How can we best prevent suicide in young people? More questions than answers

Jan 7 2014

Listening to a World Health Organisation podcast recently I learnt that someone dies as a result of suicide every 40 seconds; this equates to a million suicides each year. The podcast contains a myriad of such stark statistics and the contributors’ highlight how it is well established that young people are often at risk, and that suicide is the second largest cause of mortality in the 10-24 age group.

Much has been written about preventing the growing trend of suicide and self-harm across the age spectrum and especially about how we might address the increases we have seen in young people attempting suicide and self-harm. In 2010, the Royal College of Psychiatrists published a 137 page report which “examines the evidence of practice on the ground” and this made numerous recommendations to reduce risk and hence prevent or at very least reduce the incidence of suicide and self-harm in young people.

Self-harm is common among young people and the related impacts are wide-ranging:

It is reported that in England, for people aged 15–16 years, more than 10% of females and more than 3% of males self-harm in any year
For all age groups, annual prevalence is approximately 0.5%
Self-harm increases the likelihood that the person will eventually die by suicide by between 50- and 100-fold above the rest of the population in a 12-month period
A wide range of mental health disorders (borderline personality disorder, depression, bipolar disorder, schizophrenia, and drug and alcohol-use disorders) are associated with self-harm.

In Britain, we have NICE guidelines on the treatment of self-harm, which focus on the management of self-harm in the short term (CG16) and longer term (CG133) affects.

Despite the size, seriousness, impact and tragic nature of suicide and self-harm in young people, little evidence-based research has been conducted to establish the best strategies for preventing it from happening.

A recent review, carried out by a multidisciplinary group based in Melbourne, Australia, has been published that aimed at investigating “the extent and nature of research on interventions to prevent SSH (suicide and self-harm) in young people using evidence mapping”. This has once again brought to the elves’ attention the gaping holes in our current understanding of suicide prevention.

People who have self-harmed are 50-100 times more likely to die from suicide than the rest of the population

Methods

The Melbourne based authors searched using MEDLINE, PsycINFO, EMBASE and CENTRAL. They used a technique called “evidence mapping” to evaluate the scientific literature published interventions for suicide and self-harm. This method “allows a concise summary of the extent and distribution of evidence in a broad field of interest”. They restricted their study to studies published in English after 1980. The study used two foci for the map:

What good quality evidence exists regarding the prevention of and interventions for SSH behaviours among young people?
What areas are, and what areas are not, well researched?

Their criteria for inclusion in the study included a definition of the term “young people” (6-25 years), attempted to exclude studies on non-suicidal self-injury (NSSI) and to include only “good quality” evidence (only randomised controlled trials – RCTs -, pseudo-RCTs, clinical control trials, systematic controlled trials and meta-analyses of RCTs).

This new review did not analyse the studies found, but simply mapped the evidence to provide an overview of the current research landscape

Results

From an initial 7,498 studies they found 38 controlled studies and 6 systematic reviews that met their search criteria. From their data they established that:

Most studies (n=32) involved psychological interventions
Few studies (n=9) involved treating young people with mental disorders or substance abuse (n=1)

Conclusions

The authors concluded:

…the evidence base for SSH interventions in young people is not well established.

Sadly the authors did not assess the benefits or the efficacy of any of the reported interventions and so their conclusions are somewhat muted. They did however make a number of recommendations:

School-based prevention programmes are worth expanding on
Various “talking therapies” warrant further investigation (CBT, IPT and attachment based family therapy)

Limitations

De Silva and her colleagues identified a number of limitations of their own study including limiting their study to studies in English published after 1980. They also identified the obvious problem of actually carrying out controlled trials to test the efficacy of interventions aimed at preventing death!

The most obvious limitation however, remains that they did not evaluate the effectiveness of the studies they mapped and this meant that the study added little to improve our understanding of what helps prevent suicide and self-harm in (young) people.

And finally…

In the time it has taken me to complete the first draft of this blog, another 176 deaths will have occurred as a result of suicide. This present study fails to tell us what might have prevented any of these deaths from occurring, but it does provide added weight to the argument that we desperately need more research to be carried out in the field of suicide prevention in young and indeed all people.

The 2010 Royal College of Psychiatrists’ report (Alderdice, 2010) on suicide in the young concludes:

…there is enough evidence to demonstrate that we are far from achieving the level of care that service users need or the standards set out in policies and guidelines. Poor assessments, relying too much on risk issues, staff unskilled in dealing with patients who harm themselves, inappropriate discharge arrangements, lack of follow-up of patients, lack of care pathways, insufficient access to psychological treatments and poor access to services for particular groups amount to inadequate standards of care that impact on the lives of service users and their families. There is a serious problem relating to the deployment and availability of senior staff, with adequate psychotherapy and psychiatry training. It is likely that because of these services and staffing defects, the majority of self-harm remains invisible until a crisis occurs, adding to human misery and to the stress on hospital services.

Time to change?

This review recommends that school-based interventions and talking therapies are areas of focus for future research

If you need help

If you need help and support now and you live in the UK or the Republic of Ireland, please call the Samaritans on 116 123.

If you live elsewhere, we recommend finding a local Crisis Centre on the IASP website.

We also highly recommend that you visit the Connecting with People: Staying Safe resource.

Links

De Silva, Stefanie; Parker, Alexandra; Purcell, Rosemary; Callahan, Patrick; Liu, Ping; Hetrick, Sarah. Mapping the evidence of prevention and intervention studies for suicidal and self-harming behaviors in young people. Crisis: The Journal of Crisis Intervention and Suicide Prevention, Vol 34(4), 2013, 223-232. doi: 10.1027/0227-5910/a000190 [PubMed abstract]

WHO podcast on suicide and self-harm: http://terrance.who.int/mediacentre/podcasts/WHO_Podcast_077.mp3

Alderdice, J. et al Self-harm, suicide and risk: helping people who self-harm: final report of a working group (PDF). Royal College of Psychiatrists, College Report CR 158, Jun 2010.

Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. NICE clinical guideline CG16, Jun 2004.

Longer-term care and treatment of self-harm. NICE clinical guideline CG133, Nov 2011.