1. Five Reasons Why Suicide Prevention Programs Are Ineffective Angus H Thompson Alberta Centre for Injury Control & Research & the Department of Public Health Sciences University of Alberta Canadian Association for Suicide Prevention Edmonton October 2004

2. “EFFECTIVE” SUICIDE PREVENTION Educating Physicians in Detection & Intervention (Gotland, Sweden) Gun Control (Canada) Individual Interventions

3. REASON 1 AN ORGANIZATION WITH “SUICIDE” IN ITS TITLE CANNOT PREVENT SUICIDE!

4. WHY DOES EARLY INTERVENTION MATTER? To Make A Difference During the Formative Years

5. Brain Sculpting Temperament Vocabulary Birth 5 Yrs 10 Yrs 15 Yrs 20 Yrs 25 Yrs Peer Influences Understands Suicide Suicide Ideation Formal Suicide Intervention AGE OF OCCURRENCE OF A NUMBER OF FACTORS RELEVANT TO SUICIDE

6. WHY DOES EARLY INTERVENTION MATTER? To Make A Difference During the Formative Years Canadian Children Are More Stressed Than Children From Many Other Countries

7. RANKINGS OF CANADIAN 11-13 YEAR-OLDS ON SELECTED HEALTH-RELATED QUESTIONS (VS 7-11 COUNTRIES)

8. WHY DOES EARLY INTERVENTION MATTER? To Make A Difference During the Formative Years Childhood Stress is Increasing in Canada Canadian Children Are More Stressed Than Children From Many Other Countries

9. Figure 3 THE PREVALENCE OF TWO OR MORE TRAUMATIC CHILDHOOD EVENTS BY “COHORT YEAR” AND SEX “Cohort Year” = Date when the youngest person in each group would have been about 15 years of age Source: Thompson AH, Cui X (2000). Increasing Childhood Trauma in Canada: Findings From the National Population Health Survey, 1994/95. Canadian Journal of Public Health, 91(3), 197-200.

10. REASON 2 SUICIDE IS NOT SEEN AS PART OF A CLUSTER OF HUMAN PROBLEMS

11. THE CANADIAN SOCIAL PROBLEM INDEX COMPONENTS Murder Attempted Murder Assault Sexual assault Robbery Suicide Divorce Alcoholism Source: Thompson AH, Howard AW, Yin J (2001). A social problem index for Canada. Canadian Journal of Psychiatry 46, 45-51.

13. THE CANADIAN SOCIAL PROBLEM INDEX: 1956 - 1996 Source: Thompson AH, Howard AW, Jin Y (2001). A social problem index for Canada. Canadian Journal of Psychiatry 46, 45-51.

14. THE ASSOCIATION BETWEEN SOCIAL PROBLEMS AND PSYCHIATRIC DIAGNOSES IN THE EDMONTON AREA EPIDEMIOLOGICAL STUDY OF PSYCHIATRIC DISORDERS Source: Thompson A & Bland RC (1995). Social dysfunction and mental illness in a community sample. Canadian Journal of Psychiatry 40, 15 – 20.

15. (r = 0.81)

16. REASON 3 THE MAJORITY OF SUICIDAL INDIVIDUALS EXHIBIT A MENTAL ILLNESS, BUT MOST OF THESE DO NOT RECEIVE TREATMENT

17. The Proportion Of Persons Who Had Completed Suicide Who Showed Evidence Of A Mental Illness DepressiveAny AuthorsCountryDisorders Disorder Robins et al. 1959USA45%94% Dorpat & Ripley 1960USA29%100% Barraclough et al. 1974UK70%93% Beskow 1979Swe45-48%97% Chynoweth et al. 1980Aust55%88% Rich et al. 1986USA46%95% Arato et al. 1988Hung58%81% Åsgård 1990Swe58%95% Henriksson et al. 1993Finl59%93% Cheng 1995Taiw88%98% Conwell et al. 1996USA47%90% Foster et al. 1997N Ire36%86%

18. BUT … Psychological autopsies are retrospective in nature

19. BUT … Psychological autopsies are retrospective in nature Treatment is far from perfect

20. BUT … Psychological autopsies are retrospective in nature Treatment is far from perfect There is an environment by mental vulnerability interaction i.e.

21. EXPRESSION OF SOCIAL PROBLEM BEHAVIOUR A Threshold Model High Stress Low Stress No Social Problem Behaviour Social Problem Behaviour Stress Threshold

22. EXPRESSION OF SOCIAL PROBLEM BEHAVIOUR Two Components 1. ENVIRONMENTAL STRESSORS 2. INDIVIDUAL DIFFERENCES IN REACTIVITY

23. Social Disintegration The Invulnerable The Resilient The Vulnerable The Disabled THE INTERACTION OF CONSTITUTIONAL AND ENVIRONMENTAL FACTORS: A MODEL SOCIAL PROBLEMS NO SOCIAL PROBLEMS

24. Social Disintegration The Invulnerable The Resilient The Vulnerable The Disabled THE INTERACTION OF CONSTITUTIONAL AND ENVIRONMENTAL FACTORS: A MODEL SOCIAL PROBLEMS NO SOCIAL PROBLEMS

25. Social Disintegration The Invulnerable The Resilient The Vulnerable The Disabled THE INTERACTION OF CONSTITUTIONAL AND ENVIRONMENTAL FACTORS: A MODEL SOCIAL PROBLEMS NO SOCIAL PROBLEMS

26. REASON 4 SUICIDE PREVENTION PROGRAMS CANNOT “LEARN”

27. “SUICIDE PREVENTION” PROGRAMS RARELY EVALUATE THEIR IMPACTS: Several years required to show an effect

28. “SUICIDE PREVENTION” PROGRAMS RARELY EVALUATE THEIR IMPACTS: Several years required to show an effect Avoidance of personal evaluation

29. “SUICIDE PREVENTION” PROGRAMS RARELY EVALUATE THEIR IMPACTS: Several years required to show an effect Avoidance of personal evaluation Not knowing what one’s job is (i.e. focus on process, not outcome)

30. REASON 5 WE DON’T KNOW WHY THE SUICIDE RATE IS SO LOW

31. If depression and hopelessness are considered to be essential components of suicide, and considering that: We all will die We will lose loved ones Most won’t be in the career of choice Our abilities will decline as we age Then, why is the suicide rate not higher - in fact, much higher - than it is?

32. WHY DO WE “GO FORWARD”?

34.  Rose Coloured Glasses  Optimism (Seligman)  Strengthening Behaviour (Skinner)  Traditions (Frankl)  Social Support  Control over one's environment  The family  Social skills

35. WHAT TO DO

36. AN ORGANIZATION WITH “SUICIDE” IN ITS TITLE CANNOT PREVENT SUICIDE! Focus on Early Intervention & Child Development prior to the onset of serious suicidal behaviour

37. WHAT TO DO SUICIDE IS NOT SEEN AS PART OF A CLUSTER OF HUMAN PROBLEMS Create a continuity of services that reflects the inter-relatedness of suicide & other social problems Create a social fabric that weakens the determinants of suicide and enhances resilience and social cohesion

38. WHAT TO DO MOST SUICIDAL INDIVIDUALS EXHIBIT A MENTAL ILLNESS, BUT THE MAJORITY DO NOT RECEIVE TREATMENT Improve detection, referral and access to treatment for those with a mental illness

39. WHAT TO DO SUICIDE PREVENTION PROGRAMS CANNOT “LEARN” Create Self-Regulating Suicide Prevention Initiatives, most of which would not have “suicide” in the title

40. WHAT TO DO WE DON’T KNOW WHY THE SUICIDE RATE IS SO LOW Ensure that every child has experience with success and defer experiences with the traumatic realities of the World - until it is too late!

41. FIN

42. Questions arising: i.How will we know if prevention programs are effective? ii.Why do we have separate programs for each definable social problem? Can/should we change this? How? iii.How is suicide similar to other social problems? How is it different? iv.How can we integrate suicide prevention with other intervention programs? v.Why do so many social/health programs persist without evidence of effectiveness? vi.Do treatment programs reach the people that need them? vii.How can we integrate suicide prevention with other intervention programs?

43. DETERMINANTS Depression Hopelessness Marginalization Competitive Disadvantage Childhood Trauma Development of Confidence

44. Overview There is little evidence that Suicide Prevention Programs work. Five reasons Why they don’t i.Most “suicide prevention” interventions are provided after the onset of suicidal behaviour & after the formative years ii.Suicide is treated outside of its social and personal context iii.The majority of suicidal people show evidence of a mental illness, but only a minority receive treatment iv.Suicide prevention programs have difficulty learning from their successes and failures v.Perhaps we don’t know why people like living. If we do know we rarely apply it in suicide prevention programs.