | 0.05 (Wienna, Austria) ‘or suicide attempts, Ringel, 1967 Sucide attompts —|2 years 2 6 (Wiens, Austra) Togistered in Vienna tn 1962 ‘Schmidt etal, 1958 | 109. |e-mth. admissions 18 (t- Louls, USA) To gen. hosp, Schneider, 1954 372 | Admissions to med, 8 33 (Lausanno, ‘surg. & paychiat. Switzerland) clinics ‘Stengel & Cook 188 Observation ward [3-5 years | 0B 18 1958 admissions, one (Condon, England) year, 1946 76 |Consecutive admis- |1/2-2years | 6 ‘sions to gen, hosp, 1961-68 ‘Szymanska & 81 |Ment. health 6mth-2years) t o Zelazowska, 1964 ‘entre admissions Warsaw, Poland) TABLE 8. PERCENTAGE OF PREVIOUS ATTEMPTS AMONG PERSONS WHO ATTEMPT OR COMMIT SUICIDE — ‘Achié & Ginman, 1986 | Consecutive admissions 7 (Holsink’, Finland) for suicide attempts by drugs | Blane et al, 1968 Psychiat. dept. gon. hosp. ‘500 wv (Gironde, France) ‘admissions, 1960-64 Bridges & Koller, 1968 | Psychiat. dept. gen. hosp., 198 16 (London, England) ‘one year’s admissions Bruhn, 1963 ‘Casualty dept. gen. hosp. or 8 (Edinburgh, Scotland) | "admissions, 1861-62annex 2 55 TABLE 8, PERCENTAGE OF PREVIOUS ATTEMPTS AMONG PERSONS WHO ATTEMPT OR COMMIT SUICIDE (Continued) piousaiene Binoy Type at popuision | See s | as Ekblom & Frisk, 195 Admissions to 2 gon. 150 (Holsink’, Finland) ‘hosps., 1950-82 Ettinger & Flordh, 1965 _|Paychvat. dept. gan. hosp. 00 (Stockholm, Sweden) | consecutive admissions, Jeeasa Goreeix & Zimbacca, |All recorded cases, 1962 | 969 2 “05 (Seino, France) Jacobziner, 1960 Reported to poison 280 6 (New York, USA). | control centres 1955-88, aged 8-18 years James etal, 1963 |Gen, hosp. admissions 100 2 (Western Australia) Kessel & McCulloch, |All casas of sslt-poisoning si 2 1965 and selFinjury (Edinburgh, Scotland) MeGulloch et al, 1967 |Consecuthe reported | 216 243 ‘Edinburgh, Scotland) | cases, 1888-65 Sainsbury, 1955 Recorded cases intive | 990 8 (London, Englana) boroughs, 1886-98 Solare & Hamilton, 1963 Psychiat. dept. gen, hosp. 180 2 (Glasgow, Scotiana) ferrals, 96082 | Seager & Flood, 1985 All recorded cases, | 6 Gristel, Englans) ‘057-81 | Stengel & Cook, 1952 [Observation ward, one 198 2 (London, England) year's admissions, 1946/7, | | luni. peyohtat. hosp. nm Ea admissions, 1949/50 | a 6 JOssention ward,one | | 17 3 year's admissions, #853 | i c ” [Other observation ward, | ava | | 28 fone year's admissions, 1988 | 1 c IGen, hosp. two years! % at ‘sdiiasions, 151-53, i . ‘Coroner's Court, 1983, 17 | “4 Seymansta & Zeazowska Mon cate | 100 % ‘edmissions, (Warsaw, Poland) ‘aged up to 18 years Whitlock & Schapira, 1967 |Gen. hosp. two year’s ame m: 43 (Newcastle, England) | admissions fo56 TABLE 4, PREVIOUS PSYCH! Capstick, 1960 (Wales) Dorpat & Riploy, 1960 (Seattle, USA) Gardner ota, 1954 (Monroe Co. NY, USA) Jones, 1965 (East Anglia, England) Motto & Greene, 1958 (San Francisco, USA) Parnell & Skottowe, 1987 (England) Prokapek, 1967 (Czechoslovakia) Robins ot a. 1959 (St Louis, USA) Soager & Flood, 1965 (Bristol, England) Walk, 1967 (Chichester, England) #3 PREVENTION OF SUICIDE IATRIC CONTACT OF PERSONS COMMITTING SUICIDE Pariog ot | Pavia oma Comments sty" | IS | Contact on various est | tosi-s5 | 14 m4 zz | Contact within 1 year eo | 1960-82 | 20 | Known to psychiatric. caso register Adaitional 6 In mental | Tosptal Before 1960 30 | 057-63 | 20 | contact witnin2 yeare 175 1956-57 | 9 Contact within 6 mth co | 0 | 2 | pod nets ors | 195368 | 27-90 | contact within 1 year 12222 | a6 ts | 190657 | 20 | period not statod ss | 1957-61 | 180 | contact withing mins 298 | ad beon in-pationts v3 | tesese | 235 | Contact within year 4950-69 TABLE 5. MORTALITY RATES PER 100000 FROM SUICIDE, BY MARITAL county and Toy potoy |e Omen | mee FS Canada’ | aiess| 10 16 | England ond | ees | seer Now Zoaland™ | 18650 |18 sweden | 0510/36 artes, s867 (so ‘Switzerland — | 1959 |e USA odin, | 14051 | a 05 «Figure In upper line fr url ar STATUS AND SEX 16 | 36 3 os |7 | Alt ages 4 0 | 26/184 over we} | 5 7 |13 29 |All ages 274] 667 800) 94 81|i04 i163 Bair 1029 1248) 151 98/205 31.0 | Al ages 2 jroo 152 |15 11 19 28 | An ages 208/759 799| 81 66/134 192/ 20-74 | | (age-adjstos) owed, = dvorcad In Towor tne for urban areas,7 ANNEX 2 91 968 a1o1eq juored uo jo uonesedee 10 le—p yBnosig seo} ywavEweg 91 060 010) 09 (2,02) wor 40 (ejdues 08) Yuosed suo Jo. 8807 ‘1 95e exojoq swqu 2} se 8 20) e0uosce enuivoa 10. "e80) feueled oidures 40 ys0us uyuoo Ayurey ‘sM0U0E ) eNyDaye 40" 998] Buol osiy “seuye) 40 soulesay

Você também pode gostar

• Modelos de Determinação Social Do Processo Saúde-Doença

  

  Documento2 páginas

  Modelos de Determinação Social Do Processo Saúde-Doença

  maelison

  Ainda não há avaliações
• Modelos de Determinação Social Do Processo Saúde-Doença

  

  Documento2 páginas

  Modelos de Determinação Social Do Processo Saúde-Doença

  maelison

  Ainda não há avaliações
• Visão de Ser Humano em Skinner e A Prática Clínica

  

  Documento8 páginas

  Visão de Ser Humano em Skinner e A Prática Clínica

  maelison

  100% (1)
• • Revistas
  • Podcasts
  • Partituras
• Epistemologia em Psicanálise

  

  Documento15 páginas

  Epistemologia em Psicanálise

  maelison

  Ainda não há avaliações