Suicide prevention means so much more than just stopping the act.
It's first and foremost about stopping people from contemplating the act, from reaching the point where they have the means and intent to harm themselves.
It's about tackling the root causes of suicide: mental illness, alcohol abuse, educational disadvantage, to name but a few.
It's about making health professionals more adept at spotting signs of suicidal intent in their patients. It's about encouraging people in need to look for help. It's about removing the stigma from depression.
It is, in other words, a complex task, a fact reflected by the report of the National Task Force on Suicide, a landmark study of the problems of suicide and para-suicide in Ireland. Published in 1998, the report makes more than 80 recommendations in the areas of prevention, aftercare and research, ranging from the establishment of an extensive network of community-based psychiatric services to restricting the availability of harmful medicines.
One of the most tangible outcomes has been the creation of a new post in each health board area - that of the regional suicide resource officer, whose task is to co-ordinate local anti-suicide initiatives.
Such projects are now beginning to flourish. The Southern Health Board, for instance, is currently training 50 staff in crisis intervention and hopes to have local response teams in place next month. It is establishing a suicide help-line for the region and is sponsoring a pioneering intervention study at Cork University Hospital. Under the research project, more than 200 people who have attempted suicide will be selected for a skills-training programme to test its effectiveness as a deterrent against further self-harming behaviour.
The Government has made £830,000 available to health boards this year for such suicide prevention programmes. A further £8.3 million has been allocated to developing community-based mental health services and £5 million for the expansion of child and adolescent psychiatry services.
In addition, the National Suicide Review Group, an overseeing body established in line with the task force recommendations, will receive £125,000. Apart from acting as an advisory body to the health boards, the review group is involved in sponsoring local initiatives. Many of the health board initiatives are targeted at primary care level - this largely because of statistics which show that up to 40 per cent of victims are in contact with GP or psychiatric services in the month before suicidal behaviour.
The North Eastern Area Health Board, for example, is piloting a GP training programme aimed at improving the diagnosis of mental illness. Resource officer for the area, Ms Theresa Mason, admits that "it's quite challenging to get GPs to buy into" such projects. Of 21 places at a multi-disciplinary training programme recently, she said, only one was filled by a GP.
She adds that, for those in her position, "it's very much at the awareness-raising stage. A lot of health professionals have not even heard of the task force report. So we're starting from there."
Dr Niall Maguire of the Irish College of General Practitioners stresses, however, that GPs "shouldn't be bashed on this. It's not as simple as saying that doctors are not responding to subtle signs of distress in their patients." A good GP has always taken mental health into account, he says. However, spotting signs of suicidal intent are more difficult "when you are having to see 50 people a day. Doctors are working in sub-optimal standards at the moment and the gap between what we know we should do and what we can do is widening."
Studies show that a GP will see at least three patients with severe depression each day but will encounter only one suicide every six years on average.
Dr Maguire notes there is a "slight tension" between GPs and psychiatrists on the issue and says he does not believe claims by a school of psychiatry that up to 40 per cent of people suffer clinical depression. "There is a slightly radical current about them that says everyone should be on Prozac. That is not to say the college does not entirely support efforts to prevent suicide as best we can."
Dr Pat McKeon, director of St Patrick's Hospital, Dublin, sympathises with the plight of GPs and says nothing less than a "root and branch" reform of the health services is necessary to combat suicide. "GPs are not properly resourced," he says. "For people presenting themselves at hospitals, there is limited follow-up. Child psychiatric services are very primitive. We don't have crisis intervention facilities."
A longer-term need, he says, is the introduction of life-long emotional education programmes, starting in primary school. "Education is a key issue. We need to start learning about ourselves emotionally."
For Prof Patricia Casey, professor of psychiatry at UCD, tackling alcohol abuse is where the priority lies. Citing a number of recent European studies, which show alcohol abuse is at least as prevalent in suicide victims as mental illness, she says "there is no point telling GPs what to do, or anything else for that matter, if one of the biggest factors is not being addressed. You might as well be whistling in the wind."
Dr John F Connolly of the Irish Association of Suicidology says the "only effective prevention measures which are really evidence-based are the early recognition and assertive treatment of depression, and the introduction of a sane alcohol policy. They are the two more immediate things we can do. The other options are more vague and unspecific."
Controlling means of suicide, he notes, is very difficult in this country, given that drowning and hanging are the most common methods used. One measure which could help, however, is restricting the size and distribution of paracetamol packs, as recommended by the Irish Medicines Board and the task force report.
"Ironically, the UK has taken on board our recommendation on this, and enforced it, while we have ignored it," said Dr Connolly.
Finally, he said there was a need for an integrated national strategy which included targets for reducing suicide and para-suicide. On this, all practitioners in the area are agreed.
"Initially, maybe the task force report was seen as a strategy," says Mr Derek Chambers of the National Suicide Review Group. "But in retrospect people working in suicide see it as only a draft form. It does not involve time scales or map out who is responsible for certain aspects of prevention. That needs to be done now."