Innovative Approaches in Asia to Identifying Those at Risk for Suicide

The majority of the Asian countries involved in the Strategies to Prevent Suicide (STOPS) project have adopted novel approaches to identifying those at heightened risk of suicide, with a view to encouraging them to seek help. These approaches include: screening and detection programmes in mental health and suicide prevention services, and identification programmes conducted in the community or by schools, welfare agencies or other non-medical organizations. These approaches appear to have potential as suicide prevention strategies, but their effectiveness may be limited in communities where lack of mental health services or intense stigma about using mental health services makes it unlikely that identified individuals will seek professional help. Further evaluation is necessary before definitive conclusions about the benefit of these innovative identification programmes can be drawn. Need for innovation Help-seeking behaviour among suicidal individuals in Asia is generally limited. Although around half of those who die by suicide communicate with friends and family about their intention to die, few seek any sort of professional help (Barnes et al., 2001; Hong Kong Centre for Suicide Research and Prevention, 2005). For this reason, innovative approaches to identifying those at risk of suicide and bringing them to the attention of professionals who can help them may be valuable in saving lives. These professionals may or may not be specialist mental health care providers; in under-resourced countries with few mental health professionals there will need to be a heavy reliance on trained professionals and volunteers from allied sectors. The current chapter describes some of the innovative approaches to identifying those at risk of suicide that are currently being undertaken by the Asian countries involved in the Strategies to Prevent Suicide (STOPS) project. The focus is on novel approaches to detecting those at risk rather than on the direct provision of specialist care, though the immediate support and referral pathways provided once those at high risk have been identified are also discussed. SUICIDE AND SUICIDE PREVENTION IN ASIA 64 Innovative approaches The approaches employed by Asian countries to identify high-risk individuals can be divided into three types: (1) identification via community-based approaches; (2) identification via services provided in other sectors (e.g., welfare services, education services) and (3) screening and detection via mental health or suicide prevention services. Examples of each are provided below. Identification via community-based approaches Several countries have taken a community-based approach to identifying high-risk individuals, using innovative means of delivering positive messages about helpseeking. In India, for example, a street theatre group known as Nalanthana put on 12 street plays for the residents of informal settlements in different parts of Chennai. The plays contained plot-lines related to depression and suicide, in which the main character was about to take his or her life and a kind friend or relative intervened and provided information about a local nongovernmental organization known as SNEHA, which has a befriending service. The character would, with the help of SNEHA, reconsider his or her decision. The rationale was that audience members who might be at risk of suicide would be made aware of the services provided by SNEHA and, thus, be more likely to seek help from the service (Vijayakumar et al., 2005). Other countries that have taken a community-based approach have focused on improving community capacity to respond to suicidal individuals. In Australia, for example, a number of local projects funded through the National Suicide Prevention Strategy have conducted workshops aimed at teaching key community members how to identify and assist people at risk of suicide (Headey et al., 2006). Similarly, in New Zealand, the Ministry of Health has funded training, resource development activities and community development projects to build the capacity of communities to prevent suicidal behaviour among Maori people by identifying those individuals at highest risk. Identification via services provided in other sectors Some countries have used an inter-sectoral approach to identify those at heightened risk of suicide, employing existing services in sectors other than the specialist mental health sector to identify at-risk individuals. The mandate of these services is often quite broad so they routinely come into contact with people who may be considering suicide. IDENTIFYING THOSE AT RISK 65 Some of these approaches have occurred within the education sector. The Travellers programme in New Zealand conducts a needs assessment for Year 9 high school students that identifies distressed individuals and offers them resiliency training. The Republic of Korea trains school staff to identify students at risk. Sri Lanka and China have university-based suicide prevention programmes which, amongst other elements, encourage students to contact academic staff if they are concerned about the emotional wellbeing of a friend. Some of these non-medical identification efforts have occurred within the social welfare sector. In China, Hong Kong Special Administrative Region (Hong Kong SAR), counsellors involved in the indebtedness counselling services for people with unmanageable debts and problem gamblers (and their families) are trained to recognize signs of suicidality in their clients. Recognizing that their clients may be at increased risk of suicide, Australia’s Child Support Agency and Family Court have provided the training, support and infrastructure needed to help staff identify those who may be particularly likely to engage in self-harming behaviour. Similarly, in New Zealand, the Family Start / Early Start intervention programme for families with young children includes the identification of individuals at-risk for suicide. New Zealand’s Towards Well-Being programme is a highly-structured initiative that straddles the welfare and education sectors. The programme assists in identifying and managing young people who are at risk of suicide and may need to be referred to mental health services. Most of them are current clients of the Department of Child, Youth and Family Services. The programme receives case data on each client from the Department and assigns a clinical advisor to help the responsible welfare worker, school social worker or counsellor provide optimal care and (where necessary) referral until the client is assessed as stable. Programmes aimed at identifying those at risk of suicide are also conducted in other sectors. For example, in the Republic of Korea correctional and army staff are educated to detect those at risk of suicide and take appropriate measures. Army chaplains identify soldiers struggling to adapt to army life or at high risk of suicide and offer them a four-day supportive care programme in a special camp. Screening and detection via mental health services or suicide prevention services A number of countries have integrated screening and detection activities for suicide within mental health services, or have developed stand-alone suicide SUICIDE AND SUICIDE PREVENTION IN ASIA 66 prevention services that include early identification and intervention components. In Hong Kong SAR, for example, the Hospital Authority runs an Early Assessment Service for Young People with Psychosis and an Elderly Suicide Prevention Program that involve screening, early detection, emergency or fast-track treatment services, and follow-up care. Hong Kong SAR also has a Suicide Crisis Intervention Centre run by Samaritan Befrienders that provides an outreach service to identify people at moderate to high risk of suicide and to offer them crisis intervention and intensive counselling. Sri Lanka, Viet Nam, and the Republic of Korea have similar counselling services, delivered via hotlines (and, in some cases, the Internet). Thailand conducts screening for depression and suicidality in hospital and primary care settings. Research and Evaluation Few of the above programmes have undergone rigorous evaluation to determine their effectiveness in reducing suicidal behaviour, but most of the programmes in Hong Kong SAR and New Zealand have assessed ‘intermediate outcomes’ such as the psychological well-being and level of suicidal ideation in participants. Hong Kong SAR’s Elderly Suicide Prevention Program demonstrated an improvement in the psychological profile of elders, and its Suicide Crisis Intervention Centre reports reduced levels of suicide risk among those using the service. A randomized controlled trial of New Zealand’s Family Start / Early Start programme and a controlled study of its Towards Well-Being programme both reported positive outcomes for participants. These identification efforts, however, are typically embedded in larger suicide prevention initiatives so it is not possible to parse out the effectiveness of the identification component of the programmes. Future research should aim to apportion the reported benefits to specific components of the programmes, otherwise it will not be possible to tailor effectively the programmes to the needs of specific populations. Next steps Among the strategies that may prove useful in suicide prevention, identifying individuals at high risk would appear to have potential. Such efforts should be fostered in Asian countries, but with some caveats. Firstly, identifying individuals at high risk is only a useful strategy if there are services in place that can assist them and there are no strong negative attitudes about receiving psychological care that would prevent identified individuals from accepting IDENTIFYING THOSE AT RISK 67 referrals for treatment. In resource-poor countries, where mental health and other relevant services are meagre, identifying such high-risk individuals may only serve to increase frustration over the lack of services. Similarly, in countries where persons who receive psychological services are heavily stigmatized, parallel efforts to reduce this stigma need to be undertaken to increase the likelihood that identified at-risk individuals will, indeed, accept referrals for treatment. Secondly, some caution must be exercised to ensure that identifying individuals in this way does not label them or breach their confidentiality. Doing so may be counterproductive in that it may increase the stigma they feel and may reduce their likelihood of seeking help. Thirdly, there is a need for ongoing efforts to be carefully evaluated. Evaluations should be as rigorous as possible and should explicitly consider the effectiveness of the identification component of multi-component prevention programmes. Specifically, these evaluations should consider the extent to which these programmes are successful in identifying suicidal individuals and encouraging them to seek help, and, ultimately, in reducing their suicidal thoughts and behaviours. Wherever possible, comparisons should be made with appropriate groups of individuals who have not had access to the intervention. The evaluations should also consider the context within which these programmes are operating, checking, for example, that they are not creating a demand for services that cannot be met. Consideration should also be given to the extent to which the findings of any evaluation can be generalized to other settings. Summary and conclusions The Asian countries participating in the STOPS project have put in place some innovative programmes designed to identify those at high risk – some conducted in mental health and suicide prevention service settings, some based in services provided through other sectors, and some run in community settings. Programmes identifying those at high risk show potential as a suicide prevention strategy, providing they do not increase the stigma felt by suicidal individuals and they occur in circumstances where targeted interventions can be provided to those identified as being at high risk. Further evaluation work is necessary to confirm this potential. SUICIDE AND SUICIDE PREVENTION IN ASIA 68ReferencesBarnes LS, Ikeda RM, Kresnow MJ (2001). Help-seeking behaviour prior to nearlylethal suicide attempts. 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