World Suicide Prevention Day - 10th September 2008

From: International Association for Suicide Prevention

2008 - Think Globally, Plan Nationally, Act Locally

(Click the link above to find World Suicide Prevention Day flyers in English, French, German, Italian, Spanish and Chinese, and to find a listing of activities from around the world.)

Think Globally - Extent of the Problem
Think Globally - Collaboration
Think Globally - Research
Plan Nationally - Strategy
Plan Nationally - Evaluation
Plan Nationally - Collaboration
Act Locally - Implementation of Programs
Act Locally - Community Initiatives
Act Locally - Advocacy
What You can do to Support World Suicide Prevention Day

• World Suicide Prevention Day Activities Submission Form

World Suicide Prevention Day is held on September 10 each year as an initiative of the International Association for Suicide Prevention (IASP), and is co-sponsored by the World Health Organisation (WHO). The 2008 theme is "Think Globally. Plan Nationally. Act Locally." This phrase, first used by the movement to save the environment, can equally well be applied to suicide prevention:

• to develop global awareness of suicide as a major preventable cause of premature death,
• to describe the political leadership and policy frameworks for suicide prevention provided by national suicide prevention strategies,
• and to highlight the many practical prevention programmes that translate policy statements and research outcomes into activities at local, community levels.

This year's theme "Think Globally. Plan Nationally. Act Locally", is an opportunity for all sectors of the community: the public, charitable organizations, communities, researchers, clinicians, practitioners, politicians and policy makers, volunteers and those bereaved by suicide, to join with the IASP and WHO on World Suicide Prevention Day in focusing public attention on the unacceptable burden and costs of suicidal behaviours with diverse activities to promote understanding about suicide and highlight effective prevention activities.

Think Globally - Extent of the Problem

The WHO estimates that one million people die in the world each year by suicide. These figures represent an annual world mortality rate from suicide of 14.5 per 100 000 population. The reality is that every minute there are two more deaths by suicide.

In many developed countries suicide can be either the 2nd or 3rd leading cause of death among teenagers and young adults and is the 13th leading cause of death worldwide for people of all ages. In addition to those who die by suicide, many millions make non-fatal suicide attempts in the context of emotional distress and suffering for the people involved and their families.

There are substantial variations in suicide rates among different countries. However, one must be cautious in comparing suicide rates between countries since some countries report accurate suicide data and others fail to count a significant proportion of their suicides. Suicide rates, as reported to the WHO, are highest in Eastern European countries including Lithuania, Estonia, Belarus and the Russian Federation. These countries have suicide rates of the order of 45 to 75 per 100 000.

By contrast, reported suicide rates are lowest in the countries of Mediterranean Europe and the predominantly Catholic countries of Latin America (Colombia, Paraguay) and Asia (such as the Philippines) and in Muslim countries (such as Pakistan). These countries have suicide rates of less than 6 per 100 000. In the developed countries of North America, Europe and Australasia suicide rates tend to lie between these two extremes, ranging from 10-35 per 100 000.

Suicide data are not available from many countries in Africa and South America. In 2009 IASP will provide an opportunity for countries in South America to highlight the problem of suicide and to share knowledge in order to expand suicide prevention activities at its 25th International Congress in Montevideo, Uruguay.

Most suicides in the world occur in Asia, which is estimated to account for up to 60% of all suicides. Together, three countries - China India and Japan - because of their large populations, may account for up to 40% of all world suicides. However, because of the sheer size of their populations, some of these countries do not have complete national registration systems for deaths, including suicide, and may lack comprehensive medical verdict or coronial systems. Official mortality data which are reported to the WHO may be based on a sample of the population which is not necessarily representative. In addition, accurate suicide data may be difficult to establish if suicide remains stigmatized, criminalized or penalized.

A recent study attempted to overcome some of these problems to estimate suicide rates more accurately. This study was conducted in Tamil Nadu, India, and used trained lay interviewers to conduct 'verbal autopsy' interviews with family members for 39 000 deaths. Using this approach, the study found that suicide rates were 10 times those reported officially to the WHO. If these findings are applicable to other countries they suggest that global suicide deaths may, in fact, be much higher than the near one million previously estimated.

Think Globally - Collaboration

A number of international agencies including IASP, WHO the United Nations, and International NGOS working in the voluntary sector have all identified suicide as a largely preventable public health problem, called for recognition of this issue at a global level and work actively in suicide prevention activities internationally.

There are many cross-national collaborative suicide research and prevention efforts. For example, people from Norway work in Uganda, the American Foundation for Suicide Prevention funded research in Hungary to explore the high suicide rates in that country; the University of Rochester works in China training local suicide researchers; researchers and funders from the UK, Europe and Australia are conducting research trials in Asia trying to reduce suicides by pesticide ingestion; researchers from Canada and Denmark evaluated a Befrienders-funded programme in Denmark and Lithuania to improve children's coping skills. Collaborative research and prevention efforts such as these advance and disseminate information about suicide.

The study conducted in India which reported high rates of suicide also found that about half of these suicides were by self-poisoning, generally by agricultural pesticides. Similar findings are reported for rural China where it is estimated that 60% of suicides involve pesticides, and rural Sri Lanka where pesticides may be involved in as many as 70% of suicides. In these regions pesticides also account for an estimated more than two million hospital admissions for self-poisoning. Pesticides are widely used and valued in agriculture in developing countries and usually stored in the home. Their ready availability may result in impulsive, stress-related suicide attempts with relatively low intent to die resulting in tragic deaths.

Recent initiatives concerning the prevention of suicides involving pesticides provide another example of collaborative efforts in suicide prevention. Given the extent of the problem of suicide in Asia and the predominance of pesticides in suicide in this region, global suicide rates will only fall if we can achieve reductions in pesticide suicides. A number of organizations including IASP and WHO, multinational companies, and university-based international programmes are involved in community efforts in Asia and Central America to reduce suicide by pesticides.

Since the 10th of September, 2004, World Suicide Prevention Day has become established around the world as a well-recognized occasion to increase public awareness about suicide prevention and to appeal to governments, policymakers and regional health authoritues to take leadership and to set and meet targets for reducing suicide.

Think Globally - Research

While suicide rates differ widely around the world research conducted in different countries tends to produce findings about the causes of suicide which are remarkably similar across countries and cultures.

This year a large study of suicide, involving 85 000 adults in 17 countries, found that the prevalence of suicidal behaviours varied between countries but there was strong consistency in the characteristics and risk factors for these behaviours across countries. In particular, this study showed that risk factors for suicidal behaviour that were consistent across countries were being female, younger, having fewer years of education, being unmarried and having a mental disorder. People who had more than one mental disorder had significantly increased suicide risk compared to people who had one disorder. Interestingly, the strongest risk factor for suicidal behaviour in high income countries was a mood disorder, whereas an impulse control disorder was the strongest factor in middle and low income studies.

These findings from global studies highlight the fact that suicidal behaviour is a complex phenomenon and, usually, no single cause is sufficient to explain a suicidal act. During the last three decades an extensive body of knowledge has accumulated about the biological, cultural, social, psychological and contextual factors that can influence risk of suicidal behaviour.

Risk of suicide can be influenced by individual vulnerability or resiliency related to age, gender, ethnicity, religious values, genetic and biologic factors, personality traits and sexual orientation. People from socially and economically disadvantaged backgrounds are at increased risk of suicidal behaviour. Childhood adversity and trauma, and various life stresses as an adult influence risks of suicidal behaviour.

Serious mental illnesses, most commonly depression, substance abuse, anxiety disorders and schizophrenia, are associated with increased risk of suicide. Diminished social interaction increases suicide risk, particularly among adults and older adults. At a population level, social cohesion and integration protect against suicide. At a community level factors such as the availability of means of suicide (such as firearms or pesticides) and media reporting practices may increase suicide risk.

All of these various risk factors tend to act cumulatively to increase suicide risk. The fact that there are multiple causes of suicidal behaviour and the absence of a single, readily identifiable high risk group accounting for the majority of suicides, implies that many different types of programmes and activities are needed to prevent suicide. Each programme and action may contribute to reducing suicide.

Plan Nationally - Strategy

In 1996 the United Nations and subsequently, the World Health Organisation, recommended that individual countries should develop national suicide prevention policies, linked where possible to other public health programmes, and establish national co-ordinating committees to monitor their implementation and evaluation.

In response to this counsel an increasing number of countries have developed national suicide prevention plans. Generally these plans adopt a public health framework. National strategies are valuable in that they compel governments to acknowledge the problem of suicide, increase national awareness about suicide, have the capacity to enact legislation for suicide prevention (for example, to ensure stricter controls on firearms) and may increase funding for suicide prevention. Such political championship is highly effective, indeed it appears to be vital, in maintaining a government focus on suicide prevention.

National suicide prevention plans generally include a broad range of strategies which typically include efforts to:

• Control the access to means of suicide;
• Enhance training, recognition, assessment, treatment and management of depression by medical practitioners, particularly in primary care;
• Increase public awareness of depression by public programmes;
• Improve assessment, treatment and follow-up care of people who make suicide attempts and present to emergency departments;
• Enhance access to mental health services and Improve the care of people with serious mental illness;
• Provide targeted prevention programmes for identified high-risk populations
• Encourage responsible media reporting and portrayal of suicide;
• Improve control of alcohol;
• Provide crisis centres and crisis counselling;
• Encourage school-based competency-promoting and skill-enhancing programmes for young people;
• Provide effective support for families and others bereaved by suicide;
• Encourage research, evidence-based approaches to programme development, evaluation of components of the national strategy, and the production of timely and accurate statistics on suicide and attempted suicide.

Plan Nationally - Evaluation

An important factor in advancing national plans is the formation of national expert committees to oversee the implementation, evaluation and revision of these plans, as recommended by the United Nations and WHO. However, not all countries have appointed such committees and, overall, the evaluation of national strategies tends to have been conducted poorly and infrequently.

Finland provides one exception. The Finnish national suicide prevention strategy was built strongly on the findings of local research and consisted of a broad national framework which was implemented at a local level. The national strategy was evaluated, and the decline in the suicide rate subsequent to the introduction of the strategy may well be attributable to the strategy.

Generally, however, despite the fact that most countries are now attempting to address suicide in some way at a national level, plans for both implementation and evaluation are generally much less developed than what would constitute a complete national strategy. World Suicide Prevention Day may provide an opportunity to highlight the strengths and promise of national strategies by presenting results of the evaluations of suicide prevention initiatives.

Plan Nationally - Collaboration

Another interpretation of the "think globally, act locally" maxim is IASP's practice of establishing task forces of members of the association to consider topical issues and problems in suicide prevention.

The task forces consider specific issues which are of global interest, such as developing recommendations for the media reporting and portrayal of suicide, suicide in the military and police, suicide in prisons, suicide in older adults, and establishing support for people bereaved by suicide. Recommendations and guidelines developed by these task forces are disseminated widely on the web and in publications and their adaptation, interpretation and implementation in local contexts are encouraged.

Act Locally - Implementation of programmes

Think Globally, Plan Nationally, Act Locally is particularly relevant in considering the local implementation of national plans for suicide prevention and the development of suicide prevention activities at the local level where national plans do not exist.

Internationally, there is broad consensus about the types of interventions which are effective in suicide prevention. National plans articulate more specific policy agendas that are adapted to national specificities. However, the translation of those policy agendas requires effective implementation at a local level. At a local level national plans must be customized and implemented to meet the distinct ecological, economic, and cultural requirements of their communities. Further, while global and national efforts may take years to implement, community efforts may be substantially less time consuming.

This process of local execution of national plans raises important issues about how broad policy directions by governments and ministries can be translated into effective locally based programmes. Greater use of the principles of prevention science by community planners and service providers may help resolve these issues. A prevention science approach requires that broad policy action advocated by governments and ministries is carefully translated into service development.

The key principles of programme development within the prevention science framework include: using theory and research evidence to develop promising policies and interventions; using pilot, model and demonstration programmes to determine the acceptability, feasibility, safety and effectiveness of a proposed programme to the targeted population; programme evaluations to examine the processes by which the programme is delivered and the efficacy, effectiveness and cost-effectiveness of the programme; identifying meaningful outcome measures, and refining and identifying the critical elements of effective programmes.

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Act Locally - Community Initiatives

Of course, the Think Globally, Plan Nationally, Act Locally process is not uni-directional and does not always involve the devolution from national plans to local activities.

An example of local programme development evolving to national and global action is provided by a current collaborative project, the European Alliance Against Depression. This developed from a community-based project, the Nuremberg Alliance Against Depression, established in the German city of Nuremberg (population 500 000). Based on research that shows depression is the most common risk factor for suicide, the aims of this project were to improve the care of depressed people and thereby prevent suicide. A four-component intervention was mounted which included: increasing public awareness about suicide; improving the care provided by primary care practitioners; educating community gatekeepers; and targeting care available to high-risk groups. On the basis of evaluation results indicating sigtnificant decreases in suicide attempts and suicides, more than 40 German towns have implemented the Nuremberg model under the umbrella of the German Alliance Against Depression.

The model has been expanded further with the European Commission funding 20 partners in 18 countries to implement the programme. These sites have adapted programme materials somewhat to take account of differing cultures and heterogeneous health and social service structures. While individual partner sites will conduct evaluations (acting locally), the rationale for the programme and its development is based upon research findings around the world (thinking globally).

Another example of a local community suicide prevention programme is provided by the US Air Force. The institution employed a multimodal strategy involving changing institutional policies and norms in order to encourage helpseeking for mental health, substance abuse or psychosocial problems, strengthening social support, and promoting effective coping strategies. The programme was associated with reductions in suicide, homicide and family violence, and is now being adapted to college and workplace settings.

Act Locally - Advocacy

In many countries, local voluntary organizations have been extremely effective in influencing governments to develop national suicide prevention strategies and increase funding for suicide prevention activities. For example, SPAN in the United States, is an organization of survivors, persons bereaved by suicide. This organization was instrumental in convincing the national government to develop, implement and finance a national strategy for suicide prevention.

Suicide prevention is a young field. Despite the large body of research about the risk factors for suicidal behaviour, the field is only now converting this information into effective programmes to prevent and reduce suicide. Although it is now possible to develop clearly articulated policies and goals for suicide prevention at global and national levels, we know less about how these goals can be translated into effective action. In the coming decades the major challenges for the Think Globally, Plan Nationally, Act Locally dictum is to find ways of linking international ideals and national policies with well-implemented and well-evaluated local programmes and actions.

WHAT YOU CAN DO TO SUPPORT WORLD SUICIDE PREVENTION DAY

World Suicide Prevention Day 2008 provides a unique opportunity to organize local, regional and national activities to increase public awareness of the problem of suicidal behaviour, and the opportunities for suicide prevention. All people who are interested in and involved in suicide prevention at international, national, state, regional and community levels can participate in various activities on World Suicide Prevention Day 2008. Those activities may call attention to the global burden of suicidal behaviour, discuss national strategies for suicide prevention and how they can be implemented and evaluated, and showcase local community initiatives and responses for suicide prevention.

Initiatives which actively educate and involve people are likely to be most effective in helping people learn new information about suicide and suicide prevention. Examples of activities which can support World Suicide Prevention Day include:

• Launching new initiatives, policies and strategies on World Suicide Prevention Day
• Holding conferences, open days, educational seminars or public lectures and panels
• Writing articles for national, regional and community newspapers and magazines
• Holding press conferences
• Placing information on your website
• Securing interviews and speaking spots on radio and television
• Organizing memorial services, events, candlelight ceremonies or walks to remember those who have died by suicide
• Asking national politicians with responsibility for health, public health, mental health or suicide prevention to make relevant announcements, release policies or make supportive statements or press releases on WSPD
• Holding depression awareness events in public places and offering screening for depression
• Organizing cultural or spiritual events, fairs or exhibitions
• Organizing walks to political or public places to highlight suicide prevention
• Holding book launches, or launches for new booklets, guides or pamphlets
• Distributing leaflets, posters and other written information
• Organising concerts, BBQs, breakfasts, luncheons, contests, fairs in public places
• Writing editorials for scientific, medical, education, nursing, law and other relevant journals
• Producing press releases for new research papers
• Holding training courses in suicide and depression awareness

A list of initiatives and activities that have been undertaken around the world on previous World Suicide Prevention Days can be accessed in the right panel of this page. We encourage you to consult this list and see what others have done to publicise suicide prevention. Also, please fill out World Suicide Prevention Day Activities Form to tell us what activities you plan for WSPD 2008.