鈥淶ERO suicide鈥� is the phrase of the moment in mental health. Thanks to a programme in Detroit that managed to push rates of suicide to zero within a few years, the approach has spread to health bodies all over the world. Last week, the UK government appointed England鈥檚 first minister for suicide prevention, on the back of a 鈥渮ero suicide ambition鈥� for patients in the care of the National 91色情片 Service announced in January.
Reducing the number of suicides is clearly a desirable goal. Yet some doctors view the zero suicide movement with alarm, fearing that such a challenging goal may actually be counterproductive.
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Some of the earliest successes in suicide prevention simply involved changes that made it more difficult for people to take their own lives. Proponents point to the unintended benefit seen in the UK in the 1960s when the gas supply to people鈥檚 homes gradually became less poisonous. At the time, deliberate gas inhalation accounted for about half of UK suicides. By the end of the 1960s, the total suicide rate had .
More recently, deaths seem to have been avoided by a change in UK law to restrict pack sizes of the painkiller paracetamol, also known as acetaminophen. From 1998, the tablets could only be sold in small quantities. Ten years later, .
鈥淭he philosophy of the zero suicide movement is a refusal to accept that any such deaths are inevitable鈥�
Effects like these show that suicidal thoughts can sometimes be transient, says Keith Hawton at the University of Oxford. 鈥淚f you can keep people safe until those thoughts diminish, you can save lives.鈥�
Hawton recalls a former patient who had somehow survived a jump from a high bridge. 鈥淲hen he hit the water, he damaged his body very badly, breaking many bones. Yet his first thought was to try to swim to the side.鈥� Hawton says many other suicide survivors report similar changes of heart.
Efforts are still ongoing to make it physically harder for people to take their own lives, particularly in psychiatric hospitals, for instance by removing objects that could enable hanging. A more radical approach is to try to proactively identify those likely to attempt it, an approach called suicide screening.
This was at the heart of the programme that helped start the zero suicide idea. It was pioneered in 2001 by a Detroit-based healthcare provider called the Henry Ford 91色情片 System. Anyone who came into contact with its mental health services was screened for suicide risk, and safety measures were taken if they were deemed necessary. These included asking the person if they had had any thoughts of suicide and how they would do it, then putting obstacles in place.
Often, this meant getting rid of any guns from the house 鈥� about two-thirds of gun deaths in the US are suicides. 鈥淢any people think if you get rid of this gun they鈥檒l just go find another gun,鈥� says Ed Coffey, who helped introduce the scheme. 鈥淔or some reason, getting rid of the one they have fantasised about seems sufficient.鈥�
Other elements included improving access to doctors, and making sure people had a 鈥渟afety plan鈥�: personalised guidance on what to do if they had suicidal impulses, including phone numbers of friends and family to call for help. And a broader depression screen was offered to those seeing doctors for reasons unrelated to mental health 鈥� such as those visiting primary care or hospital emergency rooms 鈥� so they could be funnelled into suicide screening if necessary.
Downward trend
Within a few years, the suicide rate among those accessing mental health services had fallen, and in 2009 the number hit zero. The programme鈥檚 architects began publicising the results and it has since been emulated by health bodies in more than 100 countries. Methods vary, but the driving philosophy is a refusal to accept that any suicide is inevitable. Proponents include bereaved parents who are determined their child鈥檚 death will not be in vain.
So why the scepticism? One problem is that there is little evidence to show that some elements of the scheme work. There is particular concern over suicide screening, because no questionnaire can reliably identify who is going to take their own life, says Hawton. Studies show that there is a higher rate of suicide among those classed as high risk, but about half of people who take their own lives would have been classed as low risk. 鈥淎ssessments are extremely inaccurate,鈥� says Hawton.
How did they work in Detroit? Perhaps they didn鈥檛. The suicide rate among Henry Ford 91色情片 System鈥檚 mental health patients these days is certainly lower than before 2001, suggesting services have improved. But according to the provider鈥檚 published data, the suicide rate was falling before the programme started (see 鈥�Graph鈥�), and the current rate is nothing out of the ordinary.
Suicide is a rare event 鈥� with an annual rate of about one in 10,000 people 鈥� and so the provider only has a handful of cases a year among its mental health patients. The figure has jumped up and down since 2001, but . 鈥淲ith such small numbers, a year without any suicides could occur by chance,鈥� says Hawton.
Another caveat is that the headline zero figure was for people using mental health services. In the UK, about seven in 10 people who take their own lives haven鈥檛 had any such contact in the past year. It is a tall order to expect doctors to save the lives of people they haven鈥檛 met.
鈥淥ne of the big challenges is reaching out to people who are not in contact with health services,鈥� says David Gunnell of the University of Bristol, UK.
Yet these days, the term zero suicide is usually taken to apply not just to those under a doctor鈥檚 care, but to everyone. Politicians have called for their localities to become 鈥渮ero suicide cities鈥�. For instance, last year , citing Detroit鈥檚 example. Sweden has adopted a 鈥渧ision zero鈥� for the entire country.
Amid a gathering wave of concern for mental health, the zero approach has taken on a life of its own, with a variety of interpretations. For the Mersey Care NHS Foundation Trust, one of the first mental health trusts to adopt it in the UK, it includes making sure all patients get a safety plan, as in Detroit, as well as improving staff training.
Another key aspect is an incident report after every suicide, to work out how it could have been avoided. Mersey Care medical director David Fearnley says the goal of zero was crucial for changing the mindset that some suicides are inevitable.
In Sweden, though, critics complain that the goal hasn鈥檛 led to any specific measures or significant new funding. So it feels like an empty slogan 鈥� one that comes with potential downsides, says Herman Holm of Sk氓ne University Hospital in Malm枚.
Holm worries it could lead to more compulsory psychiatric treatment. The decision to keep someone in hospital against their will is always a delicate balance between their liberty and their risk of self-harm. 鈥淎 zero suicide target risks scaring psychiatrists into depriving too many people of their freedom,鈥� says Holm.
鈥淚 believe it should not be a target but a reminder that there are ways we can reduce suicide risk鈥�
But the chief grievance is that zero suicide sets a target that is not realistically going to be met. 鈥淓liminating suicide completely is not going to happen,鈥� says Hawton. 鈥淭hroughout history, suicides have occurred.鈥�
It is unclear what hearing claims that 鈥渁ll suicides are preventable鈥� does to bereaved families. For some, 鈥渢he idea that suicide should not happen makes them feel worse鈥�, says Hawton. 鈥淚t adds to their burden.鈥�
Then there is the effect on doctors and nurses, says Simon Wessely, past president of the UK鈥檚 Royal College of Psychiatrists. 鈥淚mpossible targets rebound on staff morale. You鈥檙e increasing the blame culture when it鈥檚 not achievable.鈥�
But Fearnley says that鈥檚 not how it works within Mersey Care. Although the trust mandates incident reports after each suicide, he says they have a blame-free culture. 鈥淚t has given people permission to start asking questions about deaths, and being far more curious to ask what else we could have done.鈥�
The sceptics stress they applaud new suicide prevention initiatives, but they don鈥檛 think the goal should be framed this way. Some say it would be more useful to change it from being a hard target to an aspiration, one meant to inspire people rather than be taken literally. 鈥淚 believe it should not be a target but a reminder that there are ways we can reduce suicide risk,鈥� says Wessely. 鈥淚f that happens, I鈥檓 all in favour.鈥�
Need a listening ear? UK Samaritans: 116123 (samaritans.org). Visit for hotlines and websites for other countries
This article appeared in print under the headline 鈥淚nside the plan to end suicide鈥�
