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Post by Former NIMH Director Thomas Insel: The Under-recognized Public Health Crisis of Suicide

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September 10 is World Suicide Prevention Day. In 2007, the most recent year for which we have statistics, 34,598 Americans died by suicide—about 11 suicides per 100,000 people, according to the Centers for Disease Control and Prevention.1 We know from the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Survey on Drug Use and Health (NSDUH) that in 2008, about 3.7 percent of people had serious thoughts of suicide, and about 1 percent actually made suicide plans. Over the past decade, the overall rate of suicide has not declined, although there have been slight decreases in the young and elderly, offset by a compensatory increase in suicide for people between 24 and 65.

What has research revealed about suicide prevention? One approach, sometimes called selective or indicated prevention, has focused on identifying people at risk. About 90 percent of suicides are thought be associated with mental illness -- and certain forms of illness, such as depression and PTSD, increase the risk several fold. Perhaps no risk factor is greater than having previously made an attempt; the mortality rate from suicide is 10-15 percent following a non-fatal suicide attempt.2

Studies have shown that treating mental illness with either medication or psychotherapy can reduce the rate of suicide. Lithium has been shown to reduce suicide among those with mood disorders, and clozapine has been reported to reduce suicide in people with schizophrenia.3 In terms of psychotherapy, dialectical behavior therapy reduces suicide attempts in young women with borderline personality disorder, and a form of cognitive behavior therapy for those seen in emergency rooms for suicide attempts reduced re-attempts by 50 percent over the subsequent year.4, 5 But surprisingly, while epidemiological evidence demonstrates that treatment of mental illness has increased over the past two decades, suicide rates have not decreased. Is this because the treatments being used are not those shown to be effective? Or is suicide occurring in people who are not treated? It is likely that both of these possibilities contribute to the persistent high rate of mortality and high rate of suicide attempts.

A second prevention approach called universal prevention aims to decrease suicide by broad public education and enhancing protective or mitigating factors. Restricting means of suicide (e.g. firearm safety and bridge barriers), developing suicide hot lines and school programs are all approaches that have been developed to reduce the rate of suicide. Since 2005, SAMHSA has administered more than $100 million in grants from the Garrett Lee Smith Memorial Act to fund programs for young people aimed at reducing violence and suicide.

In one sense, public health preventive interventions can be thought of as “upstream” from selective interventions, essentially trying to prevent the development of risk factors. While there have been examples of the efficacy of a public health approach, such as changes implemented in the Air Force in 1998, the durability and the magnitude of effects remain to be tested. Indeed, for some of the most widely used interventions, such as school education programs focused on gatekeepers, there is still no data to support any impact on mortality.

Looking at the history of preventive approaches to suicide, what is perhaps most surprising is the lack of results relative to concurrent reductions in mortality from cardiovascular disease, stroke, homicide, and auto accidents. One might fairly conclude that suicide is fundamentally a more difficult public health problem, and far less understood. Indeed, we still know very little about risk at the individual level. Individual risk is defined best via prospective research, as the Framingham Study did for cardiovascular mortality. The Army STARRS Study is designed to follow prospectively large numbers of soldiers at risk to define individual profiles of risk and resilience as done previously for heart disease. We know too little about detecting suicidal risk even in the emergency room. The Emergency Department Safety Assessment and Follow-up Evaluation (EDSAFE) trial, based at Massachusetts General Hospital, began this summer and will be conducted at eight sites throughout the nation. The researchers will evaluate a universal screening process in which all patients, regardless of their psychiatric status, will be screened for suicidal ideation. And we know very little about optimizing hot lines or social networking interventions. Funds from the American Recovery and Reinvestment Act made possible an important grant to evaluate the effectiveness of a new training program for telephone crisis counselors. Led by SAMHSA, the evaluation will afford us an important opportunity to ensure that counselors staffing the National Suicide Prevention Lifeline are doing the best job possible to help those in crisis.

But aside from these individual NIMH-funded efforts, we now have an opportunity for a coordinated, full court press across Federal agencies. With the announcement of a new Alliance for Suicide Prevention on Sept 10, 2010, NIMH will join with its HHS partners for a fresh push on research, policies, and practices that will reduce suicide. For this effort to succeed, we will need both selective and universal prevention. We will need more evidence, we will need more implementation of the existing evidence, and we will need more integration of science and service. All of this will be essential if we are to bend the curve, ensuring that suicide deaths decrease dramatically in the next decade.

1 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS).

2 Suominen K, Isometsä E, Suokas J, Haukka J, Achte K, Lönnqvist J. Completed suicide after a suicide attempt: a 37-year follow-up study. Am J Psychiatry. 2004 Mar;161(3):562-3.

3 Cipriani A, Pretty H, Hawton K, Geddes JR. Lithium in the prevention of suicidal behavior and all-cause mortality in patients with mood disorders: a systematic review of randomized trials. Am J Psychiatry. 2005 Oct;162(10):1805-19.

4 Meltzer HY, Alphs L, Green AI, Altamura AC, Anand R, Bertoldi A, Bourgeois M, Chouinard G, Islam MZ, Kane J, Krishnan R, Lindenmayer JP, Potkin S; International Suicide Prevention Trial Study Group. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry. 2003 Jan;60(1):82-91

Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim M. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006 Jul;63(7):757-766.

5 Brown GK, Have TT, Henriques GR, Xie SX, Hollander JE, Beck AT. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294:563-570.