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Psychiatry Investigation 2006;3(2):51-6.
Community Psychiatry Approach to Suicide Prevention
Dong-Woo Lee, MD, PhD1;Min-Sook Kim, MD1; and Myung-Soo Lee, MD2;
1;Department of Psychiatry, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, 2;Yong-in Mental Hospital, Yong-in city, Kyunggi-do, Korea
Abstract

The suicide rate in Korea is increasing rapidly. Suicide has become a major public health problem in Korea. This article will review the essential elements required for the building of a cost-effective system for suicide prevention, as well as the currently existing services in Korea. Both a high-risk approach and a population approach are adjudged to be necessary for effective suicide prevention. Like any other community mental health problem, the problem of suicide can be most effectively managed when it is approached via a process of surveillance, risk factor analysis, intervention design and evaluation, and intervention implementation. In 2004, the Korean government has established a five-year plan for suicide prevention. Local governments, including the Seoul Municipal government, have recently implemented suicide prevention service programs. After reviewing the services currently in place in Korea, we will advance some suggestions regarding future tasks which may contribute to more effective suicide prevention.

Keywords: Suicide; Prevention; Community mental health.

Correspondence: Dong-woo Lee, M.D., Ph.D., Department of Psychiatry, Inje University Sanggye Paik Hospital 761-1, Sanggye-7-dong, Nowon-gu, Seoul 139-707, Korea
Tel: +82-2-950-1083, Fax: +82-2-936-8069, E-mail: dwlee@sanggyepaik.ac.kr 

Introduction


Suicide is a universal phenomenon, which has occurred in every known society and culture. It constitutes one of the principal problems in most countries, although the details inherent to suicide differ among different countries. The suicide rates in many countries are also increasing rapidly.
In Korea, suicide also represents a significant public health problem. In 2003, suicide was the fifth leading cause of death in Korea.1 One suicide attempt occurs every 90 seconds in Korea, and a suicide is completed once every 48 minutes. In particular, individuals in their twenties and thirties are significantly affected by suicide, as it represents the leading cause of death in this demographic group.
Currently, an urgent need for action to halt the precipitous increase in this disastrous problem has been pointed out. Generally, a profound societal taboo with regard to suicide prohibits open discussions of the problem.2 Thus, suicides are frequently concealed, resulting in a lack of appropriate intervention, and this phenomenon further exacerbates the problem. In order to disrupt this vicious cycle, an open discussion regarding suicide, as well as possible intervention strategies, is urgently needed.
In this article, we have examined the phenomenon of suicide from a community mental health perspective, and have suggested some community-based suicide prevention strategies. Thereby, we are hoping to find that reducing the suicide rate is a possible, although difficult, task.

The community mental health approach as applied to suicide

Community mental health is closely associated with public health in general. It can be most succinctly described as the application of public health strategies and concepts to a mental health problem. Therefore, in this study, we will treat the terms "public health approach" and "community mental health approach" as essentially interchangeable.
Early public health efforts were classically targeted toward the protection of individuals and populations against infectious diseases, and the main target of intervention involved alterations in the identified harmful elements of the environment. Public health efforts today tend to be targeted toward the reduction of chronic diseases and injury, and the primary target of intervention has become the modulation of human behaviors.
With regard to the cause of suicide, two contrasting viewpoints exist, one of which implicates society and the other the individual. The former viewpoint was first advanced by Emile Durkheim,3 who theorized that suicide rates in a population were related to overarching social conditions. The contrasting viewpoint was first suggested in the psychoanalytic psychiatry of Sigmund Freud, in which suicide was attributed to problems developing during the evolution of an individual personality. In his approach to the issue of suicide, Geoffrey Rose4 drew similar distinctions between "sick individuals and sick populations". In accordance with this distinction, Rose suggested two methods of suicide prevention: ie, the "high-risk approach," which seeks to protect susceptible individuals, and the "population approach," which addresses the broader social and environmental factors that influence suicidal behavior. These two approaches appear to be equally important with regard to suicide prevention.
The high-risk approach to suicide prevention involves case finding and referral. Screening and referral by crisis centers are common examples of this approach. In the population approach, interventions are targeted at the general population, and involve suicide awareness or education activities, media guidelines, and means restrictions, etc. (Table 1). Currently, no evidence has been discovered to support the efficacy of one approach over another. Thus, we should attempt to develop both of these approaches, in order to construct an integrated and effective suicide prevention system.
Potter et al.5 described four fundamental activities of the public health approach: health-event surveillance to describe the problem, epidemiological analysis to identify risk factors, intervention design and evaluation, and the implementation of prevention programs. Satcher6 also identified four elements of suicide prevention, which were quite similar to those elucidated by Potter et al.
The first step, surveillance, endeavors to answer the fundamental question, "What is the problem?" Surveillance seeks to identify, quantify, and characterize the selected problem. In this step, we attempt to both define and describe the problem, and also to determine its magnitude.
For surveillance purposes, suicidal behavior can be measured on a continuum of seriousness, from merely thinking about self-destruction to actually completing the act, ie. suicidal ideation, suicide attempt, and suicide completion. Suicide completion is regularly documented and reported. Suicide attempts, especially those which result in no or very minor injuries, are almost impossible to monitor with any degree of accuracy. Suicidal ideation is, similarly, difficult or impossible to monitor. Despite the difficulty inherent to the monitoring of suicidal ideation and attempts, the construction and implementation of a surveillance system that encompasses the entire continuum of suicide-associated behavior is clearly necessary for effective suicide prevention.
The second step, epidemiological analysis of risk factors, is purposed toward the answering of the question, "What are the causes of the problem?" The identification of modifiable risk factors via epidemiological analysis is closely associated with the identification of intervention targets. Again, this analysis of risk factors must, in order to be effective, encompass and address the entire range of suicide-associated behavior, from suicidal ideation to suicide completion.
After the establishment of causal relationships, the third step, the development and evaluation of intervention, becomes possible. In order to design cost-effective intervention programs, the causal sequence of suicidal ideation, suicide attempts, and suicide completion should be carefully considered, and comprehensive interventions targeting each of these chains should be planned. The targeting of an intervention at the primary prevention of suicidal ideation may be the most powerful method of reducing suicide rates, but this approach would cover a large population, and should probably focus primarily on indirect services and general efforts, including public advertisement and the general bolstering and shoring up of mental health systems. Interventions targeting suicidal completion tend to be both more focused and more direct. Crisis intervention and referral are two specific examples of this variety of intervention.
After a prevention strategy has been demonstrated to be effective, we move to the last step, the implementation of a suicide intervention program. In this step, we implement a strategy in the broader population, then evaluate the outcomes of the intervention.
In summary, an effective suicide prevention system must take into account both the high-risk approach and the population approach, via a process involving the following four steps: surveillance, risk factor analysis, intervention design and evaluation, and the implementation of an intervention scheme.
We shall now review the currently available suicide prevention services in Korea, and present a discussion regarding the pitfalls of the current services in accordance with the basic viewpoints reviewed in the previous section. Finally, we will suggest a series of future tasks that may contribute to a more effective suicide prevention system.

Services for suicide prevention in Korea

Korea currently has an array of suicide prevention services in place. Since 1976, Korea has maintained a Lifeline service, which consists of civic participation, counseling services, and a social campaign. In 2003, the Korean Association for Suicide Prevention was established for the purposes of research and education, on-line and off-line counseling, the establishment of media guidelines, and other social activities. One university-based suicide prevention institute in Korea focuses specifically on education programs.7
The Korean central government has established a very comprehensive "5 year national plan for suicide prevention" in 2004.8 The national strategy involves the fostering of a life-respecting society, the development and dissemination of media guidelines for suicide reports, the promotion of mental health systems and care for children and adolescents, the early detection of high-risk groups, the construction of counseling systems, the introduction of community-based after-care systems, education for teachers and other medical systems, and the construction of a monitoring system.
Some suicide prevention activities are also conducted on the local governmental level. The city of Seoul has implemented several such activities, the majority of which are principally predicated on the community mental health perspective. Lee7 has assessed several problems of suicide prevention systems on the regional level via a matrix model, which evaluates problems using the three dimensions of input, process, and outcome. In the input dimension, the problems include lack of leadership, lack of objective guidelines, short-age of community-based infrastructure, absence of crisis beds, insufficient workforce, and lack of data formation. The problems in process dimension include the fragmentation of service systems, absence of community-based crisis intervention systems, and the absence of a public awareness program.
Based on this analysis, the city of Seoul has instituted a 24-hour crisis intervention service, as well as emergency beds. These advancements are meant to function as a back-up system for crisis intervention teams. Lee7 has also listed some essential tasks for effective suicide prevention, which should be implemented as soon as possible.
These listed tasks are as follows:
- setting up emergency beds in communities
- providing education programs for workforces.
- setting up standard guidelines for high-risk group interventions
- strengthening delivery systems via the intensification of entry systems, contracts with police and 119 programs for crisis intervention, and the implementation of community-based after- care systems with psychiatrists and community mental health workers.

Future tasks and conclusion

Finally, we present a critical review of the existing services for suicide prevention, concentrating on the two points of view outlined in the previous sections. First, we will attempt to determine whether the high-risk and population approaches are sufficiently addressed in Korea. We will then assess the existing services with regard to whether they have been systematically constructed on the basis of four fundamental activities: surveillance, epidemiological analysis to determine causality, the design and evaluation of interventions to disrupt this causative chain, and the implementation of programs consisting of proven interventions. During this review, we will also make some suggestions regarding future intervention-related tasks.
First, we believe that existing programs in Korea are slightly biased toward a high-risk prevention model, and the population approach-based initiatives, although comprehensively designed, have some weaknesses and require strengthening. Many population-targeted interventions exist within the context of national strategy, including the fostering of a life-respecting society, the establishment of media guidelines for suicide reports, and the restriction of access to sedatives and toxic materials. However, the detailed action plans for these interventions have yet to be provided. Thus, we believe that the population approach is relatively weak and unreliable as compared with the high-risk approach, which is characterized by more detailed action plans. For example, public awareness programs such as "World suicide prevention day" constitute an essential portion of the fostering of a life-respecting society. However, a degree of risk exists, in that poorly devised information inputs may actually elicit or provoke suicidal acts, particularly among adolescents and certain sensitive individuals.9 Thus, careful design with regard to details of the public awareness program are crucial. This also applies to other intervention schemes.
Another weak point of the current population approach is that the action plans for psychosocial support are not fully developed. Connecting elderly people with risk factors of depression to the social support system is currently a component of the national strategy. However, more comprehensive plans for psychosocial support must be prepared for all age groups. Modern society is currently evolving along paths which charge individuals with greater responsibility for their own lives. Simultaneously, many people are becoming increasingly isolated, and tend to lack support in their immediate surroundings. The population approach for suicide prevention should focus on the construction of supportive networks and the strengthening of life skills, which would protect people in all age groups who are in difficult situations, but lack a network of family and friends.9
Second, we believe the build-up of hospital-based suicide monitoring systems, a component of the national strategy, represents an extremely important and urgent task, and this is even more desirable if this monitoring system can be connected to the improvement of quality of care of suicide. In order to make this possible, we should first establish a network of psychiatrists in hospitals with emergency beds, and should also develop a common manual for the evaluation, management, and documentation of suicide attempters to be used in these hospitals. Then, we should expand this network to include larger groups of psychiatrists.
Third, although the current national strategy implements suicide prevention programs without evaluations of effectiveness due to the urgent need for action, we believe that the ultimate development of a suicide prevention program should follow the sequence of epidemiological research in order to identify the causal chain inherent to suicide, the design and evaluation of interventions to disrupt this causal chain, and finally, the implementation of these proven suicide prevention programs. This entire sequence will start with reliable and relevant research regarding suicide-related behaviors, which will require a great deal of investment. Thus, associated professionals should persuade both national and regional governments to commit this investment, by demonstrating the cost-effectiveness inherent to the establishment of effective suicide prevention programs.
Fourth, an urgent need exists for the development of suicide prevention systems for elderly people. Although many countries target a large percentage of suicide prevention efforts toward adolescents and teenagers of school age, suicide rates tend to be higher among the elderly. This is also the case in Korea, and the community mental health system for the elderly is relatively weak as compared with systems targeted toward other age groups. Thus, an urgent need exists for the construction and implementation of an elderly mental health team in community mental health centers, who are equipped to begin to address the problem of elderly suicide.
Fifth, there is a need for the establishment of a national center for suicide prevention, which would co-ordinate research, guideline and program development, education of associated personnel, and the evaluation of related activities.
While suicide prevention services currently exist in Korea, many of these services are in their initial stages, and a need continues to exist for more planning, evaluation, and co-ordination. In this situation, the community mental health perspective can make a breakthrough by making some helpful suggestions, which may facilitate the establishment of a system that encompasses not only high-risk groups, but also the general population.
The national strategy, as well as the activities under-taken by some local governments, are already predicated on this perspective, and we hope that the suggestions advanced in this article may contribute to the further development of more effective suicide prevention programs in Korea. 


REFERENCES

  1. Korea National Statistical Office. The statistical data of a cause of death in 2003, 2004.

  2. O'Carroll PW. A consideration of the validity and reliability of suicide mortality data. Suicide Life Threat Behav 1989; 19: 1-16.

  3. Durkheim E. Suicide: A study in sociology. New York: The Free Press, 1951.

  4. Rose G. Sick individuals and sick populations. International J Epidem 1986; 14 (1): 32-38.

  5. Potter LB, Powell KE, Kachur SP. Suicide prevention from a public health perspective. Suicide Life Threat Behav 1995; 25 (1): 82-91.

  6. Satcher D. Bringing the public health approach to the problem of suicide. Suicide Life Threat Behav 1998; 28 (4): 325-327.

  7. Lee MS. The community-based integrated suicide prevention & intervention system. Seoul international mental health symposium, 2006, pp114-123.

  8. Ministry of Health and Welfare. Five year plan for suicide prevention, 2004.

  9. Wasserman D. Strategy in suicide prevention, In: Suicide, an unnecessary death. Ed. By Wasserman D. London, Martin Dunitz, 2001, pp211-216.

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