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Suicide prevention by means restriction

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Twig just pointed me to a fascinating article about preventing impulsive suicide, by Scott Anderson.

I found the first couple of paragraphs annoying, and for the next few paragraphs I couldn't figure out what Anderson was getting at. But starting near the beginning of page 2 of the article, Anderson presents a compelling case, backed up by studies, for the notion that "means restriction"--making it even a little bit harder or more time-consuming to use any given specific method of suicide--can be an extremely effective preventative.

The focus is mainly on impulsive suicide rather than on people who make detailed plans over a period of time. A couple of notes about impulsivity:

  • The most common impulsive methods (such as jumping off a bridge or shooting oneself with a gun) are also the most lethal, whereas the most commonly used planned-out methods (such as overdosing on sleeping pills or cutting one's wrists) are much less likely to succeed. (p. 4)
  • People who choose those impulsive and lethal methods are often acting extremely impulsively: "In a 2001 University of Houston study of 153 survivors of nearly lethal attempts between the ages of 13 and 34, only 13 percent reported having contemplated their act for eight hours or longer. To the contrary, 70 percent set the interval between deciding to kill themselves and acting at less than an hour, including an astonishing 24 percent who pegged the interval at less than five minutes." (p. 5)

One of the main thrusts of the article is that, contrary to popular belief, suicide barriers on bridges do actually work. I was pretty dubious about that idea, but the article's argument (backed up with statistics) is pretty convincing.

The article also notes that doing things like keeping your ammunition in a separate room from your gun(s), and/or locking guns in a lockbox, makes it significantly less likely that those guns will be used for suicide.

Anyway, I find the whole means-restriction paradigm fascinating. Well worth taking a look at the article, though you won't miss much (imo) if you skip the first page.

Or, for a somewhat dryer but more compact discussion of much of the same material, see the New York State Office of Mental Health's page on Means Restriction.

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Well, of course I have to respond. Some of the stats are compelling, some seem a bit off to me. One good paragraph comparing the suicide rates in high- and low-gun-ownership states finally did the comparison I was looking for -- showed that other means were equal in incidence in the two places, so the higher rate of gun-suicides did seem to directly lead to an increase in the overall suicide rate. Other arguments didn't work for me -- like the low incidence of later completed suicide among those thwarted from jumping. The studies that argue against suicide barriers on bridges show that cities with those often have higher rates of completed suicide, the theory being that if there's no barrier, the person is attempting suicide in a public place, where there's a good chance of intervention; whereas if there's a fence, they switch to an alternate means that lacks the intervention. Once an intervention happens, then you'd expect the rate to go down -- as they point out, the suicidal person is trying to fix the pain in their life, and mental health treatment can help them do that.

I guess my overall negative reaction to the article is from its tone, as if until these studies, no one (and certainly, ongoingly, no one in the mental health field) is looking at details such as impulsivity, means, and means restriction. Hello? That's what we do! When a person is hospitalized, it is to restrict their means of self-harm until they can be safe on their own. The management of the environment is focussed not just on removing objects with which a patient could hurt themselves or others, but also because having such objects removed reduces the person's urge to be unsafe. When we discuss (and when I teach about) suicide, we focus a lot on impulsivity, ambivalence, etc. I often draw a graph with "Lethality of Means" on one axis and "Death Wish" (eg, ambivalence) on the other, and talk about how the approach differs depending on where a suicidal person falls on the chart.

So, yeah, cool article, and good for lay people to see and understand this more, but please know that it's not exactly news to those working in mental health. (And note I read it once, quickly, so I might be overreacting to the tone.)

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