Our Submission to Ministry of Health Concerning Suicide Prevention Strategy
MoMA asked Hans Laven to prepare a submission and we post it here with thanks for his hard work. It’s not short but hopefully worthwhile.
We draw attention here particularly to Section 2, Section 3 and Section 6.1. And the sentence that pretty well sums up the previous and the currently proposed Suicide Prevention Strategy: “While partnering with Maori, Pacific and other groups is justified, partnering with men’s groups and men’s services is more justified, indeed essential, and excluding men from mention here amounts to appalling sexism.”
Submission Regarding Proposed Suicide Prevention Strategy 2017
Hans Laven, Clinical Psychologist 26/06/2017
1. The proposed strategy (hereinafter referred to as ‘the Strategy’) has little focus on reducing suicide. Its focus is much more towards reducing intentional self-harm. Indeed, on page 7 it states “The purpose of the strategy is to reduce the suicide rate through reducing suicidal behaviour”. Surely the purpose of a suicide prevention strategy should be to reduce the suicide rate through all effective means?
The Strategy goes on to state “Reducing suicide behaviour for all people means fewer people hurting themselves intentionally, thinking about suicide and dying by suicide”. Although a history of self-harm has been shown to be one of many risk factors for suicide, like most other risk factors its particular contribution towards suicide risk is small. Further, most intentional self-harm is not suicide behaviour, so targeting intentional self-harm will tend to divert resources and attention away from reducing suicide. I may have missed it but I am unaware of research supporting the notion that targeting intentional self-harm is an effective way of either preventing individual suicides or reducing suicide rates. There is no scientific basis for estimating any degree of impact on suicide rates that might be achieved by targeting self-harm behaviour. There is no such estimation mentioned in the strategy and there is no explanation of how reducing self-harm behaviour might reduce suicide rates.
The same applies to suicidal ideation. A huge proportion of people have thought about suicide at some time in their lives yet only a tiny proportion act on those thoughts. Targeting ‘thinking about suicide’ will therefore tend to divert resources away from the task of reducing suicide. Greater impact on suicide rates will be achieved by targeting warning signs shown to be more highly correlated with actual suicide.
A history of suicide attempts is a significant risk factor for actual suicide and is more justified as a target as part of reducing suicide. Yet even there only a small proportion of people who commit suicide have a history of suicide attempts. Further, only a minority of people attempting suicide go on at some stage to commit suicide. One reason for this is that many events defined as ‘suicide attempts’ do not involve genuine intention to die. For example, the statistics for suicide attempts (and intentional self-harm) disproportionately reflect repeated events by a small group of personality disordered people who express their deep distress and need for support through suicide threats, gestures and apparent attempts in which they almost always ensure they will be rescued. If the Strategy is to target suicide attempts, the first step will be to assess and categorize true suicide attempts separately from those that are more accurately seen as help-seeking gestures or self-harm that probably did not involve any intention of dying. Until that happens, targeting the range of what are recorded as ‘suicide attempts’ will divert resources away from reducing suicide.
In its present form the Strategy should be called a ‘Self-Harm Prevention Strategy’. That may be a worthwhile enterprise but inconsistent with the role required of the Ministry regarding suicide prevention, and it leaves the area of suicide prevention inadequately addressed.
2. The Strategy acknowledges that males commit suicide at around 3 times the rate for females but then fails to provide one single plan targeting male suicide specifically or tailored to males. To achieve significant reductions in suicide rates it seems obvious that a priority focus would need to be on male suicide. Suicide rates justify approximately 75% of efforts and resources to be devoted to male suicide, both generally and within other special target groups such as Maori and Pacific peoples. The fact is that all differences between groups based on any other demographic do not come close to the gender difference. From the Ministry’s own figures, the Maori:non-Maori ratio is about 1.4:1, the highest deprivation:lowest deprivation ratio is about 1.7:1; the youth:’adult to middle age’ ratio is only about 1.1:1. The male:female ratio is about 3:1, this being the average ratio over the last 10 years of figures published by the Ministry.
Official suicide rates are likely to be an underestimation because some suicides will be recorded as road accident deaths, workplace deaths, police shooting deaths etc, while other suicides by slower processes of self-neglect, substance abuse and risky lifestyles will also be left out of suicide statistics. What we know about male driving, offending, work-roles, homelessness, substance abuse and other factors relevant to unrecorded suicides suggests that if including those statistics would maintain or increase the gender suicide disparity.
The Strategy states on page 11:
“It is also important to tailor activities…to address the needs of individuals in other groups or sub-groups with markedly higher rates of suicidal behaviour, such as males, LGBTI and the Rainbow community, and disabled people.”
However, there is nothing then recommended in the Strategy that is tailored to men. For example, on page 22 it states:
“Improve understanding of how to prevent suicidal behaviour in New Zealand, particularly among
– Pacific Peoples
– young people
– LGBTI and Rainbow community”
Why is the most prominent group in suicide left out?
The Strategy states on page 7 that its intention is
“… to reduce and remove the differences in the suicide rates between different groups.”
It’s difficult to understand then why the Strategy avoids considering men and male suicide specifically and avoids any focus on reducing and removing the gender difference. Instead, it focuses heavily on reducing Maori suicide and reducing and removing racial differences even though they are less than half that for gender. The Strategy avoids giving any attention or priority to men as a group but disproportionately favours other groups including women on the basis that they show more suicidal gestures and potential attempts but don’t actually kill themselves as often. It is difficult to avoid a conclusion that the Strategy favours groups according to political correctness, and as such is deliberately sexist against men.
Is this related to attitudes to men as disposable and to traditionally lower empathy for men’s suffering? The traditional and continuing sacrifice of males in war and in male work roles (e.g. almost 100% of workplace deaths year after year) is hardly mentioned in media or in official reports and the gender issues are studiously ignored; the same pattern is evident regarding suicide and in the Strategy.
There have been in news media and the literature various suggestions and some examples of approaches that might be expected to impact on male suicide (e.g. Poole, 2016). Firstly, research is needed to gain better understanding of male suicide specifically, and why in ‘western’ but not in Muslim and some other non-western countries male rates rose significantly over the last few decades of the 20th century while female rates remained relatively stable (Phillips, 2011, in ‘Suicide – Suicide rates’, Te Ara – the Encyclopedia of New Zealand, http://www.TeAra.govt.nz/en/suicide/page-2). Research has looked at numerous factors correlated with male suicide yet when the known factors are controlled for, a large proportion of male suicide remains unaccounted for (Mann et al, 2005).
A theme apparent but not specifically explored in research on risk factors for male suicide is that of men’s need to feel useful and valued. For example, Danish research by Qin et al (2000) found that unemployment, retirement, sickness absence rate and being single were all risk factors correlated with male but not female suicide rates. Shiner et al (2009) analysed coroners’ files including suicide notes in the UK and found that relationship breakdown was more likely to be identified as the main trigger for males than for females, while work-related problems and financial debt were each cited at twice the rate for males than for females. Historically, a good proportion of men who saw themselves as not being useful or valued would readily fall on their swords and that appears still to be the case. It may be that many men are struggling to feel useful and valued in the face of gender-role changes over the last 50 or so years, and this is reflected in increased male suicide rates. Research is needed to clarify such matters and to allow solutions to be developed.
Other male-oriented approaches to reduce suicide have been proposed but are totally absent from the Strategy. For example, advertisements in male-rich employment places, bars and sports clubs are likely to reach men. Screen advertisements during male sport broadcasts and during male-oriented movies at theatres and on television could convey messages likely to reduce suicide. Depictions of men seeking support and being heard and understood would be helpful, as would depictions associating worthy masculinity with seeking help and staying alive in the face of humiliation etc. It is not difficult to think of approaches likely to be effective for men but there is a conspicuous absence of such effort in the Strategy.
3. The Strategy provides insufficient emphasis on researching suicide and approaches likely to reduce it. Not much in New Zealand or elsewhere has changed since the following was published in 2011 in The British Columbia Medical Journal:
(Bilsker D, White J. The silent epidemic of male suicide, BCMJ, Vol. 53, No. 10, December 2011, page(s) 529-534)
‘It is remarkable how little we have learned about causal factors and preventive strategies specifically relevant to male suicide. One would think that the hugely elevated rate of suicide in men compared with women would have sparked a substantial investment of resources into systematic research and enhanced clinical practice. Instead, the high rate of male suicide has been treated as somehow natural and inevitable. The time has come to give this problem high priority.’
There is no such priority in the Strategy. Where is the interest in finding out and addressing the reasons men are much more prone to seeing themselves as so worthless or to feeling in so much emotional pain that they kill themselves in such large numbers?
Areas needing research include
– More accurate categorization of suicide attempts vs manipulative gestures vs deliberate self-harm.
– Risk assessment instruments, both for screening purposes and for more intensive intervention purposes.
– Specific management and intervention programs for reducing suicide. There are promising options but none have been tested, researched and developed sufficiently to provide confidence as a routine pathway, and even those with some support have not been researched or adapted for the New Zealand situation.
– Social factors contributing to suicide rates, possibly including the devaluation and demonization of men and maleness in the feminist era; and specific strategies to address any such factors.
– Understanding why psychiatric treatment and hospitalization are associated with such high subsequent suicide rates.
4. The ‘Potential Areas for Action’ have merit but it is unclear why those 10 were chosen and numerous others ignored. Other Action Areas such as promoting physical exercise and family integrity, encouraging respect for men in our society and countering hate-speech and unbalanced propaganda that unfairly disparages men, and targeting male suicide specifically all deserve to be in this list and are more likely to have a beneficial impact on suicide rates than are many of those currently included.
There are approaches that have some research backing regarding reducing suicide, such as various forms of psychotherapy, and an approach called the ‘Collaborative Assessment and Management of Suicidality (CAMS)’ (Jobes, 2012). Such evidence-based approaches should be prioritized in the Strategy.
Subjectively uncontrollable emotions have been shown to predict imminent suicide attempts better than any other risk factor or warning sign (Hendin et al, 2010). Encouraging awareness of this and of using screening and risk assessment instruments concerning this should be part of the Strategy.
Dealing with suicidality as a stand-alone intervention in DHB and other services may be useful, as opposed to dealing with suicide risk as simply a symptom of some psychiatric diagnosis.
Avoiding coercion in treatment is likely to be important, and working to develop alternative approaches to forcing medication and ECT on suicidal people would be a meritorious inclusion in the Strategy.
5. The Strategy’s recommended approaches are vague and fail to identify who is responsible for bringing them about, how this will be done and funded, or how it will be determined that they have or have not been achieved.
6. Comment on each of the strategies:
6.1 Support positive wellbeing throughout people’s lives
This is a laudable aim and the recommended activities may well help to achieve this.
Male-specific approaches should be included. For example:
– Working to achieve gender equality in sentencing, prison conditions and likelihood of Mental Health Act coercion;
– Providing facilities in prisons and psychiatric wards conducive for fathers to spend quality time with children;
– Working to achieve a presumption of equal shared care of children following separation. If separating fathers were confident that their role as equal parent and their bonds with children were going to be protected by the state, this would have an immediate impact on reducing suicide rates;
– Working to achieve gender equality in how we manage all areas in which men are disadvantaged including hate-speech, homelessness, addictions, family law, support for victims of violence and crime, workplace deaths and injuries, health care and suicide prevention;
– Reforming our system of ‘child support’ taxation to overcoming the financial destruction of separated fathers;
– Reforming relationship property laws to reduce inequities and injustice mainly towards men;
– Recognition of the heavily disproportionate sacrifice men make with their lives and health in the dirtiest, most dangerous, most uncomfortable and health-damaging jobs that men overwhelmingly provide to maintain the infrastructure of our privileged lifestyles;
– Increasing recognition of men’s huge contribution historically to developing our civilization and privileged lifestyles;
– Developing a rite-of-passage for transitioning teenage boys into men, involving respect and obligations in relation to the adult male role.
6.2 Build social awareness of and well-informed social attitudes to suicidal behaviour
This seems to be a confused recommendation. It wants to make it easier for people who have lost someone to suicide to seek care and support; that is laudable but of limited relevance to suicide prevention.
This Action Area refers to ‘common myths’ about suicide but does not elaborate. Suicide myths have been suggested (e.g. Joiner, 2011) but those suggestions are poorly supported by research regarding the extent to which these myths are held. Further, it has not been established whether countering any such myths (even assuming we are able to do so confidently based on good research) will reduce suicide rates and if so to what extent.
There is no good scientific basis for ‘running a campaign to reduce the stigma around suicidal behaviour’ as a method to reduce suicide. Indeed, historical evidence suggests that suicide rates vary in correlation with beliefs concerning the acceptability of suicide and the individual’s right to commit suicide (Saul, 2014). While we may not wish to return to criminalizing suicide or punishing families of those who committed suicide, it may well be that a more effective way to reduce suicide would be to increase stigma around suicide and to increase its perceived moral unacceptability.
Reducing stigma concerning depression, mental illness and especially psychotic conditions may increase people’s likelihood of seeking help for themselves or others and thereby avoiding suicide. However, we first need to be confident about how such help is best provided. Some guidance would be desirable in the Strategy. For example, people with depression, grief or adjustment issues should not be too quick to engage with psychiatric treatment because that does not result reliably in suicide prevention, whereas participation in counselling and psychotherapy services is more likely to be helpful. However, severe psychosis should be managed by medication if suicide prevention is the goal, because we know such treatment will reduce suicide risk despite the downsides and inadequacies remaining in that approach. It would be helpful in the Strategy to include an Action Plan to highlight some of the risks of participation in our psychiatric and ‘mental health’ services and to provide some advice about managing such participation.
Raising awareness of ‘signs of distress’ is likely to involve excessive sensitivity and grossly insufficient specificity. Instead it would be more effective to raise awareness of suicide warning signs such as subjectively uncontrollable emotional arousal, preparatory actions towards suicide and large changes in personality or presentation.
While partnering with Maori communities will be important in reducing suicide, partnering with men and men’s groups will be even more important yet there is absolutely no mention of men.
6.3 Encourage responsible conversations about suicidal behaviour and preventing suicidal behaviour
The recommendation to encourage media to report on stories of people overcoming distress and avoiding suicide is a good one.
Teaching people how to discuss suicide and to support suicidal people ‘responsibly’ is commendable but there is a lack of specifics or explanation about this. It is difficult to rely on evidence-based guidance regarding this because the research is unclear and contradictory.
The Strategy could usefully include some specific guidance regarding ‘responsible’ discussion about suicide. For example, supportive listening skills, avoiding unnecessary blame, normalizing people’s errors, imperfections and distress, expressing how much the suicidal person is valued and highlighting the person’s qualities and strengths. Specific guidance on avoiding male-blaming, male-demeaning attitudes and other maleness-disparaging comments would be especially important.
The emphasis on ‘suicidal behaviour’ is appropriate in this Action Area but it would be desirable to include some guidance regarding what would be ‘responsible’ in the case of serious warning signs versus vague suicidal ideation, and some guidance on how to tell the difference.
Again, this Action Area focuses on ‘reducing stigma’ for which there is not good evidence as a suicide-reduction strategy, and on helping those bereft through suicide to seek help which is to some extent a distraction from actual suicide prevention.
6.4 Increase mental health literacy and suicide prevention literacy
‘Mental health literacy’ is not defined. Unfortunately, this will be assumed by many to involve increased readiness to submit to psychiatric diagnosis and treatment, and this believed to prevent suicide. The control of psychotic symptoms through antipsychotic medication, and the control of bipolar disorder through mood stabilizers are supported by most research as bringing significant suicide reduction; however, relying solely on such treatments will only avert a relatively small proportion of suicides, and many people who commit suicide are being treated with medications at the time. Regarding SSRI’s, meta-analyses of Randomized Controlled Trials did not detect reliable suicide-reduction benefit of antidepressants in mood and other psychiatric disorders (Mann et al, 2005). Indeed, SSRI medication has been associated with increased suicide risk for some populations. While several antidepressants have been associated with reduction in depressive symptoms, suicidal ideation and suicide-related behaviour, this did not extend to reducing the rate of completed suicides (e.g. Gibbons et all, 2012), emphasizing that targeting suicide behaviour of vaguely defined nature is not justified as the main focus of a suicide-prevention strategy.
This Action Area implies that addressing mental illness will significantly reduce suicide risk, and this is widely believed in our society. Many media articles conflate the two issues as though suicidality only arises because of mental illness. It will be important in the Strategy to counter that particular myth, and any idea that being diagnosed with something and medicated is a reliable way to avoid or to prevent suicide. Instead, an emphasis on seeking counselling and psychotherapy, and increasing funding and support for telephone counselling services, should be included in the Strategy.
6.5 Support and partner with communities to develop and carry out activities that help to prevent suicidal behaviour
Providing spaces for community groups to meet is a very good idea.
Providing access to sources of funding to support community initiatives to prevent suicide is a very good idea, but such initiatives should be evidence-based as far as possible and at the very least should include requirement and funding to undertake outcome research showing reduction in suicide rates. The very real danger otherwise is that resources will be wasted on ineffective approaches such as drug company profits.
The focus on suicidal behaviour as opposed to genuine suicide attempts or completions is not justified, and substantial diversion of resources into the range of behaviours that might be categorized as ‘suicidal behaviour’ will tend to detract from actually reducing suicide.
While partnering with Maori, Pacific and other groups is justified, partnering with men’s groups and men’s services is more justified, indeed essential, and excluding men from mention here amounts to appalling sexism.
6.6 Strengthen systems to support people who are in distress
The suggested activities are good ideas but the glaring omission here as in the rest of the Strategy is an emphasis on men and systems tailored to men in distress and at risk of suicide.
6.7 Build and support the capability of the workforces in the education, health and police sectors and in the wider justice and social sectors
This is a laudable aim but relies first on knowing what capability to build specifically that is supported by good research as achieving risk reduction. For example, how will one provide suicide prevention training likely to be effective? It would be helpful for the Strategy to provide some real guidance here. For example, it will be important to avoid:
– an over-emphasis on diagnosing and medicating mental illness;
– a reliance on suicide contracts, the use of which has not been shown to avoid suicide;
– a reliance on removing guns and medication, which has been shown to reduce suicide by those means but not overall (i.e. people simply use other means that usually carry greater risk of failure, permanent disability, or additional suffering in the process of dying).
The focus on Maori and Pacific ‘workforces’ assumes an apartheid system, and the wording should perhaps be more cautious in that regard.
Again, there is a glaring absence of focus on men. Male-tailored approaches will be essential for any substantial reduction in suicide. Justice and police sectors particularly will deal overwhelmingly with men in ways that will impact on those men’s suicide risk, so male-specific suicide prevention training (e.g. knowledge of male-specific and male-predominant risk factors, and knowledge of how to influence men against suicide) will be important. For other sectors it will be important to train front-line staff to address male-denigrating attitudes and to build skills for listening and understanding of men’s situations and reactions.
6.8 Strengthen systems to support whanau, families, friends and communities
While supporting those bereaved by suicide is warranted as part of the Strategy, the emphasis here is overdone relative to actual suicide prevention. The contribution of suicide clusters and suicide contagion to overall suicide rates is minor.
Extending that emphasis to include families supporting someone who has ‘ongoing suicidal behaviour’ runs the risk of diverting suicide-prevention resources into managing too wide a range of behaviour, unless ‘suicidal behaviour’ is carefully defined to distinguish it from self-harm, fleeting or uncommitted ideation and manipulative threats. That is not to say that behaviour that may be more broadly categorized as ‘suicide behaviour’ does not deserve attention in the Strategy, but that attention does not deserve to be so emphasized at the expense of addressing real suicide.
The list of ‘Activities in this area’ should include as a priority some male-oriented initiatives, for example:
– funding and re-establishing the Men’s Line as part of the Lifeline service,
– training male-rich workplace supervisors and HR people to recognize and effectively work with men at risk of suicide.
6.9 Strengthen and broaden collaboration among those working to prevent suicidal behaviour
These suggestions are good ones except that it will be important to provide some distinction between the broad notion of ‘suicide behaviour’ and warning signs of impending suicide, in order to avoid diverting too much resource and attention into behaviour that does not carry high risk of actual suicide. The amount of resource should be allocated according to risk levels of behaviour for actual suicide, as far as we can measure them.
In such collaboration it will be most important to increase awareness of men’s issues and to address the anti-male sexism apparent in many of our state and NGO services. For example, Women’s Refuge should be discouraged from making public statements that falsely claim or imply that all domestic violence is committed only by men and suffered by women, and other agencies collaborating with Women’s Refuge should be discouraged from colluding in such anti-male false propaganda which is likely to contribute to men’s sense of worthlessness and thereby to men’s high suicide rate.
6.10 Strengthen systems for collecting and sharing evidence and knowledge about suicidal behaviour and for tracking our progress
This in general is very sensible and commendable. The glaring omission again is any focus on men, the most significant group regarding suicide. We know so little about why men are killing themselves in such large numbers, yet men are totally ignored in favour of other groups that do not have such large relative elevation in suicide numbers. Why is this?
The suggested Activity for Maori to ‘lead’ research on preventing suicidal behaviour among Maori is an apartheid policy with many dangers. Specifically in this case, the Strategy should not have a policy that discourages other groups that are not necessarily identified as ‘Maori’ from initiating and leading research into Maori suicide. It may be that other groups, state organisations etc have research skills and resources not readily available to Maori groups. The Activity would be better worded more carefully, for example, ‘Maori leading or advising research on preventing suicide among Maori’.
Again, without clearer definitions the focus on ‘suicidal behaviour’ runs the risk of diverting resources away from actual suicide reduction in favour of all manner of distress behaviour.
Beautrais AL, Fergusson DM, Horwood L J (2006). Firearms legislation and reductions in firearm-related suicide deaths in NZ. Australian and New Zealand Journal of Psychiatry, 40; 253-259
Borschmann R, Hogg J, Phillips R, Moran P (2012). Measuring self-harm in adults: A systematic review. European Psychiatry, 27; 176-180
Braun C, Bschor T, Franklin J, Baethge C (2016). Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants: A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder. Psychotherapy and Psychosomatics, Volume 85, No 3; 171-179
Gibbons R D, Hendricks Brown C, Hur K, Davis JM, Mann J (2012). Suicidal thoughts and behaviour with antidepressant treatment; Reanalysis of the randomized placebo-controlled studies of Fluoxetine and Venlafaxine. Arch Gen Psychiatry, 2012 Jun; 69(6): 580-587
Harris KM, Goh MTT (2017). Is suicide assessment harmful to participants? Findings from a randomized controlled trial. International Journal of Mental Health Nursing, Volume 26, Issue 2, Pages 181–190
Hendin H, Al Jurdi RK, Houck PR, Hughes S, Turner JB (2010). Role of intense affects in predicting short-term risk for suicidal behaviour. Journal of Nerous and Mental Disease, 198(3); 220-225
Ilgen M A, Zivin K, Austin KL, Bohnert A S B, Czyz EK, Valenstein M, Kilbourne AM (2010). Severe pain predicts greater likelihood of subsequent suicide. Suicide and Life-Threat Behaviour, 40: 597–608
Jobes DA (2012). The Collaborative Assessment and Management of Suicidality (CAMS): An evolving evidence-based clinical approach to suicidal risk. Suicide and Life-Threatening Behaviour, 42(6); 640-653
Jobes DA, Wong SA, Conrad AK, Drozd JF, Neal-Walden T (2005). The Collaborative Assessment and Management of Suicidality versus treatment as usual: A retrospective study with suicidal outpatients. Suicide and Life-Threatening Behaviour, 35 (5), 483-497
Joiner T (2011). Understanding and overcoming the myths of suicide; What goes on in the minds of those who attempt suicide. UBM Medica Psychiatric Times; 28(1), 1-5
Large M, Smith G, Sharma S, Nielssen O, Singh SP (2011). Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients. Acta Psychiatrica Scandinavica, 124; 18-29
Luoma JB, Martin CE, Pearson JL (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159:6; 909-916
Mann et al (2005). Suicide Prevention Strategies: A Systematic Review. JAMA, 2005; 294(16):2064-2074
McMillan D, Gilbody S, Beresford E, Neilly L (2007). Can we predict suicide and non-fatal self-harm with the Beck Hopelessness Scale? A meta-analysis. Psychological Medicine, 37; 769-778
Madsen T, Erlangsen A, Nordentoft M (2017). Risk Estimates and Risk Factors Related to Psychiatric Inpatient Suicide—An Overview. Int. J. Environ. Res. Public Health, 14; 253
NZ Ministry of Health (2003). Best Practice Evidence-Based Guideline: The Assessment and Management of People at Risk of Suicide.
Nischal A, Tripathi A, Nischal A, Trivedi JK (2012). Suicide and antidepressants: What current evidence indicates. Mens Sana Monographs, 10(1); 33-44
Nordentoft M, Mortensen PB, Pedersen CB (2011). Absolute risk of suicide after first hospital contact in mental disorder. Arch Gen Psychiatry, 68(10):1058-1064
Poole G (2016). ONS suicide statistics: 10 ways we can stop men killing themselves. The Telegraph, 04/02/2016
Qin P, Agerbo E, Westergård-Nielsen N, Eriksson T, Mortensen PB (2000). Gender differences in risk factors for suicide in Denmark. Br J Psychiatry. 2000 Dec;177:546-50
Rudd, M. D., Berman, A. L., Joiner, T. E., Jr., Nock, M. K., Silverman, M. M., Mandrusiak, M., et al. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and LifeThreatening Behavior, 36(3), 255-262
Shelef L, Tatsa-Laur L, Derazne E, Mann JJ, Fruchter E (2016). An effective suicide prevention program in the Israeli Defence Forces: A cohort study. European Psychiatry,31; 37-43
Sakinofsky I (2007). Treating suicidality in depressive illness. Part 2: Does treatment cure or cause suicidality? Canadian Journal of Psychiatry; Jun 2007; 52, 6; 85S-101S
Zamorski MA (2011). Suicide prevention in military organizations. International Review of Psychiatry, 23; 173-180
Saul P (2014). Do people really have the right to a rational suicide? The Conversation, 28/07/2014, at http://theconversation.com/do-people-really-have-the-right-to-a-rational-suicide-29658