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We Don't Know If Suicide Prevention Saves Lives, And That's A Problem

It is not enough to implement mental-health programs. We need to know they actually work.
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Recently, I sat with grieving parents trying to find an explanation for why their child, an active and vigorous teen, had died by suicide. Sadly, there was no clear answer. There often is not. Their pain continues.

It is likely that every Canadian has been touched in some way by suicide. For many of us, that experience has resulted in a call to action — but to do what? We want to prevent as many deaths from suicide as possible. But how?

There's still a lot we don't know

How do we know what works to prevent suicide?

To answer that question we must first know what to measure so that we can properly assess the impact of interventions that purport to prevent suicide.

Suicide prevention demands urgent, scientifically supported attention.

However, suicide prevention has become a lucrative business opportunity for organizations selling or promoting suicide prevention interventions. Most have little or no evidence that they decrease death by suicide, or that they are safe.

Canadians need to know that the suicide prevention interventions that are implemented are effective and safe. And we need to know more about suicide itself.

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Over the last decade, the national suicide rate has been relatively stable — around 11 deaths each year per 100,000 Canadians. This is about a 25-per-cent drop from suicide rates in the early 1980s.

The reason for this decline is not clear. It may be related to improved treatments for mental illnesses — the group at highest risk for death by suicide.

Public education, community awareness programs, help lines, online tools, social media monitoring and smartphone apps are among the resources currently being considered as interventions to prevent suicide. For young people, school-based interventions have been widely promoted.

How do we measure success?

Unfortunately, there is very little robust evidence to support these strategies.

We need to know how to measure whether or not an intervention is effective in preventing suicide. The recent federal budget announcement saw funding allocated for a national suicide prevention initiative. It is essential that we know if this intervention has the intended impact. It must be properly evaluated.

Ideally, an effective intervention should demonstrate a significant reduction in the rate of death by suicide. This change should be sustained over time, and the interventions producing them should be cost effective and easily implementable.

Any suicide prevention program that relies on these feel-good measures to justify its implementation should be avoided.

Other indicators of suicide intervention effectiveness, such as numbers of emergency department visits for suicide attempts could be used as a proxy measure that can be used to evaluate the impact of an intervention on health care utilization.

Outside of such health utilization data, other proxy measures are not meaningful markers of suicide prevention and are potentially misleading. Some interventions measure self-reported suicidal ideation. This measure is highly sensitive to a person's perception that someone is being supportive. Any positive changes are unlikely to reflect a reduction in rates of suicide.

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Other frequently reported measures of impact for suicide prevention programs are even less useful in determining whether an intervention is effective in reducing death by suicide.

These include self-reported comfort in talking to a person who may have suicidal thoughts, satisfaction with a program or materials and recommending a program or materials to others. Any suicide prevention program that relies on these feel-good measures to justify its implementation should be avoided.

A plan that works

Suicide prevention is important. All interventions that purport to prevent suicide must meet scientifically valid standards for demonstrating that they reduce suicide rates.

It is not enough to implement suicide prevention programs. It is essential to implement those that we know work, and if we are not sure, it is essential to properly evaluate their impact using valid measures of effectiveness.

With suicide prevention, it is not OK to just do "something." It is necessary to do the right thing.

Every Canadian who has lost a loved one, a friend or a neighbour to suicide deserves interventions that work.

So we need to know that those interventions we apply actually reduce rates of suicide.

Are you in a crisis? If you need help, contact Crisis Services Canada at their website or by calling 1-833-456-4566. If you know someone who may be having thoughts of suicide, visit CAMH's resource to learn how to talk about suicide with the person you're worried about.

Sen. Stan Kutcher MD, FRCPC, is a psychiatrist and is one of the leading experts in adolescent mental health. He represents Nova Scotia in the Senate.

Sen. Kutcher thanks Sidney Kennedy, Arthur Sommer Rotenberg Chair in Suicide and Depression Studies at the University of Toronto and St. Michael's Hospital and James Coyne, Professor Emeritus, Perelman School of Medicine of the University of Pennsylvania, for their assistance and advice in the drafting of this article.

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