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Is asking the question the answer to suicide prevention?

Kashish Janiani


Close to 800,000 people commit suicide every year, which is one person every 40 seconds. Globally, this figure is on the rise. (Naghavi, 2019) Suicide is the second topmost leading cause of death among 15-29 year olds. (WHO, 2019)  Moreover, for every suicide there are twenty people who have attempted it; a previous suicide attempt being the most important risk factor for suicide. (WHO, 2019) 


Despite its urgent and preventable nature, suicide seems to lurk in the shadows of our concerns. Despite being a global public health issue, suicide is pushed aside by the stigma attached to it. Often, even mental health practitioners avoid or misunderstand the subject. Moreover, hospitals and schools are not inclined to screen for suicidal thoughts and behaviours. Pharmaceutical trials tend to exclude suicidal patients and research is severely underfunded. (Denworth 2018) Most importantly, little progress has been made in establishing effective prevention and intervention systems. 


Current suicide prevention and intervention systems are rooted in three practices; treatment of mental illnesses, working with high-risk groups like soldiers and crisis interventions such as hotlines. Despite their widespread use, these systems are failing. While no empirical evidence has been gathered for systems such as hotlines, for others, research indicates their inefficacy in reducing suicide risk. As a result, a paradigm shift is occuring in suicide prevention. 


The most fundamental shift in the new wave of research and practice is one that confronts suicide head on, despite its sensitive nature. We need to squarely focus on suicidal thoughts and behaviours rather than symptoms of mental illnesses like depression. Although depression is linked to suicide, in itself, depression is not an effective predictor. Many people diagnosed with depression commit suicide, but there are far more people who commit suicide with no previous diagnoses. (Nock, 2009)  The truth is, suicide cuts across all diagnoses.


We are moving towards a new mantra - asking the question - have you wished you were dead recently? Tell me about the day you tried to kill yourself. To tackle suicide effectively, we must ask about it directly. Simply asking the question is allowing clinicians to detect risk and manage it well in-time. Lisa Horowitz has made efforts to implement the Ask Suicide-Screening Questions tool in several emergency departments. This screening tool consists of three questions beginning with asking if they’ve wished they were dead recently. The tool allows for double the number of patients at risk to be identified than usual. (Handley et al., 2018) Being able to detect risk for suicide is a challenge in itself, so directly asking the question already overcomes the first obstacle in suicide prevention.

Traditionally, interventions have been rooted in telling a person what not to do. A popular course of treatment is the No-Harm Contract wherein a patient promises not to harm themselves. Although it may help the clinician understand the patient at risk, better, it does not help in reducing suicide-attempt risk. (Weiss, 2001)  Researchers are now beginning to develop tools that rely on helping the patient understand what they can do to help themselves, which begins with confronting suicidal thoughts and behaviours. They are focusing on helping people at risk create a plan of action - one that helps them retain a sense of control over their own lives. 


Based on this, Craig Bryan has developed the Crisis Response Planning (CRP) intervention. All CRP requires is thirty minutes and an index card. It begins with asking about suicide ideation and attempt, followed by questions to build trust and uncover warning signs. In the planning stage that follows, they brainstorm self-management strategies. The person is also asked about the good in their life. Most importantly, a ‘safety net’ checklist of emergency resources is created. It typically consists of a crisis hotline, a therapist, ER, family and friends. (Denworth, 2018) 


Bryan developed this intervention as an immediate response to times of crises. Often, suicidal patients that end up in emergency rooms and departments, do not follow up on recommended outpatient mental health treatment. An intervention as brief and easy to follow (no expert required) significantly reduces suicide risk. A group of 97 soldiers - after undergoing CRP, were 76% less likely to attempt suicide in comparison to being given the No-Harm contract. Even 6-months later, after only undergoing the CRP intervention, the effect still held and only got stronger. (Bryan, 2017) So, although a seemingly temporary solution - a simple 30-minute intervention is a ray of hope. Similar interventions such as the Safety Prevention Interventions are promising too. (Stanley et al., 2012) 


The key to suicide prevention is working towards detecting patients at risk early-on and implementing brief, but immediate interventions. These brief interventions are especially useful when opportunity for long-term treatments seems minimal and most of all, they are easy to learn and implement. All of it, however, begins by asking the question. 





Works Cited
Bryan, Craig J., et al. "Effect of crisis response planning vs. Contracts for safety on suicide risk in US Army Soldiers: A randomized clinical trial." Journal of affective disorders 212 (2017): 64-72.


Bryan, Craig J., and M. David Rudd. "Advances in the assessment of suicide risk." Journal of clinical psychology62.2 (2006): 185-200.


Denworth, L. (2018, April 1). Forestalling a Fatal Decision. Scientific American. Retrieved from https://www.scientificamerican.com/article/forestalling-a-fatal-decision/


Handley, T., Rich, J., Davies, K., Lewin, T., & Kelly, B. (2018). The Challenges of Predicting Suicidal Thoughts and Behaviours in a Sample of Rural Australians with Depression. International journal of environmental research and public health, 15(5), 928. doi:10.3390/ijerph15050928


Naghavi Mohsen. Global, regional, and national burden of suicide mortality 1990 to 2016: systematic analysis for the Global Burden of Disease Study 2016 BMJ 2019; 364 :l94


Nock, M. K., Hwang, I., Sampson, N., Kessler, R. C., Angermeyer, M., Beautrais, A., ... & De Graaf, R. (2009). Cross-national analysis of the associations among mental disorders and suicidal behavior: findings from the WHO World Mental Health Surveys. PLoS medicine, 6(8), e1000123.


Stanley, B., & Brown, G. K. (2012). Safety planning intervention: a brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264.


Weiss, A. (2001). The no-suicide contract: Possibilities and pitfalls. American Journal of Psychotherapy, 55(3), 414-419.


World Health Organisation. (2019, September 27). Suicide data. Retrieved November 12, 2019, from https://www.who.int/mental_health/prevention/suicide/suicideprevent/en/.

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