Suicide prevention: Time to change the paradigm

Australian & New Zealand Journal of Psychiatry, 54(6) There is perhaps no more emotive topic than suicide. It is among the most important determinants of mortality in medicine, particularly since it is now the most common cause of death from youth until middle age (Sinyor & Schaffer, this issue). And yet, the branch of medicine charged with trying to reduce suicide rates is Psychiatry. Much has been done to tackle suicide, but as Jorm (this issue) points out there has been a notable lack of impact of efforts to prevent suicide in Australia. He attempts to explain this by pointing out three factors. The first is that suicide is influenced by social factors that are largely outside the domain of mental health services. While this perspective has been accepted since Durkheim, it appears to make little difference to expectations imposed on mental health services. The second, and we need to face this fact, is that psychiatric treatments may have limited impact on suicide deaths. There is consistent moderate strength evidence for the benefit of lithium (which, ironically, is now used about half as often as it was 20 years ago; Rhee et al., 2020) and a little evidence for the benefits of brief intervention and contact but not much else. The third factor is that mental health professionals are often not present when suicide risk is highest. Suicidal actions are sometimes impulsive, particularly in males. These factors again emphasise the need for coherent national policies which recognise the role of broader social factors in suicide and do not expect mental health services to be the primary solution. Sinyor and Schaffer (this issue) approach the lack of success in reducing suicide in a different way. They ask what other areas of medicine would do to approach this major challenge. They point out that our concern with emphasis on prediction of suicide diverts already scant resources away from a more important potential area, namely, intervention studies. They note how strange it is to exclude suicidal patients from research trials due to concerns that some of them may die while in the trial and point out that other branches of medicine, such as oncology, do not exclude patients at increased risk of death from their clinical trials; hence, they advocate that psychiatry reverses this practice. They go on further to point out that our preoccupation in developing models and algorithms in the hope of predicting risk are likely to fail since medicine has no history of reliably predicting sentinel events. We do not expect our colleagues to predict exactly when a coronary artery occlusion or a stroke will occur but seem to expect that we can accurately predict suicide which is generally the result of a more complex process. Since so-called ‘low risk patients’ account for the majority of suicides at a population level, they advocate offering good care to all but also to redirect and enhance treatments and resources for patients at high-risk times. Turner et al. (this issue) expand on these issues and look closely at health care settings. They also note the need for a shift away from the current paradigm with its focus on assessment and categorical risk prediction, resulting in a lack of focus on meaningful interventions and a culture of blame. Looking through the lens of the clinician, they point out ‘the inconvenient truth’ that there is a second victim of patient suicide. This victim is the health care provider involved in this adverse event and subsequently often emotionally traumatised. Mental health staff experience a range of adverse outcomes and also fear legal retribution, prejudice and loss of reputation. As has been repeatedly pointed out over the past decade, risk stratification cannot predict individual suicides. Despite this overwhelming evidence, documentation used in clinical practice continues to support a categorical risk prediction model. We need to acknowledge that we are powerless to usefully classify individuals or groups of patients according to future suicide risk. This second ‘inconvenient truth’ lies at the heart of clinicians being judged in incident reviews after the loss of a patient to suicide. The authors further note the problem of hindsight bias. Reviewers who are aware of an outcome will overestimate the likelihood of that outcome and of the ability of the involved clinicians throughout to predict it. They also point out that current retrospective reviews do not take into account the complexity of how clinical incidents occur and what perpetuates them. They point out that clinicians work in complex systems which are Suicide prevention: Time to change the paradigm