Means Restriction in Suicide Prevention

What is Means Restrictions?

Means restriction is a technique for preventing suicide that involves restricting or preventing access to the tools used to attempt suicide. This can be things like pills (for overdosing), firearms (for shooting), or railways (for jumping.)

Some suicide methods have much higher lethality or chance of causing death than others. For instance, while 85% of firearm suicides results in death, only about 2% of overdoses do. Hangings are approximately 70% (Vyrostek, Annest, & Ryan, 2004).

There is a myth that if we limit one suicide method (like removing firearms from the home), that someone will simply use another suicide method. While it’s true that not all suicide methods exist in all countries and suicides still occur, suicide method restriction does not generally lead to method substitution during that time-limited suicidal crisis.

Support for Means Restrictions

The idea of means restriction (and its connection to means substitution) was first explored in the 1970s and 80s with the change from toxic coal gas to far less toxic natural gas in Great Britain. It was noted at that time that there was no displacement or substitution of suicide method. This was summarized by Clarke (1989).

Daigle (2005) reviewed a number of studies on means restriction and suggested two primary reasons for the reduction in suicide risk associated with restricting means:

  1. Individuals plan their suicide carefully, including becoming attached to specific methods. By restricting access to those methods people are less attached to the idea of dying by suicide at all
  2. Suicidal crises are often short lived periods of intense acute risk. By limiting the most lethal methods people are forced to either delay their suicide plan or switch to a less lethal method, which will either provide time for the suicidal crisis to pass or (in the event of a suicide attempt carried out) time to be rescued

The literature supporting means restriction and it’s relationship to means substitution is reviewed below based on common suicide methods, which are considered high-lethality methods and therefore most affected by means restriction.

Firearms

Anestis & Anestis (2015) examined the impact of four firearm-related laws: waiting periods to receive one, universal background checks, gun locks, and open carrying regulations on their impact of the suicide rate. Their research found that firearm suicides were reduced when each was implemented and background checks, gun locks and open carrying regulations also reduced the overall suicide rate.

This pattern, stricter firearm laws leading to lower suicide rates was observed in both England (Gunnell, Middleton, & Frankel, 2000) and Austria. (Kapusta, Etzersdorfer, Krall, & Sonneck, 2007)

Additionally, Wintemute et. al. (1999) found that the rate of suicide among handgun owners is 57x higher than the general population in the first week of ownership (because of people who buy a gun for the specific purpose of suiciding) and 7x higher at the end of the first year. It is likely that a person’s risk of dying by suicide remains elevated as long as someone owns a firearm.

Railways

Lukaschek, Baumert, Erazo, & Ladwig (2014) examined railway suicides in Germany over 2 separate periods and found that railway suicides were most common on Mondays and Tuesdays. They note that blue lights in Japan and physical barriers have been helpful in reducing railway suicides, in addition to comprehensive changes introduced by the German Railway Suicide Prevention Project.

The changes implemented included “an awareness programme, media approaches, hotspot analysis….and the introduction of a rule regarding announcements to passengers waiting in station or trains, which requires avoidance of the term ‘suicide’, and an indication that the delay is due to a ‘medical rescue operation underway.'”

Jumping

Law, Sveticic, & DeLeo (2014) examined the impact on the suicide rate in Australia after the installation of a suicide barrier on the Gateway Bridge in Brisbane. The barrier reduced the suicide rate 53%, while there was no shifting of means onto the nearby Stony Bridge.

Meanwhile in Auckland, New Zealand, a bridge barrier was removed on the Grafton Bridge and then reinstated; a 500% spike in the suicide rate occurred while the bridge barrier was absent. (Beautrais, 2009)

Counseling on Access to Lethal Means (CALM)

The Counseling on Access to Lethal Means (CALM) course provides a thorough exploration of means restriction to enable a worker to understand the theoretical basis for restricting access, but also the practical tools surrounding how, when and why to have the conversation about restricting means. It is particularly focused on youth but can be helpful for all populations.

Bibliography

Anestis, M.D., Anestis, J.C. (2015) Suicide Rates and State Laws Regulating Access and Exposure to Handguns. American Journal of Public Health. 105(10):2049-58. doi: 10.2105/AJPH.2015.302753

Beautrais, A.L., Gibb, S.J., Ferguson, D.M., Horwood, L.J., Larkin, G.L. (2009) Removing bridge barriers stimulates suicides: an unfortunate natural experiment. The Royal Australian and New Zealand College of Psychiatrists.

Clarke, R.V. Crime as OPportunity: A Note on Domestic Gas Suicide in Britain and the Netherlands. British Journal of Criminology, Delinquency and Deviant Social Behaviour, 29:1. 35

Daigle, M.S. (2005) Suicide prevention through means restriction: assessing the risk of substitution. A critical review and synthesis. Journal of Accident Analysis and Prevention. 37(4)625-32.

Gunnell, D., Middleton, N. & Frankel, S. (2000) Method availability and the prevention of suicide—A re-analysis of secular trends in England and Wales 1950–1975. Social Psychiatry and Psychiatric Epidemiology. 35:437–443

Kapusta, N.D., Etzersdorfer, E., Krall, C. & Sonneck, G. (2007) Firearm legislation reform in the European Union: Impact on firearm availability, firearm suicide and homicide rates in Austria. British Journal of Psychiatry. 191:253–257

Law, C.K., Sveticic, J., DeLeo, D. (2014) Restricting access to a suicide hotspot does not shift the problem to another location. An experiment of two river bridges in Brisbane, Australia. Australian and New Zealand Journal of Public Health. 38(2):134-8. doi: 10.1111/1753-6405.12157

Lukaschek, K., Baumert, J., Erazo, N., Ladwig, K.H. (2014). Stable time patterns of railway suicides in Germany: comparative analysis of 7,187 cases across two observation periods (1995-1998; 2005-2008). BMC Public Health. 14(1)

Vyrostek, S.B., Annest, J.L & Ryan, G.W. (2004) Surveillance for fatal and nonfatal injuries–United States, 2001. Morbidity and Mortality Weekly Report (MMWR). 53(SS07);1-57. Accessed electronically from  http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5307a1.htm on Jan 23 2016.

Wintemute, G.J., Parham, C.A., Beaumont, J.J., Wright, M., & Drake, C. (1999) Mortality among recent purchasers of handguns. New England Journal of Medicine. 341(21):1583-9

Cite this article as: MacDonald, D.K., (2016), "Means Restriction in Suicide Prevention," retrieved on July 16, 2018 from http://dustinkmacdonald.com/means-restriction-suicide-prevention/.
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Columbia Suicide Severity Rating Scale (C-SSRS)

The Columbia Suicide Severity Rating Scale (C-SSRS) is often considered the gold standard of suicide risk assessment (Giddens, Sheehan & Sheehan, 2014). It was developed in 2011 by a team from Columbia University and has been validated with both adult and adolescent populations (Posner, et. al., 2011)

Items in the C-SSRS

The C-SSRS can be downloaded here. It has the following categories and questions. Suicidal Ideation and Behaviour are scored as yes/no, while Intensity of Ideation and Actual Attempts are scored by points.

Suicidal Ideation

  1. Wish to be dead
  2. Non-Specific Active Suicidal Thoughts
  3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act
  4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan
  5. Active Suicidal Ideation with Specific Plan and Intent

Intensity of Ideation

  • Frequency
  • Duration
  • Controllability
  • Deterrents
  • Reasons for Ideation

Suicidal Behaviour

  • Actual Attempt
  • Has subject engaged in Non-Suicidal Self-Injurious Behavior?
  • Aborted Attempt
  • Preparatory Acts or Behavior
  • Suicidal Behavior
  • Completed Suicide

Answer for Actual Attempts Only

  • Actual Lethality/Medical Damage
  • Potential Lethality: Only Answer if Actual Lethality=0

Scoring

There are different scoring systems depending on the population. The important elements to note are that the higher the scores on the individual items and the more “yes” items, the higher the suicide risk. The C-SSRS training noted below lists high risk as being “ideation, a four or five in the past month; or any of the four behaviors in the last three months.”

Additionally, linked here are some scoring systems that can be used in various environments (community agencies, military, hospital inpatients, etc.)

C-SSRS Training

There is full training available online through the C-SRSS website.

Bibliography

Giddens, J.M., Sheehan, K.H., Sheehan, D.V. (2014) “The Columbia–Suicide Severity Rating Scale (C–SSRS): Has the “Gold Standard” Become a Liability?” Innovations in Clinical Neuroscience. 11(9–10):66–80

Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., & … Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial Validity and Internal Consistency Findings From Three Multisite Studies With Adolescents and Adults. American Journal Of Psychiatry, 168(12), 1256. doi:10.1176/appi.ajp.2011.10111704

Cite this article as: MacDonald, D.K., (2015), "Columbia Suicide Severity Rating Scale (C-SSRS)," retrieved on July 16, 2018 from http://dustinkmacdonald.com/columbia-suicide-severity-rating-scale-c-ssrs/.
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The Suicidal Affect-Behavior-Cognition Scale (SABCS)

The Suicide Affect-Behaviour-Cognition scale is a new public domain suicide risk assessment tool that has demonstrated ability to predict future suicidal behaviour. Individuals circle each response and sum up the results, with higher scores indicating greater risk. It’s important to note that no cut-off scores have yet been developed which may limit the utility of this tool.

Harris, K.M., Syu, J., Lello, O.D., Chew, Y.L.E., Willcox, C.H., Ho, R.H.M. (2015) The ABC’s of Suicide Risk Assessment: Applying a Tripartite Approach to Individual Evaluations. PLoS ONE 10(6): e0127442. doi:10.1371/journal.pone.0127442.

Instructions to test administrators. Present the scale as shown below, but without the item response scores. Administration is ideally done anonymously and in non-threatening environments. Note that time frames, italicized, may be altered. We would like to ask you some personal questions related to killing oneself. Please indicate the response that best applies to you.

  1. Have you ever thought about or attempted to kill yourself?
    1. Never (0)
    2. It was just a brief passing thought (1)
    3. I have had a plan at least once to kill myself but did not try to do it (2)
    4. I have attempted to kill myself, but did not want to die (3)
    5. I have had a plan at least once to kill myself and really wanted to die (4)
    6. I have attempted to kill myself, and really wanted to die (5)
  2. How often have you thought about killing yourself in the past year?
    1. Never = (0) (1) (2) (3) (4) (5) = Very Often
  3. In the past year, have you had an internal debate/argument (in your head) about whether to live or die?
    1. Never = (0) (1) (2) (3) (4) (5) = Frequently
  4. Right now, how much do you wish to live?
    1. Not at All = (5) (4) (3) (2) (1) (0) = Very Much
  5. Right now, how much do you wish to die?
    1. Not at All = (0) (2) (3) (4) (5) (6) (7) = Very Much
  6. How likely is it that you will attempt suicide someday?
    1. Not at All = (0) (1) (2) (3) (4) (5) = Very Likely

The authors of this tool also produced the following “risk barometer” to guide suicide risk assessment.

Suicide Risk Barometer



Cite this article as: MacDonald, D.K., (2015), "The Suicidal Affect-Behavior-Cognition Scale (SABCS)," retrieved on July 16, 2018 from http://dustinkmacdonald.com/the-suicidal-affect-behavior-cognition-scale-sabcs/.

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