Five Reasons Why Suicide Prevention Programs Are Ineffective
Angus H ThompsonAlberta Centre for Injury Control & Research& the Department of Public Health Sciences
University of Alberta
Canadian Association for Suicide Prevention Edmonton October 2004
“EFFECTIVE” SUICIDE PREVENTION
• Educating Physicians in Detection & Intervention (Gotland, Sweden)
• Gun Control (Canada)
• Individual Interventions
REASON 1
AN ORGANIZATION WITH “SUICIDE” IN ITS TITLE CANNOT PREVENT SUICIDE!
WHY DOES EARLY INTERVENTIONMATTER?
• To Make A Difference During the Formative Years
BrainSculpting
Temperament
Vocabulary
Birth 5 Yrs 10 Yrs 15 Yrs 20 Yrs 25 Yrs
Peer Influences
Understands Suicide
Suicide Ideation
Formal Suicide Intervention
AGE OF OCCURRENCE OF A NUMBER OF FACTORS RELEVANT TO SUICIDE
WHY DOES EARLY INTERVENTIONMATTER?
• To Make A Difference During the Formative Years
• Canadian Children Are More Stressed Than Children From Many Other Countries
RANKINGS OF CANADIAN 11-13 YEAR-OLDS ON SELECTED HEALTH-RELATED QUESTIONS (VS 7-11 COUNTRIES)
WHY DOES EARLY INTERVENTIONMATTER?
• To Make A Difference During the Formative Years
• Childhood Stress is Increasing in Canada
• Canadian Children Are More Stressed Than Children From Many Other Countries
0%
10%
20%
30%
40%
1935 1950 1965 1980 1990
Prev
alen
ce
Females
Males
Figure 3THE PREVALENCE OF TWO OR MORE TRAUMATIC
CHILDHOOD EVENTS BY “COHORT YEAR” AND SEX
“Cohort Year” = Date when the youngest person in each group would have been about 15 years of age
Source: Thompson AH, Cui X (2000). Increasing Childhood Trauma in Canada: Findings From the National Population Health Survey, 1994/95. Canadian Journal of Public Health, 91(3), 197-200.
REASON 2
SUICIDE IS NOT SEEN AS PART OF A CLUSTER OF HUMAN PROBLEMS
THE CANADIAN SOCIAL PROBLEM INDEX
COMPONENTS
MurderAttempted Murder
AssaultSexual assault
RobberySuicideDivorce
Alcoholism
Source: Thompson AH, Howard AW, Yin J (2001). A social problem index for Canada. Canadian Journal of Psychiatry 46, 45-51.
SOCIAL PROBLEM INTERCORRELATIONS ACROSS PROVINCES: 1971/1981
Att.Murder Assault Rape Robbery Divorce Suicide
Alco-Holism
Homicide .91/.90 .47/.50 .58/.69 .71/.61 .65/.66 .47/.81 .43/.82
AttemptedMurder .36/.24 .58/.44 .80/.61 .56/.48 .38/.79 .43/.59
Assault .23/.73 .26/.00 .76/.54 .41/.30 .17/.63
Rape .84/.35 .71/.68 .68/.34 .76/.83
Robbery .72/.67 .63/.66 .75/.65
Divorce .77/.70 .68/.77
Suicide .79/.66
THE CANADIAN SOCIAL PROBLEM INDEX: 1956 - 1996
90
100
110
120
130
140
150
160
170
Socia
l P
roble
m Index
1956
1976
1996
Source: Thompson AH, Howard AW, Jin Y (2001). A social problem index for Canada. Canadian Journal of Psychiatry 46, 45-51.
Alcohol Abuse
Drug Abuse Divorce
Unem- ployment
Suicide attempt Felony
Spouse Abuse
Child Abuse
Schizophrenia
Mania
Depression
Dysthymia
Phobia
Panic Disorder
Obsessive Compulsive
Antisocial Personality
OR < 5 OR 5 - 9.9 OR 10+
THE ASSOCIATION BETWEEN SOCIAL PROBLEMS AND PSYCHIATRIC DIAGNOSES IN THE EDMONTON AREA EPIDEMIOLOGICAL STUDY OF PSYCHIATRIC DISORDERS
Source: Thompson A & Bland RC (1995). Social dysfunction and mental illness in a community sample. Canadian Journal of Psychiatry 40, 15 – 20.
(r = 0.81)
REASON 3
THE MAJORITY OF SUICIDAL INDIVIDUALS EXHIBIT A MENTAL ILLNESS, BUT MOST
OF THESE DO NOT RECEIVE TREATMENT
The Proportion Of Persons Who Had Completed Suicide Who Showed Evidence Of A Mental Illness
Depressive AnyAuthors Country Disorders Disorder
Robins et al. 1959 USA 45% 94%
Dorpat & Ripley 1960 USA 29% 100%
Barraclough et al. 1974 UK 70% 93%
Beskow 1979 Swe 45-48% 97%
Chynoweth et al. 1980 Aust 55% 88%
Rich et al. 1986 USA 46% 95%
Arato et al. 1988 Hung 58% 81%
Åsgård 1990 Swe 58% 95%
Henriksson et al. 1993 Finl 59% 93%
Cheng 1995 Taiw 88% 98%
Conwell et al. 1996 USA 47% 90%
Foster et al. 1997 N Ire 36% 86%
BUT …
• Psychological autopsies are retrospective in nature
BUT …
• Psychological autopsies are retrospective in nature
• Treatment is far from perfect
BUT …
• Psychological autopsies are retrospective in nature
• Treatment is far from perfect
• There is an environment by mental vulnerability interaction
i.e.
EXPRESSION OF SOCIAL PROBLEM BEHAVIOURA Threshold Model
High Stress
Low Stress
No Social Problem Behaviour
Social Problem Behaviour
Stress Threshold
EXPRESSION OF SOCIAL PROBLEM BEHAVIOUR
Two Components
1. ENVIRONMENTAL STRESSORS
2. INDIVIDUAL DIFFERENCES IN REACTIVITY
Social Disintegration
The Invulnerable
The Resilient
The Vulnerable
The Disabled
THE INTERACTION OF CONSTITUTIONAL AND ENVIRONMENTAL FACTORS: A MODEL
SOCIAL PROBLEMS
NO SOCIAL PROBLEMS
Social Disintegration
The Invulnerable
The Resilient
The Vulnerable
The Disabled
THE INTERACTION OF CONSTITUTIONAL AND ENVIRONMENTAL FACTORS: A MODEL
SOCIAL PROBLEMS
NO SOCIAL PROBLEMS
Social Disintegration
The Invulnerable
The Resilient
The Vulnerable
The Disabled
THE INTERACTION OF CONSTITUTIONAL AND ENVIRONMENTAL FACTORS: A MODEL
SOCIAL PROBLEMS
NO SOCIAL PROBLEMS
REASON 4
SUICIDE PREVENTION PROGRAMS CANNOT “LEARN”
“SUICIDE PREVENTION” PROGRAMS RARELY EVALUATE THEIR IMPACTS:
• Several years required to show an effect
“SUICIDE PREVENTION” PROGRAMS RARELY EVALUATE THEIR IMPACTS:
• Several years required to show an effect
• Avoidance of personal evaluation
“SUICIDE PREVENTION” PROGRAMS RARELY EVALUATE THEIR IMPACTS:
• Several years required to show an effect
• Avoidance of personal evaluation
• Not knowing what one’s job is (i.e. focus on process, not outcome)
REASON 5
WE DON’T KNOW WHY THE SUICIDE RATE IS SO LOW
If depression and hopelessness are considered to be essential components of suicide, and considering that:
• We all will die
• We will lose loved ones
• Most won’t be in the career of choice
• Our abilities will decline as we age
Then, why is the suicide rate not higher - in fact, much higher - than it is?
WHY DO WE “GO FORWARD”?
WHY DO WE “GO FORWARD”?
Rose Coloured Glasses
Optimism (Seligman)
Strengthening Behaviour (Skinner)
Traditions (Frankl)
Social Support
Control over one's environment
The family
Social skills
WHAT TO DO
WHAT TO DO
AN ORGANIZATION WITH “SUICIDE” IN ITS TITLE CANNOT PREVENT SUICIDE!
Focus on Early Intervention & Child Development prior to the onset of serious suicidal behaviour
WHAT TO DO
SUICIDE IS NOT SEEN AS PART OF A CLUSTER OF HUMAN PROBLEMS
Create a continuity of services that reflects the inter-relatedness of suicide & other social problems
Create a social fabric that weakens the determinants of suicide and enhances resilience and social cohesion
WHAT TO DO
MOST SUICIDAL INDIVIDUALS EXHIBIT A MENTAL ILLNESS, BUT THE MAJORITY
DO NOT RECEIVE TREATMENT
Improve detection, referral and access to treatment for those with a mental illness
WHAT TO DO
SUICIDE PREVENTION PROGRAMS CANNOT “LEARN”
Create Self-Regulating Suicide Prevention Initiatives, most of which would not have “suicide” in the title
WHAT TO DO
WE DON’T KNOW WHY THE SUICIDE RATE IS SO LOW
Ensure that every child has experience with success and defer experiences with the traumatic realities of the World - until it is too late!
FIN
Questions arising:
i. How will we know if prevention programs are effective?
ii. Why do we have separate programs for each definable social problem? Can/should we change this? How?
iii. How is suicide similar to other social problems?How is it different?
iv. How can we integrate suicide prevention with other intervention programs?
v. Why do so many social/health programs persist without evidence of effectiveness?
vi. Do treatment programs reach the people that need them?
vii. How can we integrate suicide prevention with other intervention programs?
DETERMINANTS
• Depression
• Hopelessness
• Marginalization
• Competitive Disadvantage
• Childhood Trauma
• Development of Confidence
Overview
i. There is little evidence that Suicide Prevention Programs work.
ii. Five reasons Why they don’t
iii. Most “suicide prevention” interventions are provided after the onset of suicidal behaviour & after the formative years
iv. Suicide is treated outside of its social and personal context
v. The majority of suicidal people show evidence of a mental illness, but only a minority receive treatment
vi. Suicide prevention programs have difficulty learning from their successes and failures
vii. Perhaps we don’t know why people like living. If we do know we rarely apply it in suicide prevention programs.
