Psychiatrists can and should play a
significant role in the prevention of suicide in Canada. Whether this is
currently the case is another matter.
Scope
The
"pro" side of this argument suggests that psychiatrists can prevent suicide by
(1) adopting a shared care model with greater collaboration on general
practitioner treatment of mental disorders (particularly depression), (2)
adopting the Canadian Psychiatric Association's clinical management procedures,
and (3) collaborating with addiction services, because substance abuse is often
involved in suicide. But these important activities are insufficient for
comprehensive suicide prevention. First, the focus is on treatment with no
emphasis on child development, community development, ecologic interventions,
or early detection. The focus on depression is not in line with the evidence
that virtually all mental disorders are associated with suicidal behaviour.
Third, suicide is related to many problems, not just substance abuse (i.e.
violence, crime, injury, divorce, & child abuse). Finally, not everyone
agrees with a model that places the medical profession at its centre. Other
professionals deliver primary care, and, in any case, the primacy of any
treatment specialist declines when we engage in primary prevention with
presuicidal individuals.
Evidence
The above
notwithstanding, no one has demonstrated an enduring causal relation between
purposeful interventions and reduced suicide rates. As noted by an ediorial in
the British Journal of Psychiatry, "suicide prevention remains essentially a
land of hopes and promises but not of certainties" (2002;181, p 373). There is
a danger that unbridled skepticism could lead us to conclude that nothing
useful is going on. All we can say now is that there is an absence of evidence
for a positive effect-which is a different thing.
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It may be that societal and service factors, such as mental health treatment, family support,
social structure, and perhaps random acts of kindness, have kept the suicide
rate from being higher.
The Way Forward
Suicide is
not just a clinical issue. It is strongly linked to other social problems, is
higher in communities with a weak social fabric, is more common among those who
are left out of the mainstream, and the tendency begins many years before the
first overt suicidal act. A comprehensive approach cannot be delivered by a
service that does not mobilize until after the appearance of a major problem
and that is unable to alter social environments. It might be tempting for
psychiatry to remain involved in treatment, leaving the rest to others. But
many psychiatrists already operate in a proactive, non-clinical mode.
Psychiatry can increase its effectiveness in suicide prevention by investing
time and energy in: 1. Collaboration beyond shared care. Broader collaboration
would have significant benefit. 2. Becoming involved in monitoring patient
outcomes, evaluating performance, and improving interventions (e.g. .
practitioners could monitor their own caseloads, participate in evaluation
studies, or support systemic approaches to evaluation and planning). 3. Acting
locally. The effectiveness of many community-based intervention programs would
be enhanced by psychiatric input. It should be said that this is sometimes
impeded by psychiatrists who want to run things and/or imply that treatment is
the only option.
It is important to note that many of the points
raised here would also apply to other health professions. The In Debate
question was about psychiatry, but the answer involves many disciplines,
interested parties, and perspectives.
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