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Abstract
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dvances in injury prevention and control are among the most important public health achievements in the US in the past century.1 However, progress in injury prevention and control is largely limited to reductions in fatalities from unintentional mechanisms, such as motor vehicle crashes, occupational mishaps, drowning, and fires and burns. There is little success in preventing intentional injuries, in particular self-injury. In fact, suicide rates in the US have remained at a high level for many decades and have trended upward in recent years.2 The stagnation in suicide prevention is not for lack of trying.3 In light of the ongoing COVID-19 pandemic, the worsening opioid crisis, and the rising prevalence of depression and other mental health problems, the study by Bandara and colleagues4 offers a glimmer of hope and a window of opportunity for rethinking suicide prevention.
Many self-injury acts are impulsive behaviors taking place during an emergent personal crisis. Limiting the access to lethal means, particularly through environmental modification and engineering, is one of the few interventions with proven effectiveness to reduce suicides. For instance, studies from different countries have shown that installing physical barriers in bridges could reduce suicides in these hotspots by over 90%.5 Interventions targeting suicide hotspots, however, are often hindered by 2 concerns: the potential substitution effect and the economic costs. The substitution effect refers to the possible shifting of suicides from treated hotspots to untreated neighboring sites or other means. Although research indicates that there is no measurable increase in suicides in untreated neighboring sites following the installation of physical barriers in bridges, it is less clear to what extent shifting to other means, such as firearms and medications, may occur. Given that hotspots account for only a small fraction of the total suicide mortality, it is difficult to dispel the concern about the potential substitution effect. Evidence from other studies, however, indicates that the substitution effect, if it does factor into outcomes, is unlikely to entirely offset the effect of interventions that limit the access to lethal means. A case in point is the marked decline in suicide rates in China in the past 2 decades, after the government tightened regulations about the production, sale, and storage of highly lethal pesticides that were often used for committing suicide in rural areas.6
The Bandara et al study4 provides valuable evidence for addressing the second concern about hotspot-based interventions to reduce suicides. Using standard health economics methods, the authors estimated the costs saved and the return on investment associated with the installation of physical barriers at 26 bridge and cliff sites identified as suicide hotspots in Australia. Their results indicate that the intervention at the 7 bridge sites alone would save US $270 million over 10 years, with a return-on-investment ratio of 2.4. Moreover, their sensitivity analyses suggest that the intervention would remain cost-effective under assumptions of inflated maintenance costs. It is worth noting that the estimated cost-effectiveness results reported by Bandara et al4 are likely conservative because the intervention costs were based on retrofitting physical barriers in the identified suicide hotspots and because reductions in injuries and fatalities from unintentional falls resulting from the installation of physical barriers in the study sites were not included in the intervention effect. In general, it is costlier to remedy an environmental hazard through retrofitting than to eliminate the risk by design during the planning phase. Fortunately, as pointed out by Bandara et al,4 installation of physical barriers in bridges, cliffs, and other hotspots has become the best practice for suicide prevention in Australia, England, and Scotland. Progress is also evident in the US; fences and safety nets have been installed in the Golden Gate Bridge and the George Washington Bridge after hundreds of people ended their lives by jumping off these bridges. Furthermore, the concept of safety by design is being increasingly adopted by civil engineers, as demonstrated by safety fences in the newly constructed Governor Mario Cuomo Bridge over the Hudson River in New York...
Language: en |