摘要：Although not a disease, suicide is a tragic endpoint of complex etiology and a leading cause of death worldwide. Just as preventing heart disease once meant that specialists treated myocardial infarctions in emergency care settings, in the past decade, suicide prevention has been viewed as the responsibility of mental health professionals within clinical settings. By contrast, over the past 50 years, population-based risk reduction approaches have been used with varying levels of effectiveness to prevent morbidity and mortality associated with heart disease. We examined whether the current urgency to develop effective interventions for suicide prevention can benefit from an understanding of the evolution of population-based strategies to prevent heart disease. As for suicide. . . it is one of the leading causes of death in the world. World Health Organization, 2002 1 Worldwide, there has been a call to reduce the substantial mortality and morbidity burden associated with suicide and suicidal behavior through sweeping, national strategies. 2– 5 This development comes within an environment where there have been meager public health attempts to reduce these burdens, even while the limitations of high-risk approaches have been noted for some time. 6 Suicide prevention has narrowly focused on identifying proximate, individual-level risk factors, rather than thinking about population mental health in terms of complex social and ecological relations. 7 In 1969, at a time when the epidemiology of the risk factors for cardiovascular disease (CVD) was just beginning to be discovered (and debated), Caroline Bedell Thomas observed that “in both suicide investigations and cardiovascular studies, lifetime habits and personality factors are brought into focus as predictors of disease and death,” and that “certain precursors of suicide, accident, fatal heart attack and fatal stroke are already present and can be identified in youth , many years before the event.” 8(p282–283) Thomas further noted that while suicide prevention was in its infancy, the “preventive approach” already had been found to be effective at reducing the incidence of the most frequent cause of premature death, coronary heart disease. Public health approaches to reduce incidence coupled with clinically oriented efforts to prevent death from CVD have made significant advances in some populations since 1969, evidenced in the United States by the decline in the incidence of heart disease between 1970 and 1990 and significant reductions in mortality. 9 Prevention of CVD stands as an example of how clinicians and epidemiologists collaboratively approached overcoming the limitations of applying a purely biomedical approach to a disease whose origins are largely societal. This collabortion reflects a basic principle of the population risk reduction approach, one that many feel remains viable for preventing CVD despite the observation that declines in incidence rates stagnated during the 1990s. 10 If the basis of CVD is social and economic, the solution to the CVD epidemic has to be social and economic. 11, 12 Comparatively speaking, there have not been similar reductions in rates of depression or violence that potentially would contribute to preventing deaths due to suicide. It has only been in the past decade in the United States, with resolutions in Congress and reports from the surgeon general, that suicide prevention has been widely recognized as a problem requiring national attention and urgent action. While not a disease with a well-defined disease mechanism, suicide is nonetheless an extraordinarily adverse outcome. It reflects diverse risk factors and, like heart disease, is best understood within a complex paradigm of social, behavioral, and psychiatric factors. To the extent that efforts to reduce CVD and its precursors in some populations have risen to the challenge of preventing a disease that, like suicide, is the result of complex population processes, interdependencies, and multilevel causality, we consider these efforts to be a useful model for suicide prevention. We revisit the question raised by Thomas of whether we can learn to prevent suicide, but now within the (albeit imperfect) framework of prevention of CVD during the last 50 years.
