Commentary on Snowdon: ‘The Journal’s concerns about suicide’

Suicide deaths, along with suicidal thoughts and behaviours, place an extensive burden on individuals, with broader impact across the community. Suicide deaths account for a disproportionate number of deaths in young adulthood, although suicide remains a leading cause of death across the lifespan. The article by Snowdon (2017) draws together key threads of suicide prevention research in Australia, noting the particular role that Australian and New Zealand Journal of Psychiatry (ANZJP) has played as a flagship journal for research in this field. In recent years, ANZJP has published extensive research on suicidal thoughts and behaviours in Australia. Snowdon notes the important role that mental illness often plays in the development of suicidal thoughts and behaviours. However, he appropriately acknowledges that suicide typically emerges from a constellation of risk and protective factors including culture, availability of means, substance use, interpersonal processes, employment and negative emotions or psychological states. Although suicide prevention research is often embedded in the mental health domain, Snowdon (2017) hints at a possible tension regarding the fit of suicide prevention research within the psychiatric literature, which sometimes has a focus limited to psychiatric states, rather than on behaviours that arise from both psychiatric states and biopsychosocial context.

There are a number of areas where suicide prevention research needs to progress, including the need to innovative in epidemiological research, to better implement interventions for suicidal individuals and to conduct more research in high-risk populations. Most suicide prevention publications in ANZJP have focused on the epidemiology of suicidal thoughts or behaviours. Developing greater understanding of why people die by suicide is a crucial research endeavour. However, in the past 50 years, the field has identified very few new factors that robustly predict suicidal ideation or attempts, and our ability to predict suicide risk has not improved (Franklin et al., 2016). Research has typically examined the roles of a select few risk factors on long-term suicide outcomes (Franklin et al., 2016). Suicide prevention research may benefit from innovations such as detecting complex interactions between factors, developing intra-individual prediction approaches and improving short-term prediction in high-risk populations.

Moreover, a stronger emphasis on intervention and clinical research is also needed. If we are to address the increasing suicide rate in Australia, rigorous evaluation of innovative approaches to prevention and treatment is required. Drawing on technology, big data, novel methodologies and novel treatments to prevent suicide are emerging areas where we may see progress over the next few years. However, we also need to better implement strategies that are supported by the existing evidence, but which essentially are not put into place. Without translational research that identifies pathways for improving the uptake of evidence-based strategies for suicide prevention in the community, we may have little impact on the suicide rate. The Lifespan project is both a trial and an implementation project, which aims to introduce or reinforce nine evidence-based strategies for suicide prevention (Krysinska et al., 2016), and if successful is likely to provide a model for better implementation of evidence-based suicide prevention programmes across Australia.

There are also a number of populations and settings that may be under-researched in the suicide prevention field in Australia. In particular, there is need for greater research with people of diverse backgrounds on the basis of culture, Aboriginality, sexual orientation or socioeconomic disadvantage, all of whom have elevated risk of suicidal behaviour. Such research needs to be informed by the people who are most at risk, incorporating their rich understanding of their experience, and draw on bottom-up solutions. While there have been notable publications on suicidal behaviour within these populations, there remain gaps in our understanding of the sources of disparity in the suicide rate and what can be done about it. Suicidal behaviour often occurs outside the context of the clinical setting, so an expansion of research focusing on the online space, in schools and workplaces, and other community-based settings is also warranted. As noted by Snowdon (2017), literature examining suicide prevention initiatives internationally may add further insight to these efforts.

The current funding context for mental health research, and suicide research in particular (Christensen et al., 2011), continues to create challenges to progress. Other potential barriers to progress may include limited research capacity, insufficiency of clinical training in suicide prevention and misfit of suicidology within psychiatry as discussed above. Understanding and addressing the terrible impact of suicide require sustained effort from the research community, pressure from the broader community to prioritise suicide prevention research and commitment by governments and funding agencies to provide ongoing resourcing for this important area. ANZJP can support suicide prevention in Australia by continuing to promote this area of research, particularly through publication of suicide prevention research that involves innovative epidemiological approaches, promotes better implementation of the evidence base or focuses on specific high-risk groups.