Research Article: Secondary Prevention of Suicide

Date Published: June 1, 2010

Publisher: Public Library of Science

Author(s): Debora Ganz, M. Dolores Braquehais, Leo Sher

Abstract: Leo Sher and colleagues discuss recent research on interventions to prevent secondary suicide and discuss the additional research that is needed.

Partial Text: Suicide poses major threats to public health worldwide. In 2002, suicide accounted for about 30,000 deaths in the US alone [1] and approximately 877,000 deaths worldwide—1.5% of the global burden of disease [2]. Suicide should and can be prevented. 83% of people who commit suicide have had contact with a primary care physician within a year of their death and up to 66% of people who commit suicide have had such contact within a month of their death [3].

Suicide is often difficult to predict due to its complex nature [7],[8]. Some of the risk factors that contribute to suicidal behavior are shown in Box 1[1],[5],[9]–[11]. Research shows that these suicide risk factors are additive but can be divided into underlying causes such as biological and psychological factors, and more proximal stressors such as life events or a major depressive episode (Box 1) [7],[11]. Clinicians and others (termed gatekeepers by Mann et al. [12]) dealing with individuals who may be at risk for suicide should be taught to recognize, assess, and address such factors and to appropriately screen at-risk patients for suicidality.

Many researchers have been trying to find biological markers related to suicidal behavior that could improve secondary suicide prevention. Several biological features related to failures in neurotransmitter and neuroendocrine systems, such as the serotonergic, noradrenergic, dopaminergic, and hypothalamic-pituitary-adrenocortical (HPA) systems, have been proposed [21],[22]. For example, considerable evidence accrued using various research approaches suggests a potentially causal association between suicidal behavior and the serotonin neurotransmission system [21]–[23]. Similarly, there is some evidence that dysregulation of HPA axis function may be involved in suicidal behavior in the context of acute stress response to life events [24],[25]. In particular, nonsuppression of the HPA axis by dexamethasone is associated with a 14-fold increase in the likelihood of suicide during 15 years of follow-up [25]. Finally, postmortem analyses of the noradrenergic system, which has been studied because it is involved in the regulation of the stress response, have revealed fewer noradrenergic neurons in the locus coeruleus, elevated brainstem levels of tyrosine hydroxylase, and reduced levels of postsynaptic adrenergic receptors in the cortex in people who commit suicide compared to the general population [24]. However, these findings may be related to an increased stress response before suicide rather than being a cause of suicide.

In a recent systematic review of suicide prevention strategies, Mann et al. [12], found evidence of effectiveness in five secondary suicide prevention methods: pharmacological interventions, psychological interventions, follow-up care, reduced access to lethal means, and responsible media reporting of suicide [12].

Despite our increasing knowledge about secondary suicide prevention, there are still many gaps in the research. The prescription of SSRIs and their impact on suicidal inclinations, especially in depressed children and adolescents, remain hotly debated topics [44]. Similarly, the most effective combinations of psychotherapeutic and pharmacologic interventions for suicidal patients have yet to be determined. And, while follow-up care has proven an effective element of suicide prevention, exactly which interventions are most effective remains unclear.



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