A new resource: Activating community assisted suicide prevention

Much important work has been done in suicide prevention and yet most indicators reveal little improvement in the alarming statistics. Suicide rates are escalating, and a major challenge is to prevent the progression from suicidal thoughts to attempted or completed suicide. Whilst many initiatives are in place, few if any have targeted ‘upskilling’ family and friends. There will never be enough mental health professionals available, especially after-hours when most suicides and attempted suicides occur.

InToughTimesText.org is a cost-free innovation developed by the Australian Suicide Prevention Foundation (ASPF and is a bank of hundreds of text messages, typical of the phrases used by professionals, which can be automatically downloaded onto the phones of family and friends, as texts or WhatsApp messages. These can be sent frequently by them to the suicidal person. In this way, the people closest to the person in need become an immediate safety net enveloping the person talking about death and are armed with the right words when facing these emergency situations.

Clinical Associate Professor David Horgan

Founder/Medical Director of the Australian Suicide Prevention Foundation.

Read more below.

The messages on www.InToughTimesText.org include:

  • ‘What to Ask’ (“Do you wish you did not wake up in the morning?”, “How bad is the emotional pain?”),
  • ‘What to Say’ (“You would never advise a friend to die; tell yourself what you’d tell a friend”, “Is there anyone close to you whose suicide would not distress you?”), and
  • ‘What to Do’ (“Please talk; it helps reduce the pain”, “I will keep texting you until this crisis passes”). 

    These messages can be modified by the sender, who may wish to establish a WhatsApp group, supportive for all involved. InToughTimesText.org also includes lived experience stories and summarises national crisis services (which can be upgraded to show crisis services in multiple countries).

    Social support

    Research in USA and UK has shown that social support is associated with a decreased likelihood of a lifetime suicide attempt. Intensive and ongoing text contact combats lack of connectedness, a known risk factor for suicide. Empowering family and friends to consistently send meaningful and personal texts brings unique and emotive forces to bear in life and death situations. 

    Intensive and ongoing text contact combats lack of connectedness, a known risk factor for suicide.

    The most influential people in the patient’s life can become a persuasive safety net around the suicidal patient. On clinical grounds, this reduces suicide risk immediately, both before and in-between any professional contacts. The fear and powerlessness experienced by many people in the community listening to suicidal thoughts in a person they care about can be replaced by guided persistent intervention, especially outside normal professional hours

    The fear and powerlessness experienced by many people in the community listening to suicidal thoughts in a person they care about can be replaced by guided persistent intervention, especially outside normal professional hours

    Family and friends using InToughTimesText.org 

    Advocating for the use of InToughTimesText.org by family and friends, (with the patient’s consent), and encouraging them to communicate directly with the patient, lessens the burden of being the responsible professional in a life-threatening situation. Instead, a professional/community team is created, adding intensely meaningful persuasion to usual professional care, with shared involvement in the outcome. This cooperative sharing of care and outcome has many benefits for all involved.                                                                                                                  

    This simple-to-use service can be replicated in multiple languages and cultural settings. The face validity of this cost-free new tool, which does not require training to use it, needs to be researched to prove and maximize its potential. There is no cost to anyone for this service, and no cost to the health services, available 24/7 if people know about it. 

    More facts on suicide

    • More than 700,000 people die by suicide worldwide each year.
    • Over one in every 100 deaths (1.3%) in 2019 were the result of suicide. A busload of Australians die each week from suicide, and a plane load of Australians attempt suicide each day.
    • Two to three times as many men die by suicide compared to women (12.6 per 100.000 men compared with 5.4 per 100.000 women) while 75% of suicide attempt survivors are female in the Western world.
    • Over half (58%) of all deaths by suicide occur before the age of 50 years old. 
    • Suicide occurs across all regions in the world, however, over three quarters (77%) of global suicides in 2019 occurred in low- and middle-income countries. 
    • Every year, more people die by suicide than by HIV, Malaria, breast cancer, war, or homicide. 
    • An individual suffering with depression is twenty times more likely to die by suicide than someone without the disorder, especially if they have required hospitalisation.
    • Suicide remains illegal in over 20 countries, while people who engage in suicidal behaviour may be punished in some countries that follow Sharia law, involving legal penalties that range from a small fine or short prison sentence to life imprisonment. 

    Spotting the signs of suicidality could allow a concerned friend, colleague or loved one to start a conversation with the individual at risk and begin taking action to help them. 

    Suicide is a global health issue that may, in many cases, be prevented. In a study of people who died by suicide, half had visited a healthcare facility in the four weeks prior to their death, though only 24% had a visit related to a mental health diagnosis. Spotting the signs of suicidality could allow a concerned friend, colleague or loved one to start a conversation with the individual at risk and begin taking action to help them. 

    Spotting the signs: Tips from a frontline psychiatrist

    To avoid “crying wolf”, it is useful to avoid common depressive symptoms as indicating the statistically much less frequent characteristics of suicidal thinking, while accepting unfortunately that none of our suicide risk rating scales is reliably effective in clinical practice.

    Although the signs of suicidality are complex and diverse, there are key underlying themes. People with suicidal ideation may adopt thought patterns in which suicide appears to be the only viable option. People who feel suicidal are sometimes vocal about their internal conflict, stating that they feel useless or hopeless, or that they see “no point in living”.

    Other suicide warning signs may include: 

    • A previous suicide attempt, especially in the previous year
    • Hopelessness about recovery
    • Parting with personal effects (especially a young person)   
    • Tidying up suddenly
    • Giving presents unexpectedly
    • Organising paperwork relevant for after death (e.g. wills)
    • Meaningful “Goodbyes” or sudden calmness
    • Fighting with a therapist! “Terminal malignant alienation”

    Which groups are at risk? 

    Suicide affects people of all ages. While the highest suicide statistical rates are in older age groups, in younger people, suicide is the commonest cause of death in males or females in Australia under the age of 45. The vast majority of attempted suicides are in the same age group.

    Suicide disproportionately affects the lesbian, gay, bisexual, and transgender community, attributed to factors such as family rejection, victimization, and stigma. 

    Immigrants and ethnic minorities may also be more likely than the general population, to experience suicidal behaviour with language barriers and family separation acting as additional risk factors, described as “anomie” by the sociologist Durkheim.

    Negative life experiences 

    Stress is a factor in suicidal behaviour, influencing sleep, impulsivity, and executive function. Suicidal behaviour in a relative is linked to future suicide attempts and childhood trauma can lead to suicidality decades later. 

    Financial strain, in the form of lower-income, debt, unemployment or past homelessness, is also significantly associated with suicide. Individuals experiencing all four of these factors have a 20-times greater risk of attempting suicide than someone facing no financial strain. 

    What can you do if you think someone has thoughts of suicide? 

    InToughTimesText.org gives multiple texts or questions and suggestions appropriate to this situation.

    Being supportive and demonstrating you care about the mental health of a person at risk can play a part in preventing suicide. In fact, if you think someone is at risk for suicide, do not shy away from the topic.

    Approaching the situation diplomatically and escalating the questions as necessary is easier for all involved. Questions can include:

    • “Do you wish you did not wake up in the morning?”
    • “Do you actually wish you were dead?”
    • “How strong are these thoughts? Weak, medium, strong?”
    • “Have you thought of doing something to yourself?”
    • “How strong are these thoughts on a 0-10 scale?”

    Listen calmly 

    • Acknowledge the person’s feelings 
    • Express that the person’s thoughts are accepted and respected 
    • Communicate with concern and warmth 
    • Respond openly and honestly 

    After a connection has been established, questions can be asked to assess the person’s safety. Do they have the means to end their life? Have they made plans to end their life? Do they know when they are planning to do this? Asked with care and concern, these questions can inform subsequent preventative steps, such as removing access to the means of suicide and implementing a support strategy. 

    “Help when it's critical” on www.InToughTimesText.org gives specific advice relevant to more worrying scenarios.

    The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

    Clinical Associate Professor David Horgan

    Clinical Associate Professor David Horgan completed his medical education in Dublin and Edinburgh.  He has 6 specialist qualifications in psychiatry. He moved to the University of Melbourne and to the Royal Melbourne Hospital. He is mainly involved now in private practice, particularly treating resistant depression and high suicide risk on an outpatient basis on referral from other psychiatrists.

    • He is best known in Australia for his research and writings about combining antidepressants,
    • He founded the charity Australian Suicide Prevention Foundation.
    • He is now advocating more radical approaches by doctors to suicide prevention (www.intensivesuicideprevention.com).

    In the face of 100,000 attempted suicides annually, his charity is launching a world-first suicide prevention initiative called InToughTimesText.org, providing hundreds of medically approved texts for family and friends to intervene early when anyone mentions suicide, and to supplement any available professional input.


    AU-HLU-0015. November 2021

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