According to the article, Ireland spends 5.5 million Euros on suicide prevention each year, and there are around 500 different groups who have some activity relating to suicide prevention. These will include national groups such as the Samaritans, but also includes lots of smaller regional and community groups; most of which have a degree of uncertainty over remit, governance, and performance management. Last year there were just over 500 suicides in Ireland. That means that there is a suicide prevention group for each suicide in Ireland.
Why would there be so many groups? Well, suicide is undoubtedly an emotive subject and there is often a response among communities that 'something must be done'. We find it hard to react to apparent suicide clusters in a detached, rational way and most people struggle to distentangle tragedy from statistical chance. The apparent spike in suicides at the FoxConn manufacturing plant in China led people to associate poor working conditions with ripe conditions for suicides. However, the rate of suicide at the plant was somewhat less than the rate in Scotland, for example. The number of suicides seen was no higher than would be expected from a large population (FoxConn had around 300,000 employees - the same number as a sizeable town).
So, should there be fewer groups trying to tackle suicide? This is an area where there is disappointingly little evidence to support typical approaches. Of course, one can't count things that didn't happen, so it can always be argued (often by the charities themselves) that they were preventing suicides. However, when you start comparing areas with lots of such groups with those that don't you generally don't see any evidence that the presence or activity of such groups is having a detectable effect on suicide rates. They may be offering support for those in distress, but they don't seem to have much of an effect on actual numbers of suicides.
For example, if we look at how many people phoning The Samaritans were actually suicidal, it turns out to be a small proportion of all calls. A presentation from The Samaritans at a Choose Life conference in 2010 reported 148,000 contacts, of which 84% were by telephone. That makes 124,320 telephone contacts. Only 20% of those were in a 'suicidal crisis', which means that 28,864 were suicidal when they phoned The Samaritans. The risk of suicide in those who are suicidal is, of course, higher than the general population but it's still relatively low, and being in 'suicidal crisis' covers everything from people standing on the edge of a bridge to someone contemplating what the point of life is and thinking that they would sometimes rather be dead.
Knowing how many suicidal people will die by suicide is difficult. However, we know that between 0.5% and 1.8% of people who have self-harmed will die by suicide in the year following the incident of self-harm (Owens, 2002). If we assumed that the risks were the same, then between 124 and 520 people will die by suicide in the year following their call to The Samaritans.
But the risks aren't the same. Suicidal thinking is reasonably common. The lifetime prevalence of suicidal ideation, plans, and attempts is 9.2% (Nock, 2008). The percentage of people who will die by suicide is (assuming a rate of 20 per 100,000) is 0.02%. Therefore, suicidal ideation is at least 460 times more common than suicide. If we therefore take 28,864 people with suicidal thinking, only 62 of those will die by suicide in the following year. That's a rate of just over one per week.
We don't know how protective a call to The Samaritans is, but the effect is unlikely to last a year. Indeed, we know that almost half of all suicide attempts have less than 10 minutes between thinking and acting (Diesenhammer, 2009), so the person would have to call The Samaritans pretty quickly in order for them to prevent at least 50% of all suicides/ attempts.
If the ability of The Samaritans and other such telephone crisis lines to prevent suicides seems pretty weak, what is their point? The reasons for calling, according to the presentation cited above, are:
- 55% sad or low
- 51% lonely and isolated
- 40% anxious all the time
- 39% have mental health problems
- 35% family problems
- 35% bereavement
The Samaritans undoubtedly provides a source of support to those with a range of mental health issues, but they're unlikely to be preventing suicide. First, because at least 50% of suicides are very impulsive in that there isn't much time between thinking about it and acting upon these thoughts. Second, because they're not going to be having contact with large numbers of people at very high risk of suicide. Most callers are lonely, sad, or anxious; not suicidal.
Perhaps the Irish have a point in trying to bring some form of regulation to the field? If they're spending 5.5 million euros on a range of groups who are unlikely to be preventing suicide, then what is the state getting for their money? Some groups will be providing support for those bereaved by suicide, and others will be supporting people with a range of mental health problems, but this is a different activity to actually preventing suicide. As yet, there is precious little evidence for these activities in preventing suicide. Indeed, the only things which have compelling evidence to reduce suicide rates are "Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates." (Mann, 2005) Perhaps our (suicide prevention) money could be better spent elsewhere...
References
OWENS, D., HORROCKS, J. & HOUSE, A. (2002) Fatal and non-fatal repetition of self-harm: Systematic review. British Journal of Psychiatry, 181, 193-199)
NOCK, M. K., BORGES, G., BROMET, E. J., ALONSO, J., ANGERMEYER, M., BEAUTRAIS, A., BRUFFAERTS, R., CHIU, W. T., DE GIROLAMO, G., GLUZMAN, S., DE GRAAF, R., GUREJE, O., HARO, J. M., HUANG, Y., KARAM, E., KESSLER, R. C., LEPINE, J. P., LEVINSON, D., MEDINA-MORA, M. E., ONO, Y., POSADA-VILLA, J. & WILLIAMS, D. (2008) Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. British Journal of Psychiatry, 192, 98-105.
DEISENHAMMER, E. A., ING, C. M., STRAUSS, R., KEMMLER, G., HINTERHUBER, H. & WEISS, E. M. (2009) The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? Journal of Clinical Psychiatry, 70, 19-24.
MANN, J. J., APTER, A., BERTOLOTE, J., BEAUTRAIS, A., CURRIER, D., HAAS, A., HEGERL, U., LONNQVIST, J., MALONE, K., MARUSIC, A., MEHLUM, L., PATTON, G., PHILLIPS, M., RUTZ, W., RIHMER, Z., SCHMIDTKE, A., SHAFFER, D., SILVERMAN, M., TAKAHASHI, Y., VARNIK, A., WASSERMAN, D., YIP, P. & HENDIN, H. (2005) Suicide prevention strategies: a systematic review. JAMA, 294, 2064-74.
