Editorial
Ending the Darkness of Suicide
Paul Links, MD, FRCPC1
Almost 4000 Canadians die by suicide each year, and many more—perhaps 100 times as many—deliberately harm themselves (1). In 1998–1999, 22 887 hospital discharges for suicide attempts or intentional self-inflicted injury were recorded (1). More than 90% of suicide victims are known to have one or more psychiatric disorders at the time of their death, so psychiatric disorders may be considered a necessary, although not sufficient, cause of suicide (2). Despite more than 100 years of study since the time of Durkheim’s seminal research, suicide continues to be a terrible tragedy that must disturb all psychiatrists.
Nevertheless, today, rays of light are ending the darkness of suicide. The stigma of mental illness and suicide has been diminished by the champions among us who have stepped forward and shared their stories. Two outstanding individuals have touched me personally, and although there are several more, I must mention them specifically. More than a decade ago, Ms Doris Sommer Rotenberg courageously broke the silence enveloping death by suicide and established the Arthur Sommer Rotenberg Chair, the first academic chair in North America dedicated to suicide research. Recently, I had the great pleasure of meeting the Honourable James K Bartleman, Lieutenant Governor of Ontario. I related to him that one of my patients suffering from chronic depression and suicidality was moved to tears and felt less alienated when he read His Honour’s personal story of depression in Moods magazine (3). The impact of sharing these stories cannot be measured. Other major advances must be recognized. Research is now being undertaken that targets those individuals at high risk for suicide; they must no longer be prevented from participating in clinical research. Meltzer and colleagues’ groundbreaking study of clozapine for individuals with schizophrenia at high risk for suicide has established the value of such research (4). Systematic clinical trials now underway may have direct implications for clinical practice and for establishing evidence-based approaches. For example, I am involved in an effectiveness trial of dialectical behaviour therapy (5) compared with a therapy based on the American Psychiatric Association guidelines for the management of borderline personality disorder (6). This trial may provide insights into the clinical effectiveness and costeffectiveness of systematic treatments such as dialectical behaviour therapy. Finally we, as a nation, stand poised to advance suicide prevention in each and every community.
In October 2004, the Canadian Association for Suicide Prevention first publicly released the Blueprint for a Canadian National Suicide Prevention Strategy (1). Canada is one of the few developed nations without a national mental health action plan and without a national strategy for the prevention of suicide. The Blueprint provides a starting point for formulating the goals and objectives needed for a national suicideprevention strategy. Our national strategy must promote awareness that suicide is a preventable problem and must reduce stigma toward suicide, mental illness, and substance abuse disorders. We have to foster prevention and intervention strategies, particularly strategies by Inuit, First Nations, and Metis. The Blueprint advocates reducing access to lethal means of suicide; increasing training in the recognition of risk factors, warning signs, and at-risk behaviours; promoting effective clinical practices; and improving access to, and continuity of, care. Among other objectives, we must improve and expand surveillance systems, particularly for tracking nonfatal suicidal behaviour and for promoting suicide-related research. Finally, for a national strategy to be successful, strong leadership and commitment is required from the federal, provincial, and territorial governments. In A Call for Action (7), the Canadian Alliance on Mental Illness and Mental Health has provided crucial leadership on mental health. Psychiatrists must contribute to the advocacy for federal, provincial, and territorial governments to shoulder their roles in creating a national vision for improved access to, and quality of, mental health services and for implementing a national suicide-prevention strategy.
In keeping with the desire to mark our progress toward preventing deaths from suicide, the 2 papers in this issue’s In Review section highlight advances that have been made in 2 particular areas of research. Dr Jeannette Legris and Dr Rob van Reekum consolidate the findings on neuropsychological investigations in patients with borderline personality disorder and in those with recent suicidal behaviour, in an attempt to illuminate the causal pathways leading to suicidal and self-harm behaviour (8). Dr Marnin Heisel presents a complete review of the issue of suicide in the elderly (9). One of the most exciting advances included in this review is the demonstration that collaborative care models that combine mental health professionals with family physicians have had significant impacts on elderly patients with suicidal ideation. These novel service delivery models may hold promise for actually decreasing the risk of suicide in elderly patients seen in primary care.
Although much work remains to stop the tragedy of suicide, real hope exists that, through further research, education, advocacy, and commitment, we can brighten our prospects of preventing deaths by suicide.
References
1. Canadian Association for Suicide Prevention. Blueprint for a Canadian national suicide prevention strategy: October 2004. Available: www.suicideprevention.ca Accessed 2005 Dec 21.
2. Roy A. Consumers of mental health services. Suicide Life Threat Behav 2001;31(Suppl):60–83.
3. DiFilippe R. Ontario’s Lieutenant Governor’s living with depression. Moods: Healthy Living Through Understanding 2005;Summer. Available: www.moodsmag.com. Accessed 2005 Dec 21.
4. Meltzer HY, Alphs L, Green AI, Altamura AC, Anand R, Bertoldi A, and others. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry 2003;60:82–91.
5. Linehan M. Cognitive behavioral treatment of borderline personality disorder. New York (NY): Guilford; 1993.
6. American Psychiatric Association. Practice guideline for the treatment of patients with borderline personality disorder. Am J Psychiatry 2001;158(Suppl):1–52.
7. Canadian Alliance on Mental Illness and Mental Health. A call for action. Available: www.camimh.ca/callforaction.htm. Accessed 2005 Dec 21.
8. LeGris J, van Reekum R. The neuropsychological correlates of borderline personality disorder and suicidal behaviour. Can J Psychiatry 2006;51:131–42.
9. Heisel M. Suicide and its prevention among older adults. Can J Psychiatry 2006;51:143–54.
Author
1. Arthur Sommer Rotenberg Chair in Suicide Studies and Professor, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario.
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