In Debate
Can Psychiatrists Prevent Suicide? Yes, in Collaboration
Alain D Lesage, MD, MPhil1
(Can J Psychiatry 2005;50:507–508)
Click here for author affiliations.
Psychiatrists can help to prevent suicide, both in populations and in their patients, but they cannot do it alone. First, contributing to greater treatment of depression where it is prevalent and largely untreated can help to prevent suicide in populations. Second, optimal care of patients with depression represents an avenue of action. Third, better treatment and collaborative care for patients with comorbid affective disorders and substance abuse, in particular alcohol abuse, could be beneficial.
A Population Approach to Suicide Prevention
To demonstrate that treatment of depression can be an effective suicide prevention strategy, 6 arguments need to be made:
1. Suicide is associated with depression. Dozens of studies using psychological autopsy methods have shown that depression is involved in about one-half the cases of suicide (1).
2. Depression is associated with increased risk of suicide (as a possible complication of the disorder). Although the lifetime risk for suicide among major depression patients in contact with specialized services is estimated to be about 10%, most patients with depression do not consult specialist services. One reassessment of the lifetime risk for suicide among all population cases of depression established it at 4% (2).
3. Effective treatment for depression exists. Antidepressants and specific psychotherapies (for example, cognitive-behavioural therapy and interpersonal therapy) have been shown to have mild-to-moderate efficacy (3).
4. Depression is largely undertreated in the population and among those who commit suicide. Possibly less than one-half of individuals suffering from depression seek treatment, and there is evidence that only 10% to 20% of the general population suffering from depression or committing suicide were treated with antidepressants (4). If these groups are treated, they are generally treated by general practitioners (GPs).
5. Increasing the treatment of depression in the population will decrease suicide rates in the population. Increased prescription of antidepressants in the population was associated with decreased suicide rates in 5 European countries (4), in Australia (5), and in the US, among adolescents (6). Ludvic and Marcotte (7) conducted a study based on more countries, which confirmed these findings and indicated that the relation is more pronounced in adults than in children.
6. Suicide decreases among individuals with depression who are treated with antidepressants. Here, the evidence is limited to lithium or is otherwise not supported in the reviews of clinical trials of antidepressants (8).
My interpretation of the evidence at this point is in line with that of Hall and others (5): prescribed antidepressants are a measure of exposure to interventions delivered by GPs for depression, anxiety, and other comorbid psychological disorders. Data from Australian GP surveys showed that GPs cover a wide range of psychological disorders, that they provide more nonpharmacologic than pharmacologic interventions, and that, when they do use pharmacologic treatment, they include counselling. The observed association between prescribing antidepressants and suicide reduction may reflect increased recognition, diagnosis, and treatment of depression by GPs as much as any pharmacologic effects of antidepressant medication; if this proves to be the most plausible explanation, it supports a public policy encouraging GPs to improve community mental health care. In Canada, shared mental health care has been proposed to involve psychiatrists in greater collaboration with GPs to support them in treating common mental disorders such as depression (9). In just this way, psychiatrists can help to prevent suicide at the population level.
Optimal Treatment of Depression
Clinical management of depression in patients seen by psychiatrists, either as outpatients or inpatients, is likely to prevent immediate suicide (3). Its better application could potentially save more lives among outpatients and inpatients.
Greater Collaboration Among Specialist Mental Health and Addiction Services
Evidence in a recent audit of 100 consecutive cases of suicide in New Brunswick indicates that that about one-half suffered from depression and that two-thirds also suffered from substance abuse and dependence (10). Comorbidity between affective disorders and substance abuse was found in almost one-half. The data also indicated that specialist public or private services were used by one-third of those who committed suicide in the last month, with one-third having seen a psychiatrist in the past year but only 4% having seen addiction services. The recommendations at the provincial level point toward the following: First, primary care physicians need more training and education so that they can detect, engage in treatment and treat in collaboration patients with depression and (or) substance abuse. Here again, psychiatrists can play a role through shared care models. Second, insufficient coordination between psychiatric services and addiction services was found in more than one-third of cases. Psychiatrists need to play a greater role in fostering better treatment and coordination of care for complex cases that often involve substance abuse, affective disorders, and personality disorders.
Collaborative Care and Coordination of Care
Evidence is strong that population-level initiatives can be an effective suicide-prevention strategy. The series of complete country studies showing that increased treatment of depression is associated with decreased suicide rates is indeed impressive. However, this involves treatment of depression that has been mostly provided by GPs—hence the suggestion that psychiatrists can help support suicide prevention, but not alone. The proposal, based on an audit, that more collaborative care be given for complex cases involving substance abuse and mood disorders remains in the end a clinical judgment and a hypothesis to be tested. Here again, psychiatrists cannot fight alone; they need to collaborate with addiction services, planners, and decision makers. Since poor coordination and little outreach have been identified in at least one-third of suicide cases in New Brunswick, the potential for suicide prevention is indeed not small.
References
1. Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM. Psychological autopsy studies of suicide: a systematic review. Psychol Med 2003;33:395–405.
2. Blair-West GW, Mellsop G, Eyeson-Annan M. Down-rating lifetime suicide risk in major depression. Acta Psychiatr Scand 1997;95:259–63.
3. Canadian Psychiatric Association, Canadian Association Network for Mood and Anxiety Treatments (CANMAT). Clinical guidelines for the treatment of depressive disorders. Can J Psychiatry 2001;46(Suppl 1):5S–90S.
4. Isacsson G, Lesage AD, Grunberg F, Séguin M. Données récentes d’études scandinaves. Traiter la dépression : une stratégie efficace de prévention du suicide ? Santé Ment Que 2002;XXVII:235–59.
5. Hall WD, Mant A, Mitchell PB, Rendle VA, Hickie IB, McManus P. Association between antidepressants prescribing and suicide in Australia, 1991–2000: trend analysis. BMJ 2003;326:1008.
6. Olfson M, Shaffer D, Marcus SC, Grenberg T. Relationship between antidepressants medication treatment in suicide in adolescent. Arch Gen Psychiatry 2003;60:1236–42.
7. Ludwig J, Marcotte DE. Antidepressants, suicide and drug regulation. J Policy Anal Manage 2005;24:249–72.
8. Khan A, Warner H A, Brown WA. Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials, an analysis of the Food and Drug Administration database. Arch Gen Psychiatry 2000;57:311–7.
9. Kates N, Craven M. Shared mental health care. Canadian Psychiatric Association and College of Family Physicians of Canada Joint Working Group. Can Fam Physician 1999;45:2143–4, 2147, 2159–60.
10. Séguin M, Lesage AD, Turecki G, Daigle F, Guy A. Research Project on deaths by suicide in New Brunswick between April 2002 and May 2003. Available: http://www.gnb.ca/0055/pdf/3182-e.pdf. Accessed 2005 June 6.
Author(s)
Manuscript received and accepted May 2005..
1. Professor, Department of Psychiatry, University of Montreal, Centre de recherche Fernand-Seguin, Hôpital L-H Lafontaine, Montreal, Quebec
Address for correspondence: Dr AD Lesage, Centre de recherche Fernand-Seguin, Hôpital L-H Lafontaine, Unité 218, 7401 Hochelaga, Montréal, QC H1N 3M5
e-mail: alesage@ssss.gouv.qc.ca
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