Written by Joshua Stein, MD
A common difficulty in the outpatient office is determining the steps needed to ensure the safety of a patient once they identify that they are suicidal. There are two known methods to ensure safety; mental health treatment at the appropriate level of care and means reduction. The need to determine level of care will be examined in a future post. The significant importance of the removal of means to suicide, or Means Reduction, is the focus of this article.
A common myth is that a suicidal person, who has identified a source for completion, will substitute an alternative method if his/her original method is taken away. This belief in almost all settings represents a fallacy. The lethal means, whether overdose, a firearm, a one car crash etc, will not be substituted for another.
Given the opportunity, the removal of chosen lethal means, especially firearms, will greatly reduce the How people attempt: leading to time to determine the Why, and introduce treatment.
Per NAMI, there are numerous examples from history where the removal of a lethal means has decreased the death rate. In 1960, lethal oven gas ingestion was the leading cause suicides in the UK. By 1970, the country had substituted non-poisonous gas, resulting in a one third decrease in the suicide rate. The entirety of the drop stemmed from the change in gas, and non-gas related suicides had only increased slightly. The entirety of the change stemmed from means reduction to lethal gas.
The Israeli Defense Force (IDF) struggled significantly with suicides off base on vacations and weekends. In 2006 soldiers were no longer allowed to carry firearms off base for breaks. The suicide rate dropped approximately 40 % with no change in the rate of suicides during the week. The entirety of the change appeared to be related to the means reduction to firearms off base.
Numerous studies demonstrate that the acute action phase towards suicide is commonly brief. By removing the means to attempt, people often reach a plateau of safety when support can be introduced. The most common method of suicide attempt is by intentional overdose. The most likely lethal attempt is by firearm. Practical steps are outlined below:
- If a means is shared, it must be removed (substitutions are not likely)
- Additional means to suicide should also be removed to improve safety
- Remove all firearms
- Lockup medications, including OTC (carry in car if needed)
- Remove car keys
- Remove Sharp objects/knives
- Remove cords and ropes
- Remove alcohol
- Identify a family member or friend who can remove the means before a patient returns home
- Have the person who is removing the means alert the treatment team by phone call that this has been completed
- Document this step
At times, resistance to removing the means may occur from a friend/family member. A common desire to increase the difficulty of the attempt often is a practical point to reach agreement. As these are common objects in the home and firearms carry significant value, there is a time at which reintroduction should occur. Similar to the safety assessment in the medical office that led to removal of means, a safety assessment can take place to approve returning these objects to the home.
In conclusion, removal of the means works in significantly improving safety. If a patient is deemed appropriate to return home, whether from a hospitalization or an outpatient appointment, steps towards means reduction need to take place. Finally, when a patient identifies a means, action should be taken, the fallacy to believe an alternative means will be substituted is incorrect.
- NAMI MEANS REDUCTION LECTURE
- Shaffer D, Pfeffer CR, & the Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. JAACAP. 2001;40(7 Supplement):24S-51S.
- Shain BN. Suicide and suicide attempts in adolescents. Pediatrics. 2007;120(3):669-675.
- American Association of Suicidology. Youth Suicide Fact Sheet. January 28, 2008. Available at: http://suicidology.org/c/document_library/get_file?folderId=232&name=DLFE-24.pdf. Accessed April 19, 2009.
- American Psychiatric Association. Let’s Talk Facts About Teen Suicide. Available at: http://healthyminds.org/factsheets/LTF-TeenSuicide.pdf. Accessed April 19, 2009.