Journal Club Notes

Preventing suicide in community and custodial settings

On Monday, 24 September at 10am (GMT) we had our monthly online journal club session and we discussed the new NICE guidelines on Preventing suicide in community and custodial settings (NG105) published earlier this month. The guidelines are available at: Preventing suicide in community and custodial settings.

Here are some notes from thoughts shared in our discussion, kindly summarised by Hilary Norman:

Communication

We felt that the guidelines have value in communicating key messages about suicide and self-harm prevention to people who could act on them. It was a useful reminder of our own responsibility to communicate research findings that we might take for granted. The Basic Tool, for example, contains proposals that seem, to us, quite intuitive but might be new to others. We discussed whether the focus on community as well as custodial settings duplicated other guidance, and whether that weakened the message. Overall though we felt it was useful that the responsibility for suicide prevention is not solely placed with clinical services in this guidance, and that the repetition of key messages, such as on means restrictions and media reporting, to a potentially new audience, is welcome.

Evidence

In some areas, the evidence found by the committee appears to be particularly sparse (for example on preventing suicide in residential custodial and detention settings). They highlight four broad areas for future research:

  1. How effective and cost effective are non-clinical interventions to reduce suicidal behaviours?
  2. How effective and cost effective are interventions to support people in the community who are bereaved or affected by a suicide?
  3. What interventions are effective and cost effective in reducing suicide rates in custodial and residential settings?
  4. How effective and cost effective is gatekeeper training in preventing suicides?

We felt it would be useful to know what type of research the committee felt was lacking (e.g. RCT, experimental, qualitative).  We acknowledged that large numbers are needed for RCTs in this area, given the incidence of suicide in the population, and that naturalistic studies can be biased.  However, in other countries, particularly lower and middle income countries, evidence underpinning suicide prevention strategies tends to be based solely on epidemiological studies, and therefore the focus on interventions in these guidelines was welcomed.

Implementation

There was concern that no one organisation or person has been given overall responsibility for implementing these recommendations.  In particular there appears to be no money attached to the guidance to implement the findings or to fund the proposed research. On the other hand, it is realistic and useful to emphasise that suicide prevention requires coordinated action by a number of different agencies.  In addition, the fact that a respected body such as NICE has identified the need for more evidence will be useful in future grant applications.

We discussed the fact that there is a wider social and economic context which appears to be beyond the scope of these guidelines, but which is likely to be a factor in suicidal behaviours in custody (e.g. prisoner numbers, prison funding, pre-existing social and mental health vulnerabilities).  We would be interested to learn more about other countries’ approaches to suicide prevention in custodial settings, particularly those countries with different prison systems. Potentially, prison is a place where people who might not otherwise be accessing health care services could be reached and helped.

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