Dear Walter,

I think you are right and wrong. There is a taboo, even among researchers. Since they are individuals, it is difficult to get rid of common sense, which usually leads to ways of stigmatisation or mislead in this topic. Many concepts have been changing, Durkheim and the role of the stigma in countries now is considerate wrong. Stigma reduce the official report of cases, but not the suicide deaths, in fact it concealed them.

In addition, in suicidology, we call "survivors of suicide" to the bereaved from suicide. And what about the individuals that survive to their own suicidal events? They are seldom researched. They have been for long a sort of taboo.

Another one, suicide is preventable. (???) Is it? For whom? If you have a look at the RCT in drugs and treatments the effectiveness is very low. So, do we think it is preventable, because we are not fighting against biology? And what about the suicidal person's agency to get their goal? Convicing someone of taken a choice for life, even for clinicians, is quiet difficult. So, where is the suicidal individual, or the suicidal decisition (we call it behaviour, not decisition) in the death stats, or in risk factors studies? Have a look at "Internation suicide rates and prevention strategies", 2004, De Leo & Evans, about the ineffectiveness of most of the preventive national champaigns at that time.

This is the reason for a shift to the idiographic approach, have a look at he WHO, Euro and SUPREMISS conclusions. Still, only 3% of the articles published at the three most prominent journals, are qualitative. However, if you feel that researcher are not to happy to discuss monothetic approach, for example, assessment of risk factors like mental disease, it is because they haven't been effective in guiding prevention (Leenaars, 2002) Moreover, recently, risk factor model is showing a low level of predicitbility and a high level of sensitivity, which it does not discriminate false negative and positives (track Ryan and Large 2011 (editorial" ... and where we are?") in the Australian Medical Journal, or DE Wilde, 2002 "...., Still a well disguised blessing". So, when they suggest you to take an idiographic approach it is maybe because they know that the general cases research approach is losing its support among public and researchers. That is why you are right, they don't feel comfortable talking about quantitative approach, but it is not because of taboo in this case.

Still, the research on protective factors is promising, have a look at it, and I suggest you to take that approach, if you have a quanti mind. Have a look at Robinson, ...Pirkis, Warr, 2005 or 2009: a consultation. (Sorry, I don't have all the references in mind.

Best.

Dear Peter,

thank you for share your experiences and knowledges. I will access the quoted sites later. Nevertheless I did not understood well what you think specifically about my question, i.e. whether you think (or not) that may exist some kind of taboo surrounding suicide as a public health issue...

About your considerations concerning suicide prevention based on geopathologic hypotheses and the aversive reception of such ideas by the medics, I believe that this occurs because Geopathology is not considered as a science in the strict (formal) sense as other sciences such as Biology, Physics, Chemistry, etc. In this way, for instance, there is no comproved study specifying the biological mechanism linking the electromagnetic radiation of electronic devices with mental disease, suicide occurence, cancer and any other disease... Within all scientific publications pointing in such direction, this issues are considered only as hypotheses and the search for evidences is based on correlational studies. It is necessary to stress that a confirmed correlation between two phenomena does not necessarily mean causation. It is only possible to say that A causes B if all intermediary mechanisms and phenomena linking A with B are well known.

Walter:

Intriguing question. I think that much research on suicide has been basically atheoretical or at best microtheoretical (e.g., see Rogers and Lester, Understanding Suicide: Why we don't and how we might, 2010) and closer to idiographic . This is reasonable when research is breaking new ground, e.g., the suicide-by-cop phenomenon where most studies have been largely case studies or generalizations from statistical compilations. However, I have often wondered if suicidology (or at least suicide-oriented research) is influenced by a prevailing paradigm as Thomas Kuhn proposed. Kuhn saw paradigms as a sign of scientific maturity, but I think that even an emerging field can manifest what amounts to pervasive "rules of the game" for what is studied, by whom, and how. I believe that suicide research has been undergoing a definite "paradigm shift" over the last 10 or more years towards theory-testing (especially Joiner's Interpersonal Psychological Theory) both in reagrd to theories of suicide and theories from other fields that help us understand suicidal behavior in the context of human behavior in general. Regards!

Dear Walter,

I think you are right and wrong. There is a taboo, even among researchers. Since they are individuals, it is difficult to get rid of common sense, which usually leads to ways of stigmatisation or mislead in this topic. Many concepts have been changing, Durkheim and the role of the stigma in countries now is considerate wrong. Stigma reduce the official report of cases, but not the suicide deaths, in fact it concealed them.

In addition, in suicidology, we call "survivors of suicide" to the bereaved from suicide. And what about the individuals that survive to their own suicidal events? They are seldom researched. They have been for long a sort of taboo.

Another one, suicide is preventable. (???) Is it? For whom? If you have a look at the RCT in drugs and treatments the effectiveness is very low. So, do we think it is preventable, because we are not fighting against biology? And what about the suicidal person's agency to get their goal? Convicing someone of taken a choice for life, even for clinicians, is quiet difficult. So, where is the suicidal individual, or the suicidal decisition (we call it behaviour, not decisition) in the death stats, or in risk factors studies? Have a look at "Internation suicide rates and prevention strategies", 2004, De Leo & Evans, about the ineffectiveness of most of the preventive national champaigns at that time.

This is the reason for a shift to the idiographic approach, have a look at he WHO, Euro and SUPREMISS conclusions. Still, only 3% of the articles published at the three most prominent journals, are qualitative. However, if you feel that researcher are not to happy to discuss monothetic approach, for example, assessment of risk factors like mental disease, it is because they haven't been effective in guiding prevention (Leenaars, 2002) Moreover, recently, risk factor model is showing a low level of predicitbility and a high level of sensitivity, which it does not discriminate false negative and positives (track Ryan and Large 2011 (editorial" ... and where we are?") in the Australian Medical Journal, or DE Wilde, 2002 "...., Still a well disguised blessing". So, when they suggest you to take an idiographic approach it is maybe because they know that the general cases research approach is losing its support among public and researchers. That is why you are right, they don't feel comfortable talking about quantitative approach, but it is not because of taboo in this case.

Still, the research on protective factors is promising, have a look at it, and I suggest you to take that approach, if you have a quanti mind. Have a look at Robinson, ...Pirkis, Warr, 2005 or 2009: a consultation. (Sorry, I don't have all the references in mind.

Best.

Thank you Tony and Jaime... I really appreciated your comments and reference suggestions. Tony, I suppose that you have reason in consider that Suicidology may be suffering a paradima shift along the last decade... And Jaime, I agree with your explanations justifying the change from nomothetic to idiographic approach. However, in my opinion and the other colleagues that still persevere in the nomothetic approach, suicide as a very complex phenomenon, needs to be studied in both these approaches. That is, I think we should not feel sufficiently comfortable facing a so complex phenomenon at point to abandon an approach in favour of another. But I don´t believe that the nomothetic approach will be totally abandoned... Suicidology is a strongly interdisciplinar science and the nomothetic research will probably remain to be conducted by statisticians, mathematicians and scientists of other formations interested by this prolific theme.

Apart the researches, moving to preventing actions at population level, I think that the public health authorities have much to do - mainly with respect to a better control of access to means. One of more critical points lies in the facility to acquire firearms... Nowadays it is extremely easy to buy a firearm (specially handguns), even for an individual mentally ill (see the link: http://americablog.com/2013/02/walmart-gun-world-shooting-dismember.html). Similarly (at least in Brazil), there is a enormous facility to buy agricultural pesticides and other poisonous substances often used in suicide acts in rural communities. In regard to such problems that the employing of nomothetic approaches can be usefull in suicide research. They can help public health authorities to identify the means more often employed and the specificities of age, gender, race, social condition, etc.

Well, now this discussion is becoming interesting... Let´s carry on folks!

PS- I apologise by my english mistakes... I hope that you can understand me ;)

By the way, I found an interesting paper about quantitative vs. qualitative research is Suicidology... See the link:

http://www.suicidology-online.com/pdf/SOL-2011-2-29-37.pdf

The biggest fear in considering suicide as taboo across the public health sector is that talking about it and exposing it will increase the risk and in fact normalise the issue. When in actual fact talking about it is EXACTLY what is needed, along with guidelines as to how a community should bring it to the fore (being mindful of ethnic differences, gender, age etc). It is what it is SUICIDE and we shouldnt avoid using the term

Walter, I agree that suicide is viewed differently then, let's say, depression. The problem I encountered was data availability and data reliability. Any idea about good sources of data?

I was asked to look at literature to see if asking about suicidal ideation led to suicital idea or action. I didn't find anything. I also didn't find anything that suggested it wasn't a legitimate topic for inquiry. Many of the healh surveys have questions about depression or feelings of hopelessness.

Carole - try this:

http://www.himh.org.au/__data/assets/pdf_file/0018/4833/Community-Guidelines-Literature-Summary.pdf

I found it really useful

Thank you all for the contributions... I think Jemaima touched in a sensible point... It is true that even some professionals in the area of Public Health have the erroneous feeling that discuss suicide can lead to new suicide thoughts and actions. May be it occurs due to a lack of interaction between Mental Health professionals (which a priori are better prepared to deal with suicide related issues) and the Public Health authorities... And Carole, I recognize that there are many public health surveys and studies about suicide related issues being conducted, this is true... The problem is that even so there still exist professionals and even authorities that consider suicide as a fringe theme within the field of Public Health. Jemaina, thank you for the interesting link... About the availability and reliability of suicide data commented by Nailya, at least here in Brazil, the situation has been improved in the last decades. Here the most reliable sources are the governmental agencies, mainly the DATASUS, which is linked to Health Ministry. But there is much to improve with respect the reliability of suicide statistics from most isolated regions like Amazonia for example...

Many quantitative studies have shown higher rates of suicide in poorer areas with high unemployment (see Rehkopf and Buka, 2005). Based on this it seems clear that reducing economic inequality would decrease suicide rates, at least in the most disadvantaged sectors of society.

Poor economy could be one of the reasons for high suicide rate. Recently , in Tamil Nadu state, India, there was a high suicide rate among farmers, which was painful. There are lot of known and unknown facts, which could be a momentary one for losing a soul. Suicide and suicide prevention are strong public health issues without a taboo in my opinion. lalitha kabilan

Carole,

Have a look at this brochure for some references that would be interesting to track down. http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=2185

Jemaima, that is an interesting resource.

Thanks,

Jaime

I agree with Lalitha. Rates of self-harm attempts also appear to be higher in poorer neighborhoods (Corcoran et al., J Epidemiol Community Health 2007, 61:1050-1055; Harris and Hawton, Health Place 2011, 73:274-81). But it is clear that in the current economic context, with neoliberal policies applied mainly in developed countries, it is difficult to improve the conditions of the most disadvantaged areas.

Living Is For Everyone (LIFE) is a suicide and self-harm prevention resource providing evidence and resources toward suicide reduction in Australia, designed for the community and those involved in suicide and self-harm prevention activities. You might find the fact sheets and other information useful:

http://www.livingisforeveryone.com.au/Home.html

Melissa: Thanks for the link. I have visited LIFE and have been closely following suicide prevention and suicide loss postvention initiatives in Australia for many years. We in the US (and elsewhere) can learn much from these well-documented and evidenced-based efforts.

JFT provided the great input. Of interest ma be the fact, that in Russia (very high suicide rate) any public discussion of suicide is legally prohibited as "propaganda". Of course, it is senseless...

Walter, you previously raised the issue of access to means - in particular firearms.

In Australia, in the wake of a single-gunman massacre (35 people killed and 23 wounded) in Port Arthur in Tasmania, we had the commonwealth government initiate a "gun buyback" scheme during 1996-97. More than 660,000 weapons were "bought back" from gun owners. This scheme also involved the banning of semi-automatic and pump-action rifles and shotguns. It saw a tightening of both gun licensing and registration laws.

Overall there is strong public support for gun control following this and previous mass shootings - in my home city of Melbourne both the 1987 Hoddle Street massacre and Queen Street massacre were devastating for families and the community.

Dear MP,

is there evidence that it was effective? Did it influenced the suicide rate?

Dear Vasiliy, Yes - there is evidence that it reduced firearm suicides, firearm homicides and mass shootings. Even accounting for other factors that may have contributed also to modest declines, the rates per 100,000 of total firearm deaths, firearm homicides and firearm suicides all at least doubled existing rates of decline after the revised gun laws:

Chapman, S., Alpers, P., Agho, K., & Jones, M. (2006). Australia’s 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass shootings. Injury Prevention, 12(6), 365-372.

There is some suggestion of a substitution of method to hanging suicides in younger males though:

Klieve, H., Barnes, M., & Diego De Leo, M. D. (2009). Controlling firearms use in Australia: has the 1996 gun law reform produced the decrease in rates of suicide with this method?. Social psychiatry and psychiatric epidemiology, 44(4), 285-292.

From my clinical work this group (young males) is the most challenging to identify risk early and intervene with since:

* there are social taboos/gender norms about discussing life stressors and challenges with friends and family who might offer support/assistance,

* they tend not to help seek to the local doctor or counselling services,

* they often combine depressive thinking with heavy alcohol use and so lower inhibitions that might counteract suicidal impulses if sober,

* they are the group that will typically use more violent means.

Gun buy-back programs would not affect the suicide-by-firearm rate in the US. The guns sold to these programs are usually:

- guns that are stolen (many from museums)

- guns that are literally useless (from age, rust, etc).

- guns that are only guns in law only but aren't capable of shooting (sheet metal folded in certain ways qualify as firearms under ATF regulations)

- airsoft and bb guns

- realistic replicas (toys)

The people who sell these guns are typically:

- trying to get rid of a gun they never wanted or never knew about after an older relative dies

- trying to dispose of a weapon used in a crime

- trying to get spending money by selling a trash gun for more than it's worth

- fund-raising to send kids to firearm-training summer camps (well, maybe there's only one group that does that, but they've raised thousands of dollars)

Gun ownership correlated with gun suicide. Gun ownership is not correlated with an increase in likelihood of suicide by any means.

For someone inclined toward suicide, gun ownership increases the likelihood she will use a gun to try to kill herself. Gun ownership decreases the likelihood she will choose a different method.

At the same time, a suicide attempt with a gun is more likely than most other methods to be successful.

Gun ownership doesn't correlate to suicidal ideation.

http://marginalrevolution.com/marginalrevolution/2013/11/firearms-and-suicides-in-us-states.html

I'd say there is definitely a taboo about suicide in NZ, and as such a taboo about both suicide prevention and research about it. There appears to be a don't ask, don't tell policy on suicide in health services. Telling tends to be viewed as attention-seeking rather than help-seeking with an 'if you meant it you wouldn't be talking about it' kind of attitude. Asking about it is often feared to be something that will inspire it - so research that involves asking about it is viewed as uber risky and difficult to get through ethics. This is absolutely a vulnerable group. In our schools, we aren't allowed to say the word 'suicide' to students and prevention efforts must focus on other risk factors instead. This makes suicide prevention difficult and researching it difficult. My instinct is that prevention programmes are feared because they might not work and they will tend to involve some form of talking about it, and our culture is such that we don't talk about suicide. One problem that arises is that increased talking leads to increased requests for help that the system is not equipped to provide. For example, there are under 5 psychologists in the entire Far North of NZ, population approx 58 000 people, with one of the highest rates of youth suicides in a country where 1 in 6 people have suicidal thoughts each year. Were all the people who feel suicidal to ask for help, there would be no therapeutic help to refer them to anyway.

Across 2011 to 2013 I worked on a creative book project to share the stories of people who have survived their own suicide attempts and gone on to be glad that they are still alive. I interviewed six people who fit this description and recruited creative writers to transform the interview notes into short-stories for a book. The book came about because those who had survived their own attempts were under-represented at prevention conferences I was attending - it seemed that people were afraid of what previous-attempters might say or make others feel.

The process of creating the book was revealing of how taboo suicide is too. Firstly, people seemed reluctant to share their experiences, in that it took six months to find just six people who wanted to share their stories (finding research participants may then be tricky). Secondly, men were less likely to come forward: of those six, two were males. I specifically looked for more males to share but could not find them (finding representative study samples would be super tricky). Women appeared to be more comfortable opening up about the subject; to admit to such thoughts did not directly challenge the traditional concept of femininity in the same way as it did the traditional concept of masculinity. People did not want to be seen as weak and selfish, two words that are often thrown about in relation to suicide. Thirdly, we noticed in other professionals, a fear that the project would incite people to make attempts, re-awaken thoughts the storyteller had previously overcome or highlight things that left the bereaved with guilt about things they had missed or made mistakes with. We had to pay careful attention to all of these things from the outset and provide a lot of support to ensure people could share their stories safely - both for themselves and for others, including the writers. These concerns did not come from nowhere and addressing them involved a lot of additional attention that may be off-putting to people contemplating suicide prevention projects themselves and people contemplating researching it. There is a risk-aversion that turns people away from the subject. I felt it myself every step of the way.

Dear Miriam,

In Australia I have certainly had the experience that a funding body, with ultimate responsibility for the research conducted, was eager for intervention studies following suicide attempts to develop evidence-based practices but was unwilling to support use of a control group to clarify which changes could be attributed directly to the intervention and which were due to other factors.

There were 2 ethics committees involved - one hospital and one university - and they certainly also were concerned that interview schedules not be too demanding on already vulnerable people.

Some factors that seemed to play a part in recovery for individuals, in some cases prompted by and in some cases independent to the psychotherapeutic intervention my colleague and I were providing, included factors such as :

* time (resolution of acute crisis),

* anti-depressant medication or other concurrent counselling (resolution of some of the depressive symptoms),

* enhanced employment or education opportunities (resolution of financial difficulties and/or low self-esteem and lack of optimism), and

* involvement of family or friends (resolution of deficits or conflict in social support relationships).