Of primary importance

Since 2000, suicide has declined in almost all countries in the OECD (Organisation for Economic Co-operation and Development), with the exceptions of Greece, South Korea and the US. In Ireland, 486 people died by suicide in 2014. This was a decline from 541 in 2012, according to the National Office for Suicide Prevention (NOSP). The preliminary numbers for 2015 and 2016 are 451 and 399 respectively, although these may be revised.

In the US, by contrast, the number dying by suicide has increased by around 1,000 per year since 2003. In 2016, there were 45,000 suicides in the US, including 23,000 by gun. There has been an especially alarming increase among women: The number of US women dying by suicide rose by 39 per cent between 2006 and 2016. Even so, the ratio of male-to-female suicide in the US is still 7:2. White men are three times more likely to die by suicide than black, Hispanic and Asian men.

Of necessity, suicide statistics focus on formally-reported ‘suicides’. It is, however, also useful to consider the concept of a ‘sub-intended’ death. This occurs when a person does not identify a single moment when they decide to end their life, but rather makes a series of choices which indicate, at the very least, significant ambivalence about living and dying (eg, routine excessive use of alcohol or drugs, despite knowing the risks).

Thus, a death that results from a person knowingly taking risks that might result in death can be considered a ‘sub-intended’ death, ie, a death that is linked to a partial death-wish. These deaths are generally not captured in suicide statistics.

The issue of suicide prevention is a complex one and solutions will likely vary between countries. In the US, access to guns is clearly a key issue: There are approximately two gun suicides for every gun homicide in the US. In other countries, guns are less widely available, but public health measures are still key to prevention. Implementing paracetamol regulations and erecting barriers at known suicide locations are both proven to reduce risk. Even in the US, authorities have finally agreed to construct a suicide-prevention barrier at the Golden Gate Bridge in California, where 33 people died by suicide in 2017.

Better mental healthcare also has a key role to play, as does primary care. Last year in Ireland, the Monitoring and Evaluation Team and Clinical Advisor in the NOSP designed a survey about suicide, which was circulated to all members and associates of the Irish College of General Practitioners. The findings, based on the views of 469 GPs, are published on the HSE website, titled <em>Suicide Prevention: GPs’ Professional Views and Practice Experience</em>. The report is fascinating and important.

Over three-quarters of GP respondents (77 per cent) reported experiencing a patient suicide and 68 per cent said this had an adverse effect on them. While it is possible that GPs who had experienced patient suicide were more likely to respond to such a survey, that is still a large number of GPs affected by this issue.

Most GPs who responded had not undertaken any suicide prevention training (81 per cent), but those who had, reported more positive attitudes towards prevention and greater confidence in dealing with patient needs and identifying appropriate services for onward referral.

Just over half of GP respondents (59 per cent) reported adequate preparedness for assessing a suicidal person but only a small proportion had actually received training in formal assessment of suicide risk. Two thirds (64 per cent) said that they did not have adequate preparation for their role in the use of a safety plan.

Most concerningly, respondents reported limited access to specialist support services, with 15 per cent stating that there were additional services at their practice to deal with suicidal persons. One-third said that their practice had a personal liaison with psychiatric services. Gaps identified included “accessing urgent statutory mental health services, including child and adolescent services”, and “accessing crisis counselling/support services”.

The report concludes that “suicide prevention in primary care is important but very challenging for GPs. The evidence points towards the benefits to GPs from training on the recognition and management of suicide risk.” The report also finds, however, that “in order to facilitate GPs to manage patients with suicidal behaviour, improved connections with and access to mental health services is essential”.

These are important issues for patients, families and clinicians, including not only GPs, but also mental health teams. Between 50-to-70 per cent of consultant psychiatrists and 40-to-50 per cent of psychiatry trainees have experienced at least one patient suicide. Effects on clinicians can include increased stress, social withdrawal, disruption to relationships, symptoms of post-traumatic stress disorder and consideration of early retirement.

Formal supports are helpful for clinicians following patient suicide, but there is also evidence that the greatest support comes from informal contacts with team members, family and friends. Against this background, it is important to place appropriate emphasis on: The effects of patient suicide in GP and psychiatry training programmes; to remain aware of the importance of informal supports following patient suicide; to strengthen formal systems of support in the workplace; and to identify other potential forms of assistance for clinicians affected.

Virtually everyone in Ireland knows a family affected by suicide. Many of us also encounter its effects in our clinical practice. We need to be mindful of its impact on us too.

As Albert Camus (1913-60), the French writer and thinker, wrote in <em>The Myth of Sisyphus</em>: “There is but one truly serious philosophical problem, and that is suicide.” Patient suicide is, however, also a very practical issue for clinicians because we must deal with its effects not only in the lives of patients’ families, but in our own lives as well.