The Contribution to Suicide Prevention of Restricting Access to Methods and Sites.

Abstract

There is now a large body of research literature suggesting that restricting access to a particular method of suicide may successfully reduce suicides by that method. However, the extent to which reductions in rates of suicide by one method that is restricted are paralleled by reductions in overall suicide rates is less clear, and this has led to debates about the extent to which restriction of one method may lead to substitution through an equally lethal method. While the risk of substitution has often been used as an argument against restricting access to specific methods of suicide, even in cases in which substitution may occur, method restriction may still be justified. In particular, if it becomes apparent that some particular feature of the environment facilitates or encourages suicidal behavior it may be ethical to remove access to that feature even though there is a risk of substitution. The accumulated evidence suggests that restricting access to a wide range of means and sites of suicide can be an effective, relatively simple approach to suicide prevention – an approach that is, perhaps, sometimes undervalued. At the very least, restriction of method should be considered as one component of any integrated plan for local, regional, and national suicide prevention. This supplement presents a series of papers focusing on specific means of suicide and discusses, for each method, current developments in restricting access to that method and the impact thereof on suicide. Hawton (2007) provides an overview of major issues in restricting access to means of suicidal behavior, including the rationale for this approach, the feasibility of suicide prevention by restricting access to methods of suicide, and the fact that suicidal behavior is often ambivalent and impulsive and may not be pursued if access to a favored method of suicide is thwarted. He summarizes evidence from a range of studies reviewing the impact of restricting access to particular methods of suicide on suicidal behavior. In addition, studies that have explored subsequent suicidal behavior among persons who have survived near-fatal suicide attempts have found that most of those who survive such attempts do not go on to make further attempts by the same – or some alternative – method. Hawton, notes, in particular, that clinical assessment of suicide risk should routinely inquire about access to means of suicide, and that clinicians should strongly advocate the removal of potentially dangerous means of suicide from the households of vulnerable individuals. In the 21st century there has been increasing recognition of the contribution to world rates of suicide from countries in Asia, and a corresponding focus on restricting access to pesticides, which account for many of these deaths. In fact, poisoning by pesticides is the most common method of suicide worldwide. Mishara (2007a) explores the extent of pesticide suicide around the world. In rural Asia the ready availability of highly lethal pesticides, often coupled with limited access to prompt and adequate medical treatment, results in a profile of suicide as less planned, more impulsive, and less likely to be associated with mental illness than in the West. The pesticides available in Asia are often highly toxic (compared with those in the West) and, moreover, highly toxic even in small doses. This feature contributes to high case fatality coupled with inadequate training in medical interventions for pesticide poisoning, limited access to appropriate medical care, and lack of antidotes. Mishara also discusses the context within which pesticide suicides occur, often as impulsive responses to short-term family conflicts and stresses. A range of strategies might be employed to reduce pesticide suicides, including controlling or restricting access to the most dangerous pesticides, reducing the use of highly lethal agents, safer storage practices, education concerning the lethality of pesticides, improved medical training, treatment, and facilities, and developing supportive approaches to address the sources of family conflicts. In 1998 a single case of suicide by charcoal burning was widely publicized by the Hong Kong media as a novel way to end one’s life. The media accounts were explicit and graphic, and they provided, in effect, an advertorial guide to the use of this method. This event occurred during the Asian financial crisis of the late 1990s; the media linked charcoal burning with personal financial despair and portrayed suicide by this method as a painless, peaceful solution to such stress. Within the year charcoal burning had