Post by Former NIMH Director Thomas Insel: Targeting Suicide
The recent tragedy with the Germanwings crash in the Alps has started a worldwide discussion about mental illness and suicide. We don’t yet know what happened on this flight and we certainly don’t have access to the medical history of the copilot who is now the focus of the investigation, but this heartbreaking news from France, and the debate that it has spawned, illustrates the difficulties of understanding suicidal behavior, much less predicting it.
While much attention has focused on this tragedy, it is important to remember that 41,000 people in America died by suicide in 2013.1 Suicide is the tenth leading cause of death in our country. Most of the other top-ten causes of mortality, such as heart disease, cancer, stroke, Alzheimer’s disease, and diabetes are rightly the targets of visible and productive research efforts. For cause number four, accidents (which include automobile crashes), research has led to measures (both devices and law enforcement) that have substantially reduced mortality. Effective vaccines have been developed for the eighth leading cause of death, influenza and pneumonia.
If research on these conditions has shown anything, it is that research investments can, eventually, make a large and life-saving difference, even for issues that at first seem intractable. The National Action Alliance for Suicide Prevention, a public-private partnership, is determined to champion suicide prevention as a national priority; catalyzing efforts to implement high priority objectives of the National Strategy for Suicide Prevention, and cultivating the resources needed to sustain progress. Last month, the Action Alliance’s Research Prioritization Task Force released a comprehensive look at suicide research underway in the United States: U.S. National Suicide Prevention Research Efforts: 2008-2013 Portfolio Analyses. The report finds that “public and private investments in research are meager, given that suicide is the 10th leading cause of death in the U.S.”
Unlike many of the leading causes of death, the suicide rate has shown no appreciable decline over the last 50 years; indeed, the rate among middle-aged Americans is increasing, and for young people ages 15-34, it is not the tenth, but the second leading cause of death. Because of this significant burden, suicide is among the top conditions for DALYs—disability-adjusted life years (an aggregate of the number of years lost to premature mortality and years lost to disability). A few weeks ago I released a white paper on NIMH funding showing how mental disorder and suicide DALYs stack up compared to other NIH investments. Indeed, in terms of dollars invested/death, the suicide research number was roughly 1000, many fold less than the comparable investments in heart disease, cancer, or AIDS.
Last year, a research agenda for suicide prevention identified six broad areas of research, with short- and long-term objectives for each. As important as identifying what we don’t know, the agenda also made clear what we do know, and how we could build on current knowledge to make the quickest inroads into reducing suicide rates. The report pointed out, for example, that 51 percent of suicide deaths in the U.S. were by firearms. Research has already demonstrated that reducing access to lethal means (including gun locks and barriers on bridges) can reduce death rates. It is not correct to assume that everyone who attempts suicide but survives will continue to attempt suicide until they succeed. Research with multiple psychotherapies has shown that adult suicide attempters can be prevented from reattempting. This point was reinforced in a report from Denmark just published; over 5,000 people who attempted suicide were treated with a psychosocial intervention and followed for 20 years. Relative to 17,000 attempters who did not receive psychotherapy, the treated population had fewer subsequent acts of self-harm, fewer suicides, and fewer deaths from any cause. The results were stunning: in this population, it appeared that psychosocial therapy prevented 153 deaths, including 30 suicides.2
Perhaps the most important point brought home by the efforts of the Action Alliance and the Research Prioritization Task Force is that suicidal behavior must be a target of research in and of itself. While it is true that suicide often occurs in the context of mental illness, studying depression and schizophrenia, for example, is not enough; there are many types of individuals at risk for suicide. More empirically based tools are needed to apply early upstream prevention (e.g., community-based interventions), as well as acute and follow-up care approaches for those at highest risk. To develop the most effective and efficient interventions, risk stratification and personalized treatments will benefit from research that can be used to identify those at greatest risk and match interventions to the specific factors that are related to the genesis and maintenance of suicidal thoughts and behaviors for a given individual.
Soon, the crash of the Germanwings airliner in France will begin to fade from the headlines and our own consciousness. When will we change our national habit of paying brief attention to suicide when circumstances make it newsworthy and start viewing it as the major public health problem it is: one to be addressed by marshalling—and sustaining—research, as we have for other health issues, with the clear goal of saving lives?
1 National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System, Fatal Injury Reports, National and Regional, 1999-2013. http://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html.
2 Erlangsen A et al. Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching. Lancet Psychiatry. 2015 Jan;2:49-58. http://dx.doi.org/10.1016/S2215-0366(14)00083-2