Post by Former NIMH Director Thomas Insel: Preventing Suicide, One Employer at a Time
In spite of new treatments, more treatments, and more people getting treatment for mental illness, the suicide rate has not decreased in America. The most recent statistics from the CDC report over 36,000 suicides annually, nearly 100 per day in this country. That is twice the rate of homicide and even higher than the number of traffic fatalities—two major causes of death that have, in contrast to suicide, dropped considerably in recent years. To address this urgency, a major public-private initiative, the National Action Alliance for Suicide Prevention, has been addressing the complexity of suicide and what must be done to reduce the rate. One of the major actions of the National Action Alliance is to work with leaders in suicide prevention to complete the first major revision to the National Strategy for Suicide Prevention in more than ten years. Before the revised plan is announced, some important developments are worth highlighting.
Recently the NFL launched a 24/7 wellness program—the NFL Lifeline—for current and former players that will address not only players’ physical health, but also their mental health. This initiative comes in the midst of several recent suicides of prominent former players. The NFL is one high-profile example of an employer taking a proactive approach to suicide prevention, doing so in a way that follows best practices in raising public awareness about suicide. Heeding lessons learned from the Military Crisis Line, the NFL Lifeline provides confidential and competent support for those in crisis. It exists as a component of the National Suicide Prevention LifeLine which is available to anyone in crisis, and is supported by the Substance Abuse and Mental Health Services Administration (SAMHSA).
These kinds of efforts are essential, and preliminary research supports the notion that crisis lines are indeed effective in reducing callers’ distress.1 But we know that crisis services alone are not sufficient for preventing suicide. Many individuals who are thinking about suicide--both civilians and service members alike—have seen a health care provider prior to their suicide deaths.2, 3, 4 In some cases, they communicated their distress to the provider, but did not receive sufficient care. In other cases, they were not asked about possible distress. Undetected risk and untreated depression are critical issues in primary care, especially for older men who may seek help for medical but not emotional distress and yet die by suicide at a six-fold higher rate than the general population.
The Department of Veterans Affairs (VA) has recognized these opportunities in primary care for suicide prevention and aims to implement evidence-based treatments for preventing suicide and addressing the risk factors that precipitate the act. For instance, the agency’s Translating Initiatives for Depression into Effective Solutions (TIDES) project—a collaborative approach to depression management within primary care settings—has proven successful in the VA healthcare system.5 The military is also implementing similar efforts, such as Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) for detecting and treating depression and PTSD in primary care settings.
How well these initiatives will succeed remains to be seen. In truth, preventing suicide may prove much more difficult than preventing homicide or traffic fatalities. We don’t know enough about risk and resilience and we don’t have the equivalent of airbags and seatbelts for preventing suicide. So there is clearly a need for better science. I have described before the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) -- a partnership between the U.S. Army and NIMH -- which is examining how suicide risk evolves, who is most at risk, and who is resilient and why. This is our largest study at NIMH, already involving 80,000 soldiers. The goal is to determine the best ways to mitigate suicide attempts and deaths among Army personnel, and ultimately among the civilian population as well.
The NFL initiative reminds us that no group is exempt from suicide. Press reports of suicide in football players and our Service members have suggested that head trauma is a risk factor. However, science tells us that suicide results from a complex set of factors and that suicide prevention will require a broad approach involving health care providers, families, and employers. The NFL has sent an important message to get help, stay connected to those supporting you, and maintain hope as we work to determine additional, effective ways to prevent self-inflicted deaths.
1 Gould M, Munfakh JLH, Lake A, Kleinman M, Kalafat J. A Successful Collaboration Among Evaluators, Crisis Centers and the Federal Government: Summary of Crisis Center Evaluation Studies. Presented at the AAS 45th Annual Conference, Baltimore, MD. April 19, 2012.
2 Smith E, Craig T, Ganoczy D, Walters H, Valenstein M. Treatment of veterans with depression who died by suicide: Timing and quality of care at last Veterans Health Administration visit. J. Clin Psychiatry. 2011 May. 72(5): 622-629.
3 Trofimovich L, Skopp N, Luxton D, Reger M. Health care experiences prior to suicide and self-inflicted injury, active component, U.S. Armed Forces, 2001-2010. Medical Surveillance Monthly Report. 2012 Feb. 19(2):2-6.
5 Veterans Health Administration, Health Services Research and Development Service. Collaborative Care for Depression in the Primary Care Setting: A Primer on VAs’ Translating Initiatives for Depression into Effective Solutions (TIDES) Project. 2008. Available at http://www.hsrd.research.va.gov/publications/internal/depression_primer.pdf