Suicide Prevention: Translating Evidence Into Practice

Figure 1. 1970 to 2014 US suicide rate

Figure 2. Suicide prevention (SP) timeline

Table 1 – Signs of acceleration of suicide prevention activities: 2015-2016

Table 2 – Risk and protective factors for suicide

Sidebar

The global mortality toll for suicide exceeds that of homicide, war, and natural disasters combined.¹ Furthermore, the rate of suicide in the US has been increasing over the past 15 years (Figure 1). Clearly, it is time to take action: as clinicians, we are in a unique position to help bend the curve and practice the most effective ways to saves lives and bring hope to those affected by suicide.

The good news is that people want to help. According to a Harris Poll conducted in August 2015, nearly 90% of Americans value mental health and physical health equally. People increasingly understand suicide as the tragic outcome of untenable suffering largely rooted in mental illness, and they want to help those at risk.

As the leading organization in the fight against suicide, the American Foundation for Suicide Prevention (AFSP) has set a goal, as part of our Project 2025 initiative, of reducing our nation’s suicide rate 20% by 2025. A growing body of research has given us strategies at population, community, and clinical levels that can be put into practice. It is our hope that more and more mental health professionals will utilize the latest proven modalities to reduce suicide risk. In addition, it is imperative that we work within our communities, and as a nation, to take a public health approach to combatting what is now the 10th leading cause of death in the US.

Suicide prevention: a public health perspective

Suicide prevention activities began in the US in the late 1950s (Figure 2). However, it wasn’t until the late 1990s that significant momentum and key milestones began to occur with marked acceleration in the past few years (Table 1).

Legislative initiatives are sweeping the country. Likewise, public discourse on mental health and suicide prevention has become commonplace in many leading media sources. The Associated Press officially issued new media guidelines in the 2015 AP Stylebook, giving strong recommendations for safe and effective reporting on suicide-and notably urging a ban on the term “committed suicide” (see Sidebar).

Over the years, AFSP has grown from a small grassroots research-funding organization in 1987 to a strong voice of advocacy in all 50 states-not only for those who have lost a loved one to suicide, but for people with their own “lived experience” of suicide. Alongside our efforts to create a culture that’s smart about mental health, AFSP is the largest private funder of suicide prevention research. (For more about AFSP and its work, go to http://afsp.org/.)

A public health approach is essential if we hope to stem the rising tide of suicide. First, we must invest in science at a level that is commensurate with the morbidity and mortality toll on our nation (see Infographic). In addition to providing universal education and interventions to ensure that everyone is well versed in the basic common language of mental health, those who work in the public sector (eg, teachers, first responders, police) must recognize the signs of deteriorating mental health or people in crisis.

Children in kindergarten and first grade can be taught important self-efficacy skills. Techniques such as the Good Behavior Game² have had beneficial results in terms of academic performance 15 years later, but also in terms of mental health and suicidal thinking. Skills can be taught far upstream to save a life much later.

Evidence-based treatments to effectively address suicide risk must be practiced and new techniques developed. Given the shortage of and misdistribution of mental health and even primary care providers in parts of our country, online resources should not be overlooked.

At the policy level, legislative reform must allow for true access to quality mental health care in every region of our country. Finally, measures must also be enacted to reduce access to lethal means for those times when individuals are at heightened risk for suicide.

A model for understanding suicide

Research does not allow us to predict who is at imminent risk for suicide in the short term-multiple risk factors converge to increase a person’s risk of suicide. No single event ever causes someone to take his or her life. Health factors, such as mental health conditions and substance use disorders; environmental factors, such as stressful life events and access to lethal means; and historical factors, such as previous suicide attempts or a family history of suicide, can converge to overwhelm an individual’s coping ability.

Fortunately, interacting with these risk factors-and offsetting them-are protective factors such as social support, connectedness, coping skills, cultural/religious beliefs, and problem-solving skills. These protective factors interact in a dynamic way with risk factors and real-time life events and psychosocial stressors to change a person’s risk level over time.

Some of these lifetime risk factors are more amenable to modification than others (Table 2). If we can better understand how these risk and protective factors interrelate, we stand a greater chance of addressing the factors that increase risk, enhancing those that are protective, and thus decreasing the number of completed suicides.

Means, and timing, matter

Evidence has shown that restricting access to lethal means saves lives and drives down suicide rates for entire regions. Means matter, and the notion that people who are bent on suicide will find a way simply isn’t true the majority of the time. This point is borne out by several examples. Pesticides are the leading suicide method in Sri Lanka. However, the most highly human-toxic pesticides were banned in the mid-to-late 1990s. Consequently, suicide rates dropped 50% from 1996 to 2005.³

In another telling example, domestic coal gas was the leading method of suicide in England and Wales before 1960. By 1970, because of natural changes in gas production, almost all domestic gas in the UK became nontoxic, and suicide rates dropped by roughly one-third.⁴

In yet a third example, the Israeli Defense Forces found that 90% of suicides among soldiers were by firearm, many during weekend leave. In 2006, soldiers were required to leave weapons on base during weekend leave. Weekend suicides dropped significantly. Weekday suicides did not decrease but also did not rise to make up for the weekend decrease. As a result, the suicide rate decreased in this population overall by 40%.⁵

These examples of policy/access changes that led to suicide reductions dispel the myth that people who are suicidal will find a way. The truth is that making lethal means less accessible during critical periods of distress saves lives. Clinicians can educate patients and families about storing lethal means during key times of crisis or distress, which empowers families and friends to act in a way that might save a loved one’s life.

Timing matters: the intense suicidal urge is very short-on a spectrum of minutes to hours. People who survived a serious attempt were asked about the time between the first thought of suicide during that crisis and the actual attempt. Close to 50% of attempts took place within 10 minutes; another 15% of attempts were fairly evenly spread between 11 minutes and 24 hours; the remaining 35% of attempts were made 1 day to 12 months later.⁶ For many, the period of intense danger lasts only minutes, so helping people to live through peak moments can be lifesaving. These issues of timing also highlight the importance of developing a safety plan well in advance of the crisis.

Findings consistently show that if a person can live through the high-intensity period of suicide risk, or if he survives an attempt, there is a very high likelihood of not re-attempting later in life. A review of 90 studies showed that among those who had made serious attempts, 23% made a subsequent nonfatal attempt during the next decade. But more importantly, 90% or more did not go on to die by suicide.⁷

Mental health and clinicians

It is well-known that over 90% of people who died by suicide were suffering from a mental disorder, although all too often undiagnosed, untreated, or undertreated. Furthermore, comorbidity of 2 or more psychiatric conditions is commonplace in cases of suicide. A mental disorder is diagnosed in 30% to 40% of people in treatment who die by suicide; 25% to 30% of people who take their lives tell a therapist or doctor about their distress and thoughts of suicide in the months preceding their death.⁸

It is important to move away from over-reliance on suicidal ideation as the main or sole focus of the suicide risk assessment. Instead, it is vital to explore patients’ suicide risk and protective factors proactively; listen as patients discuss their reasons for living versus their reasons for dying; and help engage them in a therapeutic alliance that puts the patient on the side of staying alive.

Pharmacotherapy

The recommendations for pharmacotherapy are simple. First, maximize the management of the patient’s psychiatric condition(s); and second, consider medications that have suicide-specific indications.

Clozapine is the only medication with an FDA indication for suicide risk reduction in people with schizophrenia. Lithium has a strong evidence base for suicide risk reduction as well. In 2 meta-analyses of over 50 studies, lithium showed a 60% to 80% reduction in suicide deaths compared with placebo and other mood-stabilizing medications.⁹ The rate of suicide attempts was lowered even more significantly than rates of suicide. These findings held true for both unipolar depression and bipolar disorder. If your patient with a mood disorder is at risk for suicide, lithium should be considered.

There are a few other promising medications for suicide risk reduction that we continue to watch. These include ketamine and other NMDA receptor antagonists and partial agonists, which have received FDA breakthrough therapy designations signifying their potential to save lives in the case of life-threatening illness. More data are needed to verify efficacy, safety, dosing, and delivery options.

Psychotherapies

The research around particular psychotherapeutic modalities has been robust and is now burgeoning with new therapies. Among the better-established therapies for suicide risk reduction are dialectical behavior therapy (DBT) and cognitive behavioral therapy for suicidal patients (CBT-SP). For example, persons who received DBT were half as likely to make a suicide attempt.¹⁰ CBT-SP is also extremely effective in preventing repeat attempts in adults who recently attempted suicide.¹¹

Safety planning intervention (SPI) can be used in many different settings during or preceding a suicidal crisis. Therapists or peer specialists can facilitate safety planning, but the patient is empowered to identify and use his own customized and stepped levels of coping to avert a crisis.¹² A mobile application for SPI has been developed so that patients can utilize their personalized safety plan in real time as needed.¹³ Another approach is the Collaborative Assessment and Management of Suicidality (CAMS), which has also been shown to be extremely helpful.¹⁴

A plethora of online resources for suicide risk reduction, such as the DBT and mindfulness-based website (nowmattersnow.org), aids in efforts to curb suicide.¹⁵ An online CBT-based insomnia tool, sleep healthy using the Internet (SHUTi), was developed by researchers from the Black Dog Institute to alleviate symptoms and prevent progression to major depression. Mood Gym, developed by eHub Mental Health at the National Institute for Mental Health Research, is a free online resource that has had positive results in some persons who do not have access to an in-person CBT therapist.

The term “committed suicide”

harkens to its historical and linguistic roots-from a time when suicide was considered a criminal act. Many scientific fields such as neuroscience and epidemiology were in their infancy, particularly with regard to their inquiry into suicide. They now shed light on suicide as a culmination of complex factors, with anguish driven by mental illness as one of the main risk factors.

Turning hope into action

Thanks to a growing body of research, each day brings us new evidence-based ways to understand, assess, and address suicide risk. Clinicians have a powerful role to play in their work with patients. They can also make a substantial difference by educating their communities about mental health and the role that everyone has to play when it comes to preventing suicide. It is our hope at AFSP that by better equipping clinicians with the latest proven methods and strategies for clinical practice-and by adopting a well-warranted public health approach to suicide prevention-we can turn hope into action and achieve our mission of saving significantly more lives.

Acknowledgment-This article is based on Dr Moutier’s presentation at the 2015 Annual Conference of the National Network of Depression Centers (NNDC). The NNDC, a partner of Psychiatric Times, develops and fosters connections among members to use the power of its network to advance scientific discovery, improve care, and drive the national conversation on depression and mood disorders through collaborative research efforts.

Disclosures:

Dr Moutier is the Chief Medical Officer of the American Foundation for Suicide Prevention, a leading private funder of suicide-related research. (The grant review process utilizes 3 levels of peer review similar to that of the National Institute of Mental Health.) She reports that she is a consultant for Otsuka.

References:

1. World Health Organization (WHO). Preventing Suicide: A Global Imperative. 2014. http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/. Accessed March 28, 2016.

2. American Institutes for Research. Good Behavior Game. http://www.air.org/topic/p-12-education- and-social-development/good-behavior-game. Accessed March 25, 2016.

3. Gunnell D, Fernando R, Hewagama M, et al. The impact of pesticide regulations on suicide in Sri Lanka. Int J Epid. 2007;36:1235-1242.

4. Kreitman N. The coal gas story: United Kingdom suicide rates 1960-71. Brit J Prev Soc Med. 1976;30:86-93.

5. Lubin G, Werbeloff N, Halperin D, et al. Decrease in suicide rates after a change of policy reducing access to firearms in adolescents: a naturalistic epidemiological study. Suicide Life Threat Behav. 2010;40:421-424.

6. Deisenhammer EA, Ing CM, Strauss R, et al. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry. 2009;70:19-24.

7. Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm: systematic review. Br J Psychiatry. 2002;181:193-199.

8. Bertolote JM, Fleischmann A. Suicide and psychiatric diagnosis: a worldwide perspective. World Psychiatry. 2002;1:181-185.

9. Baldessarini RJ, Tondo L, Davis P, et al. Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review. Bipolar Disord. 2006; 8:625-239.

10. Linehan MM, Comtois KA, Murray AM, et al. 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 Psych. 2006;63:757-766.

11. Brown GK, Ten Have T, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294:563-570.

12. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cog Behav Pract. 2011;19:256-264.

13. Kennard BD, Biernesser C, Wolfe KL, et al. Developing a brief suicide prevention intervention and mobile phone application: a qualitative report. J Tech Hum Serv. 2015;33:345-357.

14. Jobes DA. The collaborative assessment and management of suicidality (CAMS): an evolving evidence-based clinical approach to suicidal risk. Suicide Life Threat Behav. 2012;42:640-653.

15. Whiteside U, Lungu A, Richards J, et al. Designing messaging to engage patients in an online suicide prevention intervention: survey results from patients with current suicidal ideation. J Med Internet Res. 2014;16:e42.

16. Deisenhammer EA, Ing CM, Strauss R, et al. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry. 2009;70:19-24.