7. NATIONAL EFFORTS OF SUICIDE PREVENTION

A national plan for suicide prevention is a systematic approach to set up a comprehensive and integrated national response to suicidal behaviour (Platt & Niederkrotenthaler, 2020). WHO recommends countries to have a national plan for suicide prevention (World Health Organization, 2021a). A strong rationale for a national plan is the fact that it enables the country to coordinate and prioritize efforts of suicide prevention. 

As many as 40 countries in the world may currently have a national plan for suicide prevention (Schlichthorst, et al., 2022). In the Nordic countries, Finland, Greenland, Iceland, Norway, Sweden, and Aaland Islands have national plans, which are currently in effect (Table 7.1). A plan has just been passed in the Greenlandic parliament and, in Denmark, funds for drafting of a national plan for suicide prevention have recently been allocated (Ministry of the Interior and Health, 2022). The main initiatives of the national plans are described in this section.

The WHO has provided guidance for development of national plans (World Health Organization, 2021a, World Health Organization, 2018). A national plan should apply a strategic and systematic approach. It needs to have clear objectives and further, it is important to specify targets, indicators, timelines, milestones, designate responsibilities and allocate financing. Although it may be anchored in the health sector, it is important that it involves multiple sectors, such as social welfare, education, law, defence, politics, and the media. For a sustainable effort, it will also be important to ensure long-term anchorage of new initiatives. As laid out in the LIVE LIFE guide by the WHO, a range of elements should be included or considered when drafting a national plan (see Box 7.1).

Source: World Health Organization (2018).

An increasing body of evidence exists regarding the effect of national plans of suicide prevention. A statistical meta-analysis of the suicide rate in the years prior to and after the introduction of national plans for suicide prevention in 29 countries revealed ambiguous findings; while the suicide rate decreased in some countries, it remained unchanged or increased in others. The overall result of the meta-analyses showed no significant difference between pre- and post-national plan with respect to suicide rates (Schlichthorst, et al., 2022). Data from Norway and Sweden were included in the analyses and, for both countries, no significant change was found. This is further supported by an assessment of the national plan introduced in Sweden in 2008, which was followed by slight increases in the suicide rates of different age groups (Baran & Kropiwnicki, 2015).

Although there may be limited evidence for the effectiveness of a national plan for suicide prevention, having a national plan is still a good idea. A comprehensive national strategy for suicide prevention will facilitate coordination and set priorities for target groups and goals. Being backed by the government, a national plan is likely to stand better chances of being implemented, as stakeholders and collaborators might be easier motivated. Of course, it is important to ensure that there is funding to carry out the proposed efforts.

This section provides an overview and summaries of the current status of national efforts for suicide prevention in each of the Nordic countries.

Based on stakeholder interviews, information on key elements regarding national suicide preventive efforts were collected from established researchers within suicide prevention in the respective countries.

Finland was one of the first country in the world to initiate national efforts for preventing suicide; in 1987-1988, a national psychological autopsy study was conducted to gain a better understanding of the reasons for suicide (Henriksson, et al., 1993). Now, the majority of Nordic countries and nations have a national plan for suicide prevention. Most countries have first issued national plans for suicide prevention within the last 20 years. Following the general guidelines, national plans tend to be multi-level and multi-modal, acknowledging the fact that suicide is a multi-factorial outcome and that different interventions may address different high-risk groups and that different strategies generally are needed.

An important aspect of the national plans is that they are backed by funding. If an ambitious plan is not supported by sufficient funds to secure its realisation, goals might not be reached. While some countries, have earmarked funds set aside for the national plan for suicide prevention, in other countries the goals of the national plan are expected to be achieved through existing and available resources, for instance, within mental health care. Despite similarities, the infrastructure and funding of mental health care differs across the Nordic countries. For this reason, it is not feasible to draw meaningful comparisons between the level of funds allocated to suicide prevention in the individual countries. In general, suicide preventive efforts tend to be anchored within public mental health care, while some services are provided by NGOs, which may be partly funded through public sources.

To ensure an effective and sustainable national effort, it is essential with long-term planning and allocation of funds. It might take years to ensure that new tools for suicide prevention are implemented into clinical or general practice. Evaluating what is sufficient funds, depends on the general support for mental health care and other funding mechanisms, which are allocated to related fields. In addition to implementing better practices, funds allocated for research may secure evidence-based documentation of effects. Although it is important to document the effectiveness of national plans on a whole, recent findings mentioned above illustrate that a first step might be to secure insights into what elements of a national plan are responsible for suicide reductions. The International Association of Suicide Prevention (IASP) has launched a worldwide network, Partnerships for Life, which facilitates communi­cation and collaboration of stakeholders (https://www.iasp.info/partnershipsforlife/).

In the Nordic countries, telephone helplines for suicide prevention are found in all countries. Many countries have several helplines for different target groups, for instance, children and youth as well as people with mental disorders, while countries with fewer inhabitants tend to have one a central helpline, which addresses all aspects of mental health. Health care providers, in particular psychiatric staff, are reported to be knowledgeable about risk assessment and safety planning. However, seemingly hardly any of the Nordic countries have follow-up routines for individuals who present with a suicide attempt in a somatic emergency department. As many as 16% of individuals who have a suicide attempt, repeat the act within the next 12 months and 1.6% with a fatal outcome (Carroll, et al., 2014). For this reason, it is important to ensure that support (and better coping strategies) are available for this group. In some countries, specialized outpatient teams provide psychosocial therapy for individuals at risk of suicide.

In those of the Nordic countries with a relatively small population, suicide intervention is indirect, and efforts focused mental health care in general. The fact that suicide is a relatively seldom phenomenon, for instance, in Faroe Islands, can introduce a different problem; people who experience suicide thoughts might not know where to find help due to little public awareness about suicide. Another challenge is seen in remote areas, for instance in Greenland where large geographical distances and relatively few psychiatric services means that individuals with a suicide attempt might have to travel very large distances for attending care. Further, psychological services might only be available in Danish, which could be a barrier for some.

People bereaved by suicide have themselves elevated risks of suicidal behaviour (Ranning, et al., 2022b). Although this is a well-recognised problem, much of the support for this group is placed in the hands of NGOs, e.g. through peer-support groups (Higgins, et al., 2022). First-responders, such as police and forensic medics, have relatively little experience with how to best provide support for bereaved by suicide. In Iceland, efforts to coordinate support after a loss to suicide is mentioned in the national plan for suicide prevention and one of the new initiatives include training of first responders. Similarly, the latest national plan for suicide prevention in Sweden identified bereaved by suicide as a priority area and guidelines for how to support bereaved by suicide have now been developed (Folkhälsomyndigheten, 2023).

Table 7.1 National suicide prevention.

^a There is a national helpline for mental health, which includes suicide prevention.

^b A helpline in Sweden is being used.

^c NGO-based support specifically for people bereaved by suicide is available.

^d NGO-based support for people bereaved by any cause of death is available.

^e NGO-based support for people affected by mental health

Denmark has previously had a national plan for suicide prevention during 1999-2005 (Sundhedsstyrelsen, 1998). One of the main achievements of this plan was the introduction of Suicide Prevention Clinics as a national offer for people at risk of suicide, which is situated in outpatient clinics (Erlangsen, et al., 2014). A National Partnership for Suicide Prevention was formed in 2017 under the auspice of the Danish Health Agency (The Danish Health Authority, 2017). In 2022, a 10-year plan for improvements in psychiatric care was passed in the Danish Parliament (Ministry of the Interior and Health, 2022). The plan included funds to draft a national plan for suicide prevention. During 2023, the National Partnership for Suicide Prevention was involved in developing the national plan and it is expected that the plan will be passed by the Danish Parliament in the coming year. The financial bill of 2024 has allocated funds for suicide prevention from 2024 to 2030.

In the Faroe Islands, suicides are relatively seldom, almost sporadic. The Faroese Health and Social Systems are parts of the Home rule agreement, but are situated under the Danish Health Authority, and the Faroe Islands follow Danish guidelines. There is no specific national plan for suicide prevention. Due to the few incidents, suicide preventive efforts are included in the more general health plans. This also applies to treatment options, telephone helplines, and other activities. Access to psychiatric care is free of charge for all. Since 2020, psychological therapy has become publicly subsidized for individuals aged 15-35 years. Support services consist of telephone helplines run by the Psychiatric Society (Sinnisbati) and by the Children’s Help Fund (Barnabati). For drug and alcohol misuse disorders, there are special treatment centers and help groups, run by  the two private organizations, Blue Cross (Bláikrossur) and Heilbrigdi (AA and Minnesota-model) as well as a shelter, run by Salvation Army (Frelsunarherurin). Religious affiliation is common and many churches offer informal social groups. On Faroe Islands, the extended family has a strong protective effect. Restrictive laws on access to medical products, illegal drugs other poisons, and to guns are similar to Danish laws. Restrictive rules exist regarding alcohol sales. Faroese have access to Danish helplines, including the one for suicide prevention (Livslinien).

Finland was the first country in the world to initiate national efforts for suicide prevention. The National Suicide Prevention Project (1986–1996) was overall found successful (World Health Organization, 2018). However, for over two decades after the pioneering project Finland had no national plan for suicide prevention. This changed in 2020, when The Mental Health Policy Strategy 2020-2030 was introduced. One of the sections included is the Suicide Prevention Program for 2020-2030. It consists of 36 measures, and proposals for monitoring of indicators. The main goals are to: 1) increase awareness among hospital staff regarding suicide attempt to lower stigmatisation, 2) apply means restriction, 3) ensure easy access to suicide preventive care, 4) make access to treatment for mental disorders uncomplicated and provide support for relatives, 5) ensure risks assessment of individuals with substance misuse disorders, 6) implement of media guidelines, and 7) monitor risk groups with regard to suicide and suicide attempt (Partonen, 2020). The Ministry of Social Affairs and Health also funds, via Finnish Institute for Health and Welfare, five regional suicide prevention projects.

In Greenland, the previous national plan expired in 2019. Gatekeeper training of Inuit frontline workers to provide tools for risk assessment and conversation techniques was one of the key components of the previous strategy (Bloch, et al., 2021). More than 500 frontline workers in all five municipalities have been trained through this course. The newly accepted national plan, Qamani, contains four target areas: 1) referral of people at risk of suicide; 2) engaging communities in suicide prevention; 3) improving mental wellbeing in schools; and 4) reducing stigma (Greenlandic Parliament, 2023). More specifically, the goals are to, firstly, set up chains of care to ensure that all individuals at risk of suicide have access to care, for instance by strengthening locals in the community. Secondly, provide psychoeducation and support regarding alcohol consumption. Thirdly, provide gatekeeper training for staff at schools and educational institutions. Fourth, initiate media campaigns to address stigma and tabu, for instance in television. The plan extends existing efforts to improve healthy pathways through life for young individuals in Greenland.

A major challenge in Greenland is the scarcity of mental health professionals. The large geographical distances can imply an unrealistically long travel distances, for receiving adequate care after a suicide attempt. To compensate, training strives to strengthen local community-based support options. Gatekeeper training is sustained through Inuit instructors who train gatekeepers in their mother tongue, kalaallisut, in regions where the majority speak the language (Kristensen, 2021). The initiatives are funded by a finance bill and are carried out in collaboration between the Government of Greenland, the Greenlandic municipalities and the Center for Public Health in Greenland.

The first National Suicide Prevention Plan was implemented in 2004 and was based on European Alliance Against Depression (EAAD) methods. The plan involved nationwide public campaigns, workshops in all the General Healthcare regions with a focus on stakeholders. A new national plan for suicide prevention was approved by the government in 2018 (Directorate of Health, 2018). The plan is divided into 6 chapters addressing all stages of prevention through 54 recommendations, which focus on mental health promotion, emphasizing increased skills in suicide prevention, support for the bereaved, and quality improvement in psychiatric services. The plan is currently being updated and a new version will be published in 2024. The Center for Suicide Prevention was recently established within the Directorate of Health, assuming responsibility of existing national prevention programs, developing new ones, in addition to leading research in this field. Suicide prevention projects are funded through general support for mental health care. There is provision for one project manager in suicide prevention. Iceland is a participant in the Postvention project Supporting the population in Artic. Iceland is co-operating on suicide prevention with JA ImpleMENTAL and the Nordic Suicide Prevention Research Network (NSRN).

The Norwegian Directorate of Health published the first national strategy in 1995. Since then, several editions of national strategies have been issued. In 2014, the national plan for suicide prevention consisted of 29 initiatives divided into 5 focus areas (Norwegian Directorate of Health, 2014). In 2020, a new plan was launched for the period 2020-2025, this time by eight ministries of the Norwegian Government introducing a zero vision for suicide in Norway (Departementene, 2020). The focus is on better and more systematic prevention, early and effective intervention for people at risk of suicide, support for people bereaved by suicide, and strengthen research, knowledge and competences regarding suicide prevention. For the first time national suicide awareness campaigns have been launched and carried out on a regional level. Many sectors of society, such as the health care systems, education systems, transportation sector, armed forces, child well-fare, work-life sector, integration services, mass media, social media and a range of non-governmental organizations have been involved in specific parts of the comprehensive strategy. In addition, several governmental organizations, such as the National Centre for Suicide Research and Prevention and the five regional centres, have been assigned tasks within the strategy.

The Swedish Parliament introduced the first national program for suicide prevention in 2008, consisting of nine strategic priorities. In 2020, the Government commissioned the National Board of Health and Welfare and the Swedish Public Health Agency to revise the national strategy (Public Health Agency of Sweden, 2023). Twenty-four other national authorities were commissioned to take part in the work and contributed to a proposal that is broad and cross-sectoral in nature. The strategy combines the earlier national action plan for suicide prevention and the national strategy on mental health. One of the strategy’s objectives is to strengthen suicide prevention efforts by prioritizing six areas: 1) Reduce social and economic risk factors associated with suicide; 2) Ensure safe health and social care for those at risk of suicide; 3) Coordinate response efforts during acute suicidal incidents; 4) Reduce access to methods and means of suicide; 5) Reduce stigmatisation and increase knowledge about suicide and suicidality; 6) Strengthen support for those bereaved after suicide. The new strategy for Mental health and Suicide prevention has been presented to the Swedish Government in September 2023.

Since 2020, Sweden has earmarked government stimulus grants for regions and municipalities to work with suicide prevention. Thus, there is at least one regional coordinator for suicide prevention in each of Sweden’s 21 regions. Much of their work is centred on coordination and project management, education and training efforts and awareness campaigns. Several government authorities have commissions specifically addressing suicide prevention, such as The Swedish Transport Administration, The National Board of Health and Welfare and the National Medical Products Agency. Some NGOs working in the field receive public funds. The National Centre for Suicide Research and Prevention at KI receives funds on a yearly basis. The Public Health Agency has a permanent assignment to coordinate suicide prevention on a national level. As coordinator, the Agency is responsible for networks of regional coordinators, NGOs and national authorities. It is also monitors development and provides knowledge about suicide and suicide prevention to both professional target groups and the general public.

Aaland has a programme for suicide prevention, zero vision, introduced in 2019 (Ålands landskapsregering, 2019). The plan consists of 43 different actions for e.g., health- and social care, police enforcement, municipalities/schools, media and government to prevent suicides in Aaland. Many of the actions in the programme have been implemented or are in progress as part of the regular activities, while some actions remain to be implemented. The intention is to realize the entire programme and implement all the actions, as stated in the recent government programme for 2023-2027 (Ålands Landskapsregering, 2023).