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The role of the high-risk approach in suicide prevention

  • Alexandra Pitman (a1) and Eric Caine (a2)
Summary

Evidence favours the population approach over high-risk approaches to suicide prevention, but methodological problems may have obscured the contribution of the latter. This editorial uses the findings of a recent evaluation of a high-risk approach used in England to consider the role of high-risk interventions in national suicide prevention strategies.

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Copyright
Corresponding author
Alexandra Pitman, UCL Mental Health Sciences Unit, Unniversity College London, Charles Bell House, 67–73 Riding House Street, London W1W 7EJ, UK. Email: a.pitman@ucl.ac.uk
Footnotes
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See pp. 233–238, this issue.

Declaration of interest

None.

Footnotes
References
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1 Lewis, G, Hawton, K, Jones, P. Strategies for preventing suicide. Br J Psychiatry 1997; 171: 351–4.
2 Gunnell, D, Frankel, S. Prevention of suicide: aspirations and evidence. BMJ 1994; 308: 1227–33.
3 Mann, JJ, Apter, A, Bertolote, J, Beautrais, A, Currier, D, Haas, A, et al. Suicide prevention strategies: a systematic review. JAMA 2005; 294: 2064–74.
4 Leitner, M, Barr, W, Hobby, L. Effectiveness of Interventions to Prevent Suicide and Suicidal Behaviour: A Systematic Review. Scottish Government Social Research, 2008.
5 van der Feltz–Cornelis, CM, Sarchiapone, M, Postuvan, V, Volker, D, Roskar, S, Grum, AT, et al. Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews. Crisis 2011; 32: 319–33.
6 Gunnell, D, Metcalfe, C, While, D, Hawton, K, Ho, D, Appleby, L, et al. Impact of national policy initiatives on fatal and non–fatal self–harm after psychiatric hospital discharge: time series analysis. Br J Psychiatry 2012; 201: 233–8.
7 Knox, K, Conwell, Y, Caine, E. If suicide is a public health problem, what are we doing to prevent it? Am J Public Health 2004; 94: 3745.
8 Knox, KL, Pflanz, S, Talcott, GW, Campise, RL, Lavigne, JE, Bajorska, A, et al. The US Air Force suicide prevention program: implications for public health policy. Am J Public Health 2010; 100: 2457–63.
9 While, D, Bickley, H, Roscoe, A, Windfuhr, K, Rahman, S, Shaw, J, et al. Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross–sectional and before-and-after observational study. Lancet 2012; 379: 1005–12.
10 Fleischmann, A, Bertolote, JM, Wasserman, D, Bolhari, J, Botega, NK, Phillips, M, et al. Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries. Bull World Health Organ 2008; 86: 657736.
11 Page, A, Taylor, R, Gunnell, D, Carter, G, Morrell, S, Martin, G. Effectiveness of Australian youth suicide prevention initiatives. Br J Psychiatry 2011; 199: 423–9.
12 Perlis, RH. Hard outcomes: clinical trials to reduce suicide. Am J Psychiatry 2011; 168: 1009–11.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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The role of the high-risk approach in suicide prevention

  • Alexandra Pitman (a1) and Eric Caine (a2)
Submit a response

eLetters

High-risk strategies versus universal precautions against suicide

Matthew M Large, psychiatrist
05 September 2012

Dear Editor,

The recent paper by Gunnell et al. (1) and the accompanying editorialby Pitman & Caine (2) clearly out-line the practice and principles of a contemporary approach to suicide prevention in mental health settings. However, I do not think the policy initiative meaning that every patient with a serious mental illness or a recent episode of self-harm should be followed up within a week of discharge is really a high-risk approach to suicide prevention. Self-harming patients and those with serious mental illness must constitute the vast majority of people who are admitted to psychiatric hospitals and therefore this recommendation is more like a universal precaution against suicide than a targeted intervention based ona high-risk model.

In my view there are compelling reasons to doubt the usefulness of high-risk categorization for future suicide at the point of discharge frompsychiatric hospitals. It is known that discharged patients have about a hundred fold increased risk of suicide compared to the general community in their first few weeks at home (3). However, those categorized as at high-risk of suicide after discharge are only about 4 times more likely tosuicide than discharged patients categorized as at low-risk of suicide (4). Hence, compared to the risk of just being a discharged patient, beingat high-risk or low-risk is virtually meaningless.

If the English guideline for early follow up of patients has been successful, this is almost certainly because it approximates a universal precaution against suicide and not because of the success of a high-risk approach. We need to acknowledge that all those admitted to psychiatric hospitals have a very high absolute risk of suicide and that we are unableto tell who will be safe.

References

1. Gunnell D, Metcalfe C, While D, Hawton K, Ho D, Appleby L, Kapur NImpact of national policy initiatives on fatal and non-fatal self-harm after psychiatric hospital discharge: time series analysisBritish Journal of Psychiatry 2012 201:233-238

2. Pitman A, Caine EThe role of the high-risk approach in suicide preventionBritish Journal of Psychiatry 2012 201:175-177

3. Qin P, Nordentoft M. Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Archives of General Psychiatry 2005 62:427-432.

4. Large M, Sharma S, Cannon E, Ryan C, Nielssen O. Risk factors for suicide within a year of discharge from psychiatric hospital: a systematicmeta-analysis.Australian and New Zealand Journal of Psychiatry 2011;45:619-28.

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Conflict of interest: None declared

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