This public health approach recognizes that a person’s risk of suicide is profoundly influenced by the social, economic, and environmental conditions in which they live. Factors like poverty, unemployment, social isolation, and access to lethal means all play a crucial role. Importantly, these social determinants don’t just impact individuals – they create systemic inequities that disproportionately expose certain groups, such as ethnic minorities and the socioeconomically disadvantaged, to elevated suicide risk.

“Suicide is not just a mental health issue – it’s a societal issue,” says Jane Pirkis, professor of public health at the University of Melbourne and lead author of a new Lancet Public Health Series on a public health approach to suicide prevention. “We need to think beyond the individual and address the broad social factors that are driving suicide in our communities.”

Shifting the Paradigm

Historically, suicide prevention efforts have focused heavily on clinical interventions, such as mental health treatment and crisis hotlines. While these approaches remain important, they fail to address the root causes that shape suicide risk at a population level.

“The public health model recognizes that individuals don’t exist in a vacuum – their health is shaped by the social, economic, and political contexts in which they live,” explains Pirkis. “So we need to expand our focus beyond the individual and look at how these broader societal factors are driving suicide.”

This shift in perspective is crucial, the authors argue, because the greatest reductions in suicide are most likely to come from public health measures that target the whole population, rather than just those deemed to be at high individual risk. As the epidemiological principle known as “Rose’s Paradox” suggests, small changes across an entire population can have a bigger impact than large changes in high-risk individuals.

“There will never be enough mental health professionals to provide one-on-one treatment to everyone who is suicidal,” says Pirkis. “We need to think about how we can favorably shift the risk factors for suicide across whole communities, not just focus on those deemed to be at the highest risk.”

A Model for Change

The public health model presented in the Lancet Series outlines how suicide arises and how it might be prevented through a combination of universal, selective, and indicated interventions (see Figure 1).

At the foundation of the model are the social determinants of suicide – the macroeconomic policies, public policies, social policies, and regulatory frameworks that shape the circumstances in which people live, work, and age. These social determinants have a direct or indirect impact on key individual-level risk factors, such as socioeconomic status, access to means of suicide, and exposure to stressful life events.

Importantly, the model also highlights the role of commercial determinants – the actions of industries like the firearms, pesticides, alcohol, and gambling sectors, which can heighten suicide risk through the products and services they provide.

“These commercial actors often dominate the public discourse, normalizing or glamorizing the use of their potentially lethal products,” says Pirkis. “They can also influence decision-making processes to ensure their products remain easily available, even when the harms they cause are well-known.”

The model suggests that these social and commercial determinants should be addressed through universal interventions that target the whole population. These might include policies to reduce poverty and financial hardship, such as universal basic income or debt relief programs; measures to limit access to means of suicide, like bans on highly toxic pesticides; and efforts to strengthen social cohesion and support, such as community-based mental health programs.

Alongside these universal approaches, the model also emphasizes the importance of selective interventions that target individuals who may be predisposed to suicide in the future, as well as indicated interventions for those already experiencing suicidal thoughts or behaviors. Examples could include financial counseling, addiction treatment programs, and crisis support services.

The key, the authors argue, is striking the right balance between these different levels of intervention – ensuring that efforts to support high-risk individuals are complemented by bold, population-level actions to address the underlying social and commercial drivers of suicide.

“We need a comprehensive, whole-of-society approach that tackles suicide at its source,” says Pirkis. “That means going beyond the health sector and engaging a much broader range of stakeholders – from government, to the private sector, to community organizations.”

Barriers and Opportunities

Putting this public health model into practice, however, is not without its challenges. One of the biggest hurdles is the way suicide prevention is currently framed and implemented in many countries, particularly low- and middle-income nations.

“In a lot of places, suicide is still very much seen as a mental health issue that should be addressed solely within the health care system,” says Rakhi Dandona, a co-author of the Lancet Series and public health researcher at the Public Health Foundation of India. “There’s often insufficient attention paid to the broader social determinants that are driving suicide risk.”

This narrow focus can be compounded by the criminalization of suicide in some countries, which further entrenches the perception of suicide as an individual moral failing rather than a complex social problem. Even where suicide has been decriminalized, Dandona notes that “legislative changes don’t always translate to changes on the ground, and suicide continues to be dealt with in a medico-legal context.”

Overcoming these barriers will require a fundamental shift in how suicide is perceived and addressed at the policy level. The Lancet Series authors call for a “policy reset” that would transform national suicide prevention strategies into whole-of-government endeavors, with buy-in and ownership from sectors beyond health.

“Suicide prevention can’t just be the responsibility of the health ministry – it needs to become everybody’s business,” says Pirkis. “We need to see national strategies that engage a much broader range of stakeholders, from finance and social services to education and industry.”

Crucially, this shift must be underpinned by high-quality data and rigorous evaluation. Existing suicide data are often outdated, incomplete, and lacking in detail, making it difficult to identify emerging trends and target interventions effectively.

To address this, the authors highlight the importance of establishing real-time surveillance systems and suicide registers that can capture more granular, timely information on the circumstances surrounding deaths by suicide. Such systems, already in use in some countries, can provide a much clearer picture of the problem and help guide the development of tailored, evidence-based interventions.

“Good data is the foundation of the public health approach,” says Pirkis. “Without it, we’re flying blind when it comes to understanding the scope of the problem and evaluating the impact of our prevention efforts.”

Promising Practices

Despite the challenges, there are already examples of countries and communities taking a more holistic, public health-oriented approach to suicide prevention. One notable example is Scotland’s new 10-year suicide prevention strategy, “Creating Hope Together.”

Launched in 2022, the strategy places a strong emphasis on addressing the social determinants of suicide, with a focus on tackling issues like poverty, debt, addiction, homelessness, and social isolation. Crucially, it takes a whole-of-government approach, with the Scottish Government and the Convention of Scottish Local Authorities jointly leading the effort and engaging a broad range of stakeholders, including the private sector and community organizations.

“The strategy recognizes that suicide prevention can’t be the responsibility of the health sector alone,” says Pirkis. “It’s about bringing together different parts of government and society to tackle the root causes of suicide.”

Another promising example comes from Brazil and Indonesia, where conditional cash transfer programs have been shown to have a significant impact on reducing suicide rates. These programs, known as Bolsa Família in Brazil and Program Keluarga Harapan in Indonesia, provide financial assistance to low-income households, helping to mitigate the effects of poverty and economic hardship.

Ecological studies in both countries have found that areas with high coverage of these cash transfer programs experienced substantial reductions in suicide, illustrating the powerful role that social safety nets can play in suicide prevention.

“These programs don’t specifically target suicide, but by addressing the social determinants of health, they’re able to have a meaningful impact on suicide rates,” says Pirkis. “It’s a great example of how policies outside the health sector can contribute to suicide prevention.”

Looking Ahead

As the world grapples with the fallout of the COVID-19 pandemic and the looming threat of a global economic recession, the need for a comprehensive, public health-oriented approach to suicide prevention has never been more urgent.

“We know that economic downturns and financial hardship can have a devastating impact on suicide rates,” says Morton Silverman, a co-author of the Lancet Series and professor of psychiatry at the Medical College of Wisconsin. “So it’s critical that we have the right policies and interventions in place to mitigate these risks.”

The public health model presented in the Lancet Series offers a roadmap for how governments, policymakers, and communities can take on this challenge. By addressing the social determinants of suicide, strengthening data and evaluation, and fostering a whole-of-society approach, it holds the promise of making significant strides in reducing the global burden of this preventable tragedy.

“Suicide is a complex problem that requires a multifaceted solution,” says Pirkis. “But if we can shift our mindset and start tackling the root causes, I believe we can make real progress in saving lives and building healthier, more resilient communities.”

Pirkis J, Gunnell D, Hawton K, et al.

Figure 1: A Public Health Model of Suicide Prevention Adapted from originally Pirkis J, Gunnell D, Hawton K, et al. A public health, whole-ofgovernment approach to national suicide prevention strategies.Crisis 2023; 44: 85–92.

This model outlines how suicide arises and how it might be prevented through a combination of universal, selective, and indicated interventions. At the foundation are the social determinants – macroeconomic policies, public policies, social policies, and regulatory frameworks – that shape individual-level risk factors and create inequities in suicide risk. The model also highlights the role of commercial determinants, such as the firearms, pesticides, alcohol, and gambling industries.

Universal interventions target the whole population, addressing social determinants through policies like universal basic income, restrictions on means of suicide, and efforts to strengthen social cohesion. Selective interventions target individuals who may be predisposed to suicide in the future, while indicated interventions support those already experiencing suicidal thoughts or behaviors.

Key to the success of this public health approach is high-quality data and rigorous evaluation to guide the development and implementation of effective, evidence-based interventions.