Dis Manage Health Outcomes 2005; 13 (4): 245-253

REVIEW ARTICLE 1173-8790/05/0004-0245/$34.95/0

© 2005 Adis Data Information BV. All rights reserved.

The Challenge of Suicide Prevention

An Overview of National Strategies
Martin Anderson1,2 and Rachel Jenkins3
1 School of Nursing, Faculty of Medicine & Health Services, University of Nottingham, Nottingham, England
2 National Institute for Mental Health in England, East Midlands, England
3 WHO Collaborating Centre for Research and Training for Mental Health, Institute of Psychiatry, London, England

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
1. Suicide as a Global Phenomenon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
1.1 Overview of Suicide Rates in Different Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
1.2 Specific Variations in Suicide Rates According to Age and Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
1.3 Examples of Variations in Suicide Rates According to Culture and Religion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
2. Economic Implications of Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
3. Common Themes for National Suicide Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
4. National Suicide Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
5. Discussion and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

Abstract Suicide is a global phenomenon. It is estimated that 0.5–1.2 million people worldwide die by suicide each
year. Taking into account the global epidemiologic data concerning suicide and the economic impact of this
phenomenon on diverse societies, this review aims to examine national suicide prevention strategies. Recogni-
tion of suicide as an international public health problem, increased reporting by countries on suicide rates to the
WHO, and recognition of the costs (associated with suicide) to society have been crucial influences on the
establishment of national strategies. Past reviews on national suicide prevention strategies highlight the fact that
those countries with established national strategies share a number of themes relating to intervention. These are
grounded in international guidance on suicide prevention and accepted epidemiologic and treatment-based
research. This paper highlights comparative rates of suicide around the world, explores the economic implica-
tions of suicide and the nature of specific established national strategies for prevention. This paper highlights the
urgency for the development of national suicide prevention strategies in all countries. Clearly, countries can
learn from each other and integrate established, shared themes. It is argued that nations need to move towards
nation-specified prevention strategies with effective structures for research, monitoring, and evaluation. This has
been seen in countries such as Finland and New Zealand, where strategies have been effective in building
inter-agency working and so benefiting different stake-holders.

Suicide is a global phenomenon. It is estimated that between
500 000 and 1.2 million people worldwide die by suicide each
year,[1] resulting in substantial personal, psychological, social,
political, cultural, and economic impact on societies. A number of
governments across the world have developed suicide prevention
programs, at least partly in response to the marked increase in
suicide among young people (particularly men) in different coun-
tries.[1] This increase is reflected in the escalation of global suicide
rates reported by WHO.[2] Figures reported by WHO note a 60%
increase between 1950 and 1995 from 10.1 per 100 000 population
to 16 per 100 000 population. This rise has to be examined
carefully. In 1950, the figures were based on information from 21
countries but gradually increased over subsequent decades, with
105 countries reporting on rates of suicide in 1995. Such an
246
improvement in the number of countries reporting suicide may
have an impact on the increase in recorded suicides worldwide.
The increase may also be related to the disbanding of the USSR (in
1991), after which time some of the former Soviet Republics
(some indicating the highest rates of suicide in the world) began to
supply individual reports, thus inflating the global rate. However,
the distribution of global suicide rates grouped by age and sex does
highlight an increase in most age groups for men compared with
those age groups for women.[2,3]
Although the increase in suicide rates globally has led to a
recognition of the need for national policies, ‘prevention’ in vari-
ous nations may seem to range from prevention of all suicides to a
clear acceptance of an individual’s right to take his or her own life.
The world faces a whole spectrum of issues including: the exis-
tence of suicide bombers in Israel; the question of an individual’s
right to take their own life in the face of a degenerative disease;
and physician-assisted euthanasia. This paper does not address
these wider issues, but focuses on preventable suicides. A starting
point is to recognise the argument that any planned local, national,
or international intervention is dependent on the attitudes of a
society toward suicide as a phenomenon.
1. Suicide as a Global Phenomenon
1.1 Overview of Suicide Rates in Different Countries
Epidemiologic research has contributed a great deal to our
understanding of suicide and related diseases and has underpinned
investigations on the efficacy of preventative strategies. The
knowledge gathered from this work has aided the development of
approaches in the reduction of mental health problems and suicide.
This has led to various nations paying closer attention to those risk
factors which might be linked to increased rates of suicide.[4] The
move from a classical infective disease model of health/illness to a
broader concept of public health, integrating behaviors such as
injury and suicide, has facilitated the development of programs to
deal with such issues.
Epidemiologic accounts of suicide offering information on
rates in diverse nations indicate that Eastern European countries
have higher suicide rates than Western Europe and have increased
steadily, particularly between 1987 and 1992.[5,6] Cantor[5] recog-
nized the need to look at suicide rates in nations with similarities to
gain an insight into national trends. Cantor’s[5] study examined
eight English-speaking nations and discovered similar rates of
suicide between countries in the years between 1960 and 1989.
These nations were divided into two clusters (two clusters of four
nations): ‘old world’ (England and Wales/Scotland/Northern Ire-
land/Ireland) countries; and ‘new world’ (USA/Canada/Australia/
© 2005 Adis Data Information BV. All rights reserved.
Anderson & Jenkins
New Zealand). The ‘old world’ cluster included nations that had
shared characteristics and the ‘new world’ cluster of nations had
briefer histories, large distances between communities, indigenous
populations, climatic extremes, and other similarities, such as
firearm ownership. The data underpinned the hypothesis that
suicide rates would be very similar in all eight nations. However,
when comparing countries in clusters, similarities and dissimilari-
ties appeared. It is evident that many of these dissimilarities are
determined by continued cross-national differences, such as tradi-
tions, customs, religions, social attitudes, and climate.[5]
It is possible to observe other variations in Western world
countries. For example, in Southern Europe, suicide rates among
men are low within countries in this location (figures taken for
early to mid 1990s).[5] Portugal has a rate of 12.3 per 100 000
population, which is slightly higher than Italy, with 12.1 per
100 000 population. Greece has 5.5 per 100 000 population and
Spain has 11 per 100 000 population. Overall, Western European
countries show a higher rate of suicide than those in Southern
Europe. The Netherlands reported a rate of 14.3 per 100 000 of the
population. The suicide rates in Switzerland and Austria at this
point were 30.9 per 100 000 population and 33 per 100 000
population, respectively. These countries share similar cultural
factors and economic backgrounds, and, therefore, suicide rates
across ages tend to be the same. West Germany, with a rate of 22.9
per 100 000 population, showed similar trends in rates to other
European nations. Suicide rates in Scandinavian countries, with
the exception of Finland (43.6 per 100 000 population), were
lower than in Western Europe.[2,5] In England and Wales, the
suicide rate peaked at around 12.5 per 100 000 population in the
early 1990s. During the same period, a higher suicide rate was
found in Scotland (22.0 per 100 000). Also at this time, the suicide
rates in Ireland and Northern Ireland were 13.0 per 100 000
population and 12.0 per 100 000 population, respectively.[7]
1.2 Specific Variations in Suicide Rates According to Age
and Sex
The suicide rates in ‘new world’ countries show similarities to
the rates found in the UK, the rates among men in new world
countries were nearly double those found in men in the UK, across
all age groups.[8]
Male suicide rates are high in Russia, Belarus, Ukraine, and the
other Baltic countries. These rates increased during the 1990s and
now represent the highest in the world.[9] In Finland, individuals
aged 35–64 years appear to be at a higher risk for committing
suicide, with a much higher risk among men than for women
within this age group.[5] In contrast, in Sweden, there appear to be
higher rates among older (aged 50–75+ years) men and women in
Dis Manage Health Outcomes 2005; 13 (4)
National Strategies for Suicide Prevention
comparison with other age groups.[5] Suicide was clearly an older
age group (50–75+ years) problem in England and Wales in
1950.[2] The male suicide rates for those aged ≥65 years were
comparable to countries with the highest suicide rates in the
world.[2] By 1995, England and Wales witnessed a shift in the
direction of suicide, with it becoming a younger age-group prob-
lem. The rates of suicide for young men in England and Wales in
the 15–34 years-of-age band had more than doubled.[2] In New
Zealand, there is also a high rate of suicide among 15–24 and
25–34 year olds, with a marked risk of suicide for men in the
15–24 years bracket.[8] In New Zealand, there was an increase in
the total population suicide rate between 1975 and 1995, which
was almost entirely accounted for by the increase in male youth
suicide. These suicides also accounted for the increases in rates of
suicides by hanging and, to a lesser extent, vehicle exhaust gas.[10]
In New Zealand, the suicide rates among the group aged 15–24
years have declined in recent years, which would impact on the
overall suicide rate. Yet, young people still have higher rates of
suicide than other age groups.[8] In Australia, the male to female
ratio for suicide increased from 2.9 : 1 in 1950 to 4.3 : 1 in 1995.[2]
1.3 Examples of Variations in Suicide Rates According to
Culture and Religion
There are significant variations in suicide rates among Asian
populations, in particular China (where there have been sharp
increases in suicide), and Far Eastern countries.[11] The range in
rates for these countries spans from below 1.0 per 100 000 popula-
tion in countries such as Iran, Syria, Kuwait, and The Philippines
to the much higher rate of 47.3 per 100 000 population in Sri
Lanka. Indeed, Sri Lanka has experienced a nearly 8-fold increase
in the incidence of suicide over the past 50 years (in 1950 the rate
was 6.5 per 100 000 population). Thailand has also witnessed an
upward trend in suicide, with a 66% rise between 1960 (3.5 per
100 000 population) and 1985 (5.8 per 100 000 population). To
some extent, these differences may be explained by differences in
religion. That is, a study identified two clusters of variables
associated with national suicide rates; one cluster had the highest
loading (meaning a lower suicide rate) from Islamic religion and
the second cluster seemed to assess economic development.[12]
Therefore, low rates of suicide in Islamic groups could be associat-
ed with the Islamic religion, which places heavy sanctions against
suicide. Sri Lanka is a multi ethnic/cultural country and a large
proportion of the inhabitants are Sinhalese, most with Buddhism
as their religion. In 1995, the estimated rates of suicide show a
slight over-representation of Sinhalese and an under-representa-
tion of Tamil people committing suicide.[11] Although Buddhism
may appear to be associated with suicide in Sri Lanka, this religion
cannot account for the much lower incidence of suicide in Thai-
© 2005 Adis Data Information BV. All rights reserved.
247
land, which is also a Buddhist country.[11] The WHO reports a
steady upward trend in the suicide rate in India from the 1980s
onwards; indicated by a 41% increase between 1980 and 1990 and
a 39% increase between 1985 and 1995.[2]
In the 1990s, the suicide rate in Japan showed an increase from
18.8 per 100 000 population (26.0 per 100 000 population for men
and 11.9 per 100 000 population for women) in 1997 to 25.4 per
100 000 population (36.5 per 100 000 population for men and 14.7
per 100 000 population for women) in 1998.[13] The rise in the
suicide rate in Japan may be related to more pervasive social
isolation than in the past and to an absence of personal spiritual
development compared with financial success.[13] Moreover, the
decade-long depression of the Japanese economy may have had a
strong influence on the suicide rate, especially in middle aged
men.[13]
A recent study has provided an overview of the suicide rate in
China.[14] Philips et al.[14] took suicide rates for 1995–1999 by
5-year age group, sex, and region (grouping the regions as rural or
urban). These statistics, provided by the Chinese Ministry of
Health, were adjusted first for any regions that were not represent-
ed by projecting the sex, age, and region-specific mortality rates in
the vital registration data for each year to the total population for
each year reported by the Statistics Bureau. The rates were then
adjusted for general unreported deaths, which were obtained by
comparing information from the Ministry of Health vital registra-
tion system and Statistics Bureau data on mortality estimates. The
study estimated an annual suicide rate of 23 per 100 000 popula-
tion and a total of 287 000 deaths by suicide per year. Suicide
accounted for 3.6% of all deaths in China and was the fifth most
important cause of death. Suicide was found to be the leading
cause of death in young adults aged 15–34 years, accounting for
19% of all deaths. A particularly significant finding was the
differences in the size and direction of the sex ratio and rural urban
ratio.[15] The rate in women was 25% higher than in men, mainly
because of the number of suicides in young women in rural areas.
Rural rates were 3-fold higher than urban rates. These findings
contrast sharply with the rates reported in Western countries.[14]
Specific reasons for increases in suicide by women might be
that the act constitutes a traditional coping and revenge strategy for
women in Chinese society. This may be connected to women’s
lower social status in the family, the one-child policy, and lack of
control over their own lives.[11] Other factors relevant to the
suicide rate in rural areas of China might be that such regions often
do not have sufficient psychiatric and medical services. There is
also evidence from other Asian countries to suggest that risk of
suicide among young women in rural areas might be linked to the
ready availability of pesticides that are potent poisons. Thus, what
may have been an impulsive suicidal gesture becomes a completed
Dis Manage Health Outcomes 2005; 13 (4)
248
suicide.[15-17] Indeed, the National Institute of Mental Health states
that suicide methods differ between men and women and that
women in all countries are more likely to ingest poisons than
men.[18] Epidemiological studies have found that rates of at-
tempted suicides are higher in women than in men;[19-21] however,
“in countries where poisons are highly lethal and/or treatment
resources are scarce, rescue is rare and hence completed suicides
by women outnumber those of men”.[18] The high rates of suicide
amongst Chinese women may also reflect the considerable stresses
arising alongside the social, cultural, and economic changes that
China has undergone in recent times. Such changes appear mainly
in rural areas.[14]
These epidemiologic data provide an overview of suicide as a
global phenomenon. The impact of suicide in every country brings
significant personal loss for all involved. In addition, suicide
presents considerable costs to healthcare systems and society in
general, which need to be considered in the planning of national
suicide prevention strategies.
2. Economic Implications of Suicide
Suicide is a major public-health problem, particularly in those
countries with high suicide rates. In addition to the tragedy of a
loss of life, suicide may also result in the loss of a breadwinner and
parent for a family, long-lasting psychological trauma for children,
friends, and relatives, and the loss of economic productivity for the
nation for example, through increased sicknesses and work ab-
sences.[15]
Economic changes within a country can be related to increases
in suicide. A comprehensive review of the relationship between
suicidal behavior and the labor market is available.[16] Many
studies carried out in Western countries show that there is an
increased risk of suicide and self-harm among the unemployed,
which corresponds with the increases in male suicides in Western
countries. There is no strong evidence to indicate that rises in
women participating in the labor force have led to increased
suicide rates in both men and women. The risk of suicide and self-
harm are inversely related to social class (the lower the social class
the higher the suicide rate). In relation to occupational groups,
those exhibiting the greatest proportional mortality ratios for sui-
cide are found in professional (class I) and managerial and techni-
cal (class II) occupations and people working in medical and allied
professions.[16]
Although economic conditions can have an effect on the direc-
tion of the suicide rate itself, there is a significant economic cost of
suicide to society and healthcare service. In terms of disability-
adjusted life-years (DALYs), which is a composite measure of
time lost as a result of premature mortality and time lived with
© 2005 Adis Data Information BV. All rights reserved.
Anderson & Jenkins
disability, important results appear for suicide. Intentional injuries
account for 4.1% DALYs lost worldwide and this statistic is the
same in both developing and developed countries. Self-inflicted
injuries are 17th in the rank ordering for the world as a whole,
accounting for 1.4% of DALYs lost.[4] They are ninth in developed
countries, accounting for 2.3% of the total, and 19th in developing
countries, accounting for 1.3% of the total. In the group aged
15–44 years, self-inflicted injuries are the fifth highest cause
accounting for 3.5% of DALYs lost, ranking higher in the devel-
oped regions of the world. The proportion of mortality from
injuries overall is expected to rise from 10% in 1990 to 12% in
2020 and self-inflicted injuries shift from 12th to 10th on the
potential causes of death.[4] In essence, >1.4 million people com-
mitted suicide in 1990, accounting for approximately 1.6% of the
world’s mortality in that year.[4]
Inevitably, suicide mortality has become a major cost not only
to the health sector but also to society as a whole, partly because of
premature loss of life, and also because of increased costs, which
can be expected in the provision of medical (including accident
and emergency services), surgical, mental health, and rehabilita-
tive services for people engaging in non-fatal suicide attempts.
This includes the costs resulting from increased use of primary
care and specialist services and the costs of the necessary basic
training and continuing education programs for health profession-
als. The economic cost of self-harm is significant for health
services. A study carried out in England revealed estimated direct
hospital costs of self-poisoning to be £425 per episode
(1992–1993 values).[22] This average cost may vary depending on
the economic conditions. For example another study carried out in
England suggests that it is expensive to provide psychosocial
assessments and even more so to admit people who have taken an
overdose to medical beds.[23] Therefore, if specialist services are
offered and the majority of patients are admitted to hospital, the
cost is similar to that reported above – approximately £400 per
episode of self-harm (1997–1999 values).
There will be loss of productivity for those engaging in suicidal
behavior and those people affected by it (other family members).
Many of those who die by suicide may have experienced signifi-
cant mental health problems preceding the final event. This may
have made them unable to work. Finally, but in no way equal to the
personal loss of suicide, is the economic impact of bereavement.
Family and friends of people completing suicide or attempting
suicide often require subsequent psychological and emotional help
themselves. Again, the economic cost of suicide is increased post-
event, with an added requirement of services to offer care and
treatment to maintain the mental health of those bereaved by
suicide.[24]
Dis Manage Health Outcomes 2005; 13 (4)
National Strategies for Suicide Prevention
It is important to acknowledge that the costs and consequences
of intervention are not incurred by the health service alone and
tend to involve other government departments/sectors. So social,
educational, judicial, and non-statutory agencies will be involved
in the overall economic cost of the event of suicide. The financial
implications of suicide and self-injury for any country is impor-
tant, particularly when there are calls for all nations to develop
national prevention strategies.
3. Common Themes for National Suicide
Prevention Strategies
The WHO has recognized suicide as a key phenomenon within
the public health arena.[25] Subsequently, it publicized guidelines
to member states to facilitate and co-ordinate comprehensive
national and international strategies. The recommendations to the
respective states were as follows:
1. To recognize the problems as priority in public health;
2. To develop national preventive programs, interlinked to
other public health polices where possible; and
3. To establish national coordinating communities.[26]
The United Nations suggested five main components as guide-
lines on the content of National Suicide Prevention Strategies.
These were an open government policy, a coherent model for
prevention of suicidal behavior, general aims and goals, measura-
ble objectives, monitoring, and evaluation.[4,27]
A traditional model of prevention is described by Caplan[28] and
involves primary, secondary, and tertiary prevention.[28-30] A con-
temporary explanation of the three concepts is offered in the
context of a public health model.[31] Initially, primary, secondary,
and tertiary prevention was developed for diseases with clear
onsets followed by early and later phases. Primary prevention
targets populations, not individuals. When it is applied to an
uncommon condition or behavior (with a fatal outcome), it must
have reduced potential to harm and be economically viable. It also
has to be appropriate and acceptable to the population. Awareness
programs on suicide as examples of primary prevention strategies
implemented in schools have been found to fail the above require-
ments. One particular review revealed that American states with
school suicide awareness programs experienced increased suicide
trends compared with those where no program was in place.[32]
However, teaching of coping and relationship skills does appear to
be favored in policy and practice. Primary prevention may be
focused on modification of environmental factors, for example
enhanced social support,[33] and may be focussed on particular
settings, such as prison environments.
Secondary prevention includes the early treatment of all indi-
viduals at risk of harming themselves and people with an identified
© 2005 Adis Data Information BV. All rights reserved.
249
mental health problem.[29,30] Secondary prevention involves the
identification and intervention with a wide range of individuals,
many of whom may never commit suicide. This entails the training
of frontline general practice, mental health, and emergency health-
care professionals. Those charged with the duty of commissioning
and budgeting of services may not consider this to be an economic
priority. However, it is argued that early treatment offers financial
as well as health benefits.[33]
Tertiary prevention encompasses people who present obvious
concerns relating to suicidal behavior. This population constitutes
people who have already attempted suicide and those people
affected by the death of others, including family, friends, and
survivors.[29]
4. National Suicide Prevention Strategies
There are a number of factors that appear to have immediate
relevance to national suicide prevention strategies. General popu-
lation strategies in their evolution have come to focus on the
treatment of depression. Further to this, there has been growing
recognition of the role of alcohol and other substance misuse in the
progression toward suicide. This is backed up by established and
convincing evidence that suicides rarely occur without the pres-
ence of depression or some other form of breakdown in mental
health.[9] What is also apparent is that interventions in various
countries share common themes within national suicide prevention
strategies. These themes are detailed in table I.
The review carried out by Taylor et al.[25] in 1997 highlights the
level of global suicide prevention policy development. There are a
number of nations with now comprehensive strategies sharing the
common themes highlighted in table I. These include Finland,
Norway, Australia, Sweden, Slovenia, Denmark, Ireland, England,
Table I. Themes used in comprehensive national suicide prevention strate-
gies
Public education
Responsible media reporting
School-based programs
Detection and treatment of depression and other mental disorders
Attention to those abusing alcohol and drugs
Attention to individuals experiencing somatic illness
Enhanced access to mental health services
Improvement in assessment of attempted suicide
Postvention
Crisis intervention
Work and unemployment policy
Training of health professionals
Reduced access to lethal methods
Dis Manage Health Outcomes 2005; 13 (4)
250
and New Zealand (suicide prevention strategy for youth suicide
only).[34] Countries with national preventative programs, again
with some of the shared themes, included The Netherlands, the
USA, France, and Estonia. Those without explicit national action
were Japan, Denmark, Austria, Canada, and Germany.[34]
The UN guidelines[27] were established as a template for coun-
tries to follow. Finland was the first country to implement the
guidelines; therefore, this review will attend to this strategy in
more detail. The Finnish strategy was initiated by a national
research project, which included an audit of suicides occurring in
Finland and, subsequently, evaluated by reviewing the 1397 sui-
cides between 1986 and 1996.[35] Following the 1986 audit, Fin-
land set out their assumptions and principles of suicide prevention.
These assumptions were that suicide tends to include a cumulative
effect of life events and burdens, which sometimes endure over the
span of an individual’s life. Such burdens can build up into
insurmountable problems and lead to suicide, which may not be
expected or predicted by friends, neighbors, or colleagues. The
risk factors can be understood as either antecedent or precipitat-
ing.[27] With these assumptions in mind, the subsequent approach
to suicide prevention in Finland focussed on the need to help
people identify their own and other resources in specific stages of
life and so incorporated four stages.
1. Prevent suicide from occurring.
2. Prevent problems from becoming worse and becoming insur-
mountable, e.g. by supporting resources.
3. Prevent those circumstances that lead to problems.
4. Teach individuals to manage their own lives, while providing
alternatives and support.[4,31]
The Finnish government believed that the suicide rate could be
reduced if:
• everyone who attempts suicide receives effective help as soon
as possible;
• depression is recognized and the individual is offered all the
support he/she requires; everyone experiencing serious depres-
sion should get appropriate and effective treatment;
• alcohol can be prevented from being used as a universal solu-
tion to problems and find better means of support to cope better;
• mental and social support is enhanced within the treatment of
somatic illness;
• a person in a life crisis receives appropriate support from
relatives and friends and professionals when necessary;
• the risk of young people becoming alienated from life can be
avoided and individuals can be offered ways of coping;
• the cultural climate in the Finnish education system becomes
more relaxed, less guilt promoting, stigmatizing, and punitive.
© 2005 Adis Data Information BV. All rights reserved.
Anderson & Jenkins
The Finnish suicide prevention strategy outlines six recommen-
dations that are set out for intervention in suicide prevention.
Additional recommendations have also been prepared for young
and older (50–65+ years of age) people. Health professionals are
expected to build an understanding of each for the purposes of
assessment and future care. The following is a list of six recom-
mendations.
1. Focus on the requirement that life circumstances of an individu-
al after a suicide attempt should be investigated and the appropri-
ate treatment/care implemented.
2. Focus on awareness of the relationship between life events,
problems, and intoxication with substances.
3. Focus on the higher risk among people who may be experienc-
ing mental health problems.
4. Focus on building awareness of the fact that significant physical
illness and disability can be predisposing factors to depression.
5. Focus on situations when a person faces a crisis, which have
culminated over a period of time.
6. Focus on ensuring that professionals are perceptive of the fact
that many people who engage in suicidal behavior come from
underprivileged backgrounds.[4]
Some of the common themes of suicide prevention strategies
(outlined in table I) have been incorporated in comprehensive
national strategies. Norway proposes education programs on tele-
vision and radio to combat the stigma of suicide, whereas Finland
has set up a system of primary mental health promotion as part of
public education.[4] Norway and Finland include steps relating to
representations of suicide in the media. England and New Zealand
have included a specific goal to improve the appropriateness of
media reporting of suicidal behavior.[4,8,32]
Detection and early treatment of depression are recognized as
fundamental elements of all strategies. In England, and, subse-
quently, Australia and New Zealand, governments have used the
approach of setting specific national targets for mental illness and
suicide rates.[36-39] Active programs to detect depression have been
undertaken in a number of countries, including the USA and
Canada.[4] Improved mental health services as part of the national
strategy have been implemented in England and Australia.
Assessment of suicidal behavior is a major issue and has led to
guidelines being incorporated in all national strategies. Australia,
Finland, England, and also New Zealand, with the youth suicide
prevention strategy, have included steps and guidance on how
people who engage in suicide attempts are to be assessed.[4] In
particular, developments are targeted on procedures and services
for people presenting at casualty/emergency services with mental
health problems, and/or episodes of self-harm or substance mis-
use. This is linked to increased awareness that there is a considera-
Dis Manage Health Outcomes 2005; 13 (4)
National Strategies for Suicide Prevention
ble overlap between completed suicide and suicidal behavior.
Alongside this is the acknowledgment of high-risk groups (Fin-
land and England are clear examples) and the high prevalence of a
range of deliberate self-harm and risk-taking behaviors.[39] The
evidence that the risk of suicide escalates in the 12 months after a
suicide attempt alone underpins the reason for explicit aims and
guidance within national strategies.[40]
All countries with comprehensive strategies include postven-
tion activity in which counseling and support for relatives and
friends of suicide victims are recommended. England and Austra-
lia include such an approach.[8,36] Norway has extended such work
to provide outreach services. Finland has carried out extensive
work on developing crisis intervention services, for those who are
dealing with unemployment or a family crisis related to the death
of a relative or friend from suicide.[4,35] There is a strong recom-
mendation in the strategy for England that crisis intervention and
prompt access to services should be established. The strategy also
focuses the promotion of mental health among those who misuse
drugs or alcohol, both in accident and emergency departments and
secondary services for such people. Young people and school-
based work are also included in the strategy for England, including
mapping out ways to promote mental health in schools.[32]
Unemployment stands in its own right as a significant area to be
addressed within national suicide prevention strategies. New Zea-
land and Finland offer specific recommendations on unemploy-
ment, and both countries wish to increase work opportunities for
young people.[8,35] Finland has aimed to help people retain their
working capacity alongside supporting them in developing their
coping abilities.
Training is endorsed by all of the countries with comprehensive
strategies; however, the target group tends to vary. Finland singles
out health and welfare staff for training. New Zealand’s youth
prevention strategy includes a range of professionals:
• community personnel, which includes clergy, teachers, coun-
selors, corrections staff, youth workers, and police;
• primary health professionals, including general practitioners,
midwives, public health nurses, practice nurses, Maori health
workers, and Pacific Island health workers;
• mental health professionals, including those who work in resi-
dential, community, and inpatient services;
• emergency department professionals.[8]
Norway has included a similar range of professionals for train-
ing.[4] Much of this education is concerned with early case finding
and identification of individuals at risk, although most include
training for doctors in the management of depression.
Access to appropriate mental health services is advocated in all
established strategies. In England, access to services is to be
© 2005 Adis Data Information BV. All rights reserved.
251
improved for young men and greater availability of family coun-
seling is advocated in the Finnish strategy. Clearly, there is a need
to ensure that effective, responsive, and accessible services are
developed for people experiencing mental health problems and
who display suicidal behavior.[8]
The recommendations in the Finnish strategy did not empha-
size reducing access to the means of suicide, tackling facilitating
risk factors such as alcohol, or supporting high-risk occupational
groups, although some attention was paid to these issues as the
strategy evolved.[35] The focus of attention in initiatives tend to be
on changing means of obtaining/gaining opportunity to certain
methods, such as reducing hanging and strangulation in hospital
and prison settings. However, it can be argued that reducing the
availability and access to lethal methods of suicide is a priority for
all countries. This is an area of work in which there is a consensus
that the government may have a role in a population-based ap-
proach – developing policy on the means of suicide.[4] There has
been acceptance by governments of the need for the introduction
of catalytic converters in motor vehicles to lower the risk of
morbidity and mortality associated with exhaust gas inhalation.[36]
Other polices include policies relating to access to prescription and
non-prescription drugs and the availability of toxic substances and
pesticides. Australia has imposed restrictive legislation on the
availability of barbiturates. In England, maximum pack size for
over the counter sales of paracetamol (acetaminophen) and aspirin
(acetylsalicylic acid) was reduced to 32 for pharmacies and 16 for
other outlets. This appeared to have led to an initial fall in
overdoses involving this method of self-poisoning.[36]
5. Discussion and Conclusions
Suicide is clearly a major global concern. The direct and
indirect costs of suicide have a huge economic impact on many
countries. The economic burden of suicide is much more complex
than simply the loss of productive years from premature death.
One quantifiable cost for service commissioners is the care provid-
ed for people who self-harm. Such patients are regarded as high
risk and are often prioritized in national strategies, yet service
managers might be reluctant to advocate for investment in a
comprehensive self-harm service in general hospitals. On the other
hand, the financial cost of providing comprehensive and planned
services is possibly less than providing disjointed and disorga-
nized services, but also essential on public health grounds given
the growing size of the problem.[23]
The implications of suicide have to be looked at – not just in
terms of the costs of service provision, but also with regard to the
costs incurred to those bereaved by suicide. Various countries now
have comprehensive national suicide prevention strategies (Fin-
Dis Manage Health Outcomes 2005; 13 (4)
252
land, New Zealand [for youth only], England, Norway, Australia,
Sweden, Slovenia, Denmark, and Ireland) and others are providing
preventative programs (The Netherlands, the USA, France, and
Estonia). In terms of the effect of suicide strategies on stakehold-
ers (patients, healthcare providers and commissioners), it is evi-
dent that there will be differences for countries with comprehen-
sive strategies and those with preventative programs. That is, some
countries will have strategies that are not the exclusive responsi-
bility of any one sector of society or health service. For example,
mental health services have a crucial part to play in suicide
prevention but a high proportion of people who commit suicide are
not in contact with mental health services. Such strategies can be
seen as comprehensive (covering a range of healthcare services),
whereas preventative programs may target a specific group of
people only and possibly only within one health service sector
(older people or young people in primary care). In view of the
complex etiology of suicide and lack of an easily identifiable high-
risk population that constitutes a sizeable proportion of overall
suicides, it is not surprising that individual interventions have not
been shown to reduce suicide in controlled trials. Indeed, the range
of influences on suicidal behavior is beyond the capacity of a
single service. Preventative programs may have little demonstra-
ble benefit for stakeholders in isolation and where there is more
than one program there may be duplication and conflict, leading to
discrediting programs. Therefore, strategies should co-ordinate
interventions and facilitate communication between agencies.
The comprehensive national suicide prevention program set in
Finland can serve as an example to many other countries without a
national strategy. The strategy with its four stages commenced
with a research project evaluating the 1397 suicides that had
occurred in a single year. Target areas, interventions and those
responsible were identified. The implementation of local sub-
projects involved local decision making, incorporating local infor-
mation about suicide in the area. This merging of an ’umbrella’
policy at a national level with local implementation is a particular
strength of the Finnish project. The significant decrease in death
by suicide over the past decade in Finland may well be attributable
to this strategy.[29] It is evident that the Finnish, English, and New
Zealand strategies as examples propose a co-coordinated, inter-
agency based approach. The benefit for stakeholders of such an
eclectic approach is that voluntary, charity funded agencies can be
involved alongside statutory services (medical, mental health and
rehabilitative). For example, the Samaritans and PAPYRUS (Par-
ents Association for the Prevention of Young Suicide) in England
or the Like Minds campaign (which is not specifically a suicide
prevention program, but a mental health de-stigmatization pro-
gram) in New Zealand.[8,36]
© 2005 Adis Data Information BV. All rights reserved.
Anderson & Jenkins
These are healthy developments for such nations but there is
concern for countries without established strategies, such as China
and those in the Far East. Evidently, suicide is a major public
health problem in China that is only gradually being recognized.
Controversy over the overall suicide rate may delay the develop-
ment of specific suicide-prevention programs for China.[14] How-
ever, The Ministry of Health, in collaboration with the WHO, held
a workshop on suicide prevention in March 2000, which can be
regarded as the first move towards the establishment of a national
strategy.[41] The workshop identified the unique characteristics of
suicide in China and highlighted the need to test the feasibility of
several different preventative steps. The workshop highlighted the
potential for a range of plans found in established national preven-
tion programs. These plans included: ongoing public education
programs concerning suicide; control of access to agricultural
chemicals frequently employed in suicides; control of access to
dangerous medications; training individuals who come into con-
tact with persons who are at risk of suicide; train rural doctors and
emergency room physicians in emergency management of suicide
attempts; improved access to mental health services, particularly
in rural areas; and the development of services in urban areas. As
in any country, The Ministry of Health in China would at first want
the initiative to test the cost effectiveness of a variety of such
interventions before they were put in place.[41]
An overriding conclusion is that, irrespective of the stage at
which a nation’s suicide prevention strategy is at, the national
centre coordinating the strategy should undertake research to build
an evidence base. It should also consider the diverse experiences
of other countries and include relevant structures for monitoring
and evaluation. With this approach, a nation can progressively
adapt its strategies to take account of changing circumstances and
needs.
Acknowledgments
No sources of funding were used to assist in the preparation of this review.
The authors have no conflicts of interest that are directly relevant to the
content of this review.
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About the Author: Dr Martin Anderson is Senior Lecturer in Mental Health
at the School of Nursing, University of Nottingham and Regional Fellow in
Suicide Prevention, National Institute for Mental Health in England (East
Midlands). His specialist area of research has been on healthcare profes-
sionals’ perceptions of young people who engage in suicidal behavior.
Rachel Jenkins is head of Section of Mental Health Policy, and Director of
the WHO Collaborating Centre, Kings College London, Institute of Psychi-
atry, London. She works on mental health policy in low and middle income
countries, suicide prevention, primary care, prisons, mental health promo-
tion, prevention of mental disorders, and epidemiology.
Correspondence and offprints: Dr Martin Anderson, School of Nursing,
Faculty of Medicine and Allied Health Sciences, University of Nottingham,
Queen’s Medical Centre, Room B50, Nottingham, NG7 2UH, UK.
E-mail: martin.anderson@nottingham.ac.uk
Dis Manage Health Outcomes 2005; 13 (4)