Barbara Stanley, PhD; J. John Mann, MD
Jama Psychiatry. 2020;77(1):96 98. doi:10.1001/jamapsychiatry.2019.2769 Published online October 2, 2019
Poster’s Note: Barbara Stanley is one of the originators of Safety Planning!
The United States suicide rate has climbed more than 33% since 2000 despite declines inmost other major causes of death (1) and increased efforts devoted to suicide prevention. Over the same period, suicide rates in many European countries have declined or remained steady (2). Why has the US rate increased? No single factor likely explains this increase, and no single strategy is likely to decrease it. Absent data on the precise causes operating here, speculation abounds about possible explanations and, therefore, solutions. Public health experts believe decreasing the suicide rate is best achieved through large-scale public health efforts, such as reducing stigma around mental health and public messaging encouraging people who are suicidal to reach out for help (3). Basic researchers urge seeking a better understanding of the underlying suicidal processes (4). Implementation specialists promote greater effort in high-fidelity adoption of systemwide suicide prevention efforts (5). Improved and more scalable interventions are suggested (6).
A complement to more measures that may reduce suicide are approaches to improve identification of high-risk individuals and promote better engagement with professional help (7). However, focusing on one aspect of suicide prevention to the exclusion of others is not likely to have an effect on suicide rates. Hoge (8) addressing suicide in the military, suggests that investing funds to improve clinical treatments is not likely to reduce suicide owing to the poor level of treatment engagement by individuals in the military who are suicidal. Instead, he proposes that efforts should be devoted to broad initiatives that increase engagement and access to care. He is right in the sense that military personnel who are suicidal have generally shown a pattern of refusing mental health care because of stigma and concerns over appearing weak and getting passed over for promotion (9). However, effective treatments must be available should engagement strategies be successful.
One proposed multi-pronged solution is the Zero Suicide model, an approach to preventing suicide for patients within health care systems across the country (5, 10) and exemplified in the AIM (Assess-Intervene-Monitor) model, which describes the clinical elements of the Zero Suicide model (11). The Zero Suicide model is an action oriented, aspirational approach positing that suicide is preventable in patients who are part of a health care system. While the notion of zero suicides is admirable, it is an aspirational goal and really means making a serious effort to achieve a major lowering of suicide rates. We all applaud the idea of eliminating cancer deaths, but we understand that we are seeking to reduce such deaths to the maximum extent possible using current tools while at the same time improving prevention, detection, and treatment. The Zero Suicide model proposes that clinicians use each and every interaction to detect and mitigate suicide risk. A total of 40% of individuals who die by suicide are seen in primary care within 30 days of their suicide, and 80% are seen within 1 year (12) a much higher rate than those seeing behavioral health care. Therefore, routinely screening for suicide risk and helping those at risk receive appropriate care may help to prevent many suicide deaths. The 3 crucial assumptions here are that screening accurately identifies those at imminent risk, that patients who are suicidal are willing to seek treatment, and that established interventions are effective. None of these assumptions are certain (8, 13) but all 3 have the potential to lower suicide rates and success is likely to be greatest when all 3 are implemented together. Screening must be followed by engagement, safety planning, monitoring, and effective treatment. This comprehensive strategy has merit even if the outcome is something less than no suicide deaths.
Most likely, there are multiple contributing factors to why the suicide rate is increasing in the United States,such as the black box warning about antidepressants in 2004 and 2006, the economic recession of 2008 that persisted (14, 15). The opioid epidemic that exploded in the last 4 years (16), the persistently high rate of untreated patients with psychiatric disorders, and the availability of firearms in the home without gun safety strategies in place (17). But as Nock et al. (18) note, we too often use the types of measures repeatedly in suicide research, and therefore,we limit discovery in the same way that we limit treatment approaches. Given the alarming rise of suicides in the United States, a hypothesis-generating discovery approach may be helpful at this point. Two examples of approaches geared toward this typeof discovery are (1) psychological autopsies of suicide decedents and parallel narrative functional analytic studies of individuals who attempted suicide to detect precursors and predisposing factors to suicidal behavior and (2) use of novel smartphone and wearables technologies to closely monitor suicidal individuals actively and passively to determine physiological, behavioral, emotional,and cognitive changes that precede suicidal behaviors. While these approaches differ, they have incommon an agnostic orientation to discovering causes of the behavior. And although psychological autopsies are an older tool, the amount of personal data in electronic health records, social media, and online has greatly increased and can inform traditional interview data obtained in psychological autopsies.
In addition, we suggest that we ought to also take a similar approach to treatment development for individuals who are suicidal. In the past, interventions for patients who are suicidal were dominated by the notion that treating the primary psychiatric disorder (eg, major depression, bipolar disorder)would diminish suicidal thinking and prevent suicidal behavior. This approach has been supplemented by the development of suicide-specific treatments designed to complement disorder-specific treatment. These include adaptations of cognitive behavioral therapy in a variety of psychiatric disorders (19), dialectical behavior therapy for suicidal behavior in borderline personality disorder (20), and safety planning intervention for patients who are suicidal presenting for care (21). Certain medications have been found to have anti suicidal effects independent of their action on the primary psychiatric disorder. Examples are lithium in mood disorders (22), clozapine in psychosis (23), and ketamine for mood disorders (24). Among pharmacological antidepressant subtypes, in patients with depression, a selective serotonin reuptake inhibitor has proven more effective for suicidal ideation than a noradrenergic antidepressant (25). Given the success of broad-scale means access reduction, means access counseling, including safer gun storage to prevent firearms suicide, has been an important focus of suicide prevention interventions (26).
However, as Hoge (8) points out, engaging individuals who are suicidal to seek and remain in treatment is challenging.Many refuse care altogether. Others drop out after only a few sessions. And most of those who die by suicide did not receive behavioral health treatment in the months before their death (27). However, as we note, most had at least 1 primary care visit in the year prior to suicide, and many had a visit in the month prior to death (12). Therefore, we know that these individuals do not reject all medical care. It may be that wider availability of psychiatric treatment may solve part of the problem. However, their non engagement in care may be more specific to the psychiatric treatment.
In response to this problem, experts have adapted engagement strategies to individuals who are suicidal, which met with mixed success. But it may be that the treatments we have developed to date are not acceptable to the broad range of individuals who are suicidal. Treatment development suggests 3 possible avenues of investigation. First, it would be helpful to conduct in-depth qualitative interviews with individuals who are suicidal to better understand why these individuals reject psychiatric treatment and what, if anything,would be acceptable, eg, psychiatric care embedded in primary care or peers or religious leaders.
A second approach to improving treatment acceptance is to turn to where demographically similar individuals seek support and care. We know that men are at much greater risk than women of dying by suicide (28, 29). We also know that women are much more likely to seek psychiatric care (30). Are there treatment approaches for psychiatric problems that men find acceptable? We can look to Alcoholics Anonymous (AA). Men outnumber women almost 2 to 1 in AA (31). This ratio maps onto the proportion of men to women with alcohol use disorder (32). What makes AA acceptable to men? There are a few noteworthy characteristics of AA: it is peer led, it is structured but nondirective, and attendance is optional. While AA outcomes are mixed,we suggest considering borrowing strategies for suicide interventions that are more acceptable to men who are at greater risk of suicide than women.
Finally, a third approach is to identify points of contact in the health care system when patients are in suicidal crises and strike while the iron is hot. Two potential sites of intervention are psychiatric in patient units and emergency departments (EDs). Psychiatric inpatient units are a relatively untapped resource for implementation of suicide-specific psychosocial interventions. More than 40% of psychiatric hospitalizations are the result of a suicide crisis (33). Yet to our knowledge, there is not a single psychotherapeutic intervention with established efficacy for inpatients who are suicidal. Many inpatient units have psychotherapy groups designed to help patients improve postdischarge coping but do not focus on suicide-related issues. With respect to EDs,we know from research with patients with alcohol use disorder that brief interventions in the ED can increase their motivation for treatment and decrease usage (34). Recently, brief ED interventions have been shown to be effective in reducing suicidal behavior (21, 35). However, the obstacles to large-scale implementation are substantial. In conclusion, within health care,we have several avenues available to improve suicide prevention efforts that can make reducing the suicide rate in the United States is an attainable goal.
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