Suicide prevention gets a new lifeline

[This article is part of the 2023 Trends Report]

Historically, psychologists have viewed suicide primarily as a symptom of mental illness and have often sent patients who even mention the word “suicide” straight to the emergency room. Now that is starting to change, as psychologists on the front lines find new ways to identify individuals at risk, address the full complexity of suicide, and enlist new sources of help. Their goal? To lower a national suicide rate that is still shockingly high. After 15 years of steadily increasing rates, the overall number of suicides in the United States dropped 5% between the 2018 peak and 2020, according to provisional data from the Centers for Disease Control and Prevention (CDC) (PDF, 463KB)opens in new window.

But that progress was not shared equally. While the overall rate dropped, White men and women accounted for much of the decline, with the suicide rate for White men dropping 3% between 2019 and 2020 and the rate for White women dropping 10%. In addition to racial disparities, the overall decline obscures important changes by age. For individuals ages 10 to 34, for instance, rates were higher in 2020 than in 2019. And young people are increasingly considering suicide. Suicide is already the second most common cause of death for young people, but in 2020, emergency room visits for suspected suicide attempts increased 31% for adolescents ages 12 to 17, according to the CDC (Morbidity and Mortality Weekly Report, Vol. 70, No. 24, 2021opens in new window). For girls, visits were almost 51% higher than in 2019.

In confronting these numbers, psychologists are making the case for increased screening and are developing interventions that can help health care systems overcome their fears of being overwhelmed by the number of people who screen positive for suicidal ideation and behavior. And in the face of a nationwide shortage of mental health professionals, psychologists are training the public in a CPR-like suicide prevention intervention and harnessing technology’s power to provide support.

“With Covid-19 and everything else happening lately, people are paying greater attention to mental health,” said Jill Harkavy-Friedman, PhD, senior vice president of research at the American Foundation for Suicide Prevention.

For Craig Bryan, PsyD, ABPP, author of Rethinking Suicide: Why Prevention Fails, and How We Can Do Betteropens in new window (Oxford University Press, 2021), the reason suicide rates have remained stubbornly high for decades is the outdated notion that mental illness is what causes suicide.

“We have decades of research that that core assumption—the bedrock of prevention efforts nowadays—is wrong,” said Bryan, who directs the Suicide Prevention Program at The Ohio State University College of Medicine. “We keep zeroing in on one small piece of the puzzle, then scratching our heads that…we’re not bending the curve.” This misconception has led to focusing on mental health treatment as the primary method of preventing suicide. Bryan and a growing number of psychologists believe that practitioners should instead look at the broader problems, such as financial struggles, relationship problems, discrimination, and other factors, that put people at risk.

“Because we’ve thought of suicide as a mental health problem—something inside people—we say, ‘You suffer from depression and need to go to treatment,’” said Bryan. “But therapy and medications won’t pay your bills, won’t help you have a boss who treats you with dignity and respect, won’t change the neighborhood you’re in.” Psychologists, said Bryan, need to go beyond mental health, empower patients, and become advocates for better jobs, housing, and nondiscrimination policies.

Such efforts are already underway, with the suicide prevention field paying more attention to factors like the role structural racism plays in racial and ethnic disparities in suicide rates.

Looking at suicide data as a whole masks important differences, said Kiara Alvarez, PhD, an assistant professor of health, behavior, and society at the Johns Hopkins Bloomberg School of Public Health (American Journal of Psychiatry, Vol. 179, No. 6, 2022opens in new window). Rates of suicidal behavior have increased disproportionately among young people of color over the last few decades, with Black girls in particular reporting the highest rates of suicide attempts, said Alvarez. And very young Black children between 5 and 12 have almost twice the suicide rate of their White counterparts, said Alvarez, pointing to research (Bridge, J. A., et al., JAMA Pediatrics, Vol. 172, No. 7, 2018opens in new window) cited in the U.S. surgeon general’s 2021 advisory Protecting Youth Mental Health (PDF, 1.01MB)opens in new window.

Yet, said Alvarez, prevention efforts have focused on supposedly universal risk and protective factors without being customized for individual populations. And structural racism is apparent in the response to crises, she said, with young people of color more likely to be tagged with behavioral rather than mental health problems and funneled from school suspension all the way to the juvenile justice system.

“Just bringing mental health services into school misses the boat when it comes to suicide prevention,” said Alvarez. “You need to address who has access—who is being treated as someone needing mental health support instead of behavioral management and discipline.”

Prevention efforts are also moving upstream to target entire populations, said John Ackerman, PhD, who directs the Center for Suicide Prevention and Research at Nationwide Children’s Hospital in Columbus, Ohio. “Not all of our suicide prevention efforts should be done at the point of crisis,” said Ackerman, coeditor with Lisa Horowitz, PhD, MPH, of Youth Suicide Prevention and Intervention: Best Practices and Policy Implicationsopens in new window (Springer, 2022). “We need to be giving people tools to reduce their risk before a crisis.”

For Ackerman, that means going into schools with an evidence-based program called Signs of Suicide. The program teaches middle and high school students how to respond to a friend in crisis while also training the adults in the school, including lunchroom staff, coaches, and bus drivers. “We want everyone equipped to respond to warning signs of suicide,” said Ackerman, who has worked with 65,000 schoolchildren in almost 250 Ohio schools. Ackerman is now working with the program’s developer to create a program aimed at third to fifth graders.

Until recently, Ackerman added, schools were reluctant to introduce suicide prevention programming. “Talking about young people ending their lives is an uncomfortable topic,” he said, “but the data are very, very clear that young kids are considering suicide and acting on it.”

One ongoing controversy in the field concerns universal screening for suicide risk, especially within health care settings.

“The majority of adults and kids who have died by suicide have visited a health care provider in the months, sometimes even weeks, before they die,” said Horowitz, senior associate scientist in the National Institute of Mental Health Intramural Research Program. “What that presents is an incredible opportunity—you might even argue responsibility—to detect people at risk and be the bridge to getting them help.”

Not everyone agrees. In May 2020, the U.S. Preventive Services Task Force issued a draft recommendation statement noting insufficient evidence to recommend for or against suicide risk screening in asymptomatic children and adolescents, for example. In September, the task force issued a similar draft statement about screening in adults. But kids—and adults—can’t wait for that research, said Horowitz. “We can’t wait five more years for those studies to come out, because kids are dying from suicide right now,” she said. “We have to screen young people so that we can identify those at risk who may not be discussing their suicidal thoughts with anyone else.”

A screening tool Horowitz and her team developed called the Ask Suicide-Screening Questions takes just 20 seconds (JAMA Pediatrics, Vol. 166, No. 12, 2012opens in new window). Critics of universal screening often conflate screening and assessment, Horowitz explained, but the screening instead represents a rapid way to flag someone who needs further attention and is the first step in a clinical pathway (Academic Pediatrics, Vol. 22, No. 2, 2022opens in new window). “Screening is the way you start the conversation,” said Horowitz. “It’s an opportunity to reach out before it’s too late.”

Behind the resistance to universal screening lies the fear that such screening means opening Pandora’s box, said Edwin Boudreaux, PhD, a professor of emergency medicine, psychiatry, and quantitative health sciences at the University of Massachusetts Chan Medical School. “They argue that if they don’t have the capacity to intervene, that screening is not really going to help,” said Boudreaux.

What Boudreaux has found is that universal screening catches many who would otherwise be missed. In a large multisite study, he and colleagues found that universal screening of adult emergency department patients almost doubled risk detection, going from just under 3% to almost 6% (Contemporary Clinical Trials, Vol. 95, 2020opens in new window). That number is still low enough that hospitals do not have to worry about being inundated with at-risk patients, he said, especially if hospitals put in place protocols that are sensitive to patients’ severity of risk. Some patients with lower levels of acute risk, for example, may not need a full psychiatric workup or safety precautions such as searching their belongings for potentially lethal items or assigning someone to watch them constantly.

Plus, said Boudreaux, there are things health care systems can do to make the most of existing resources instead of the traditional—and costly—response of sending patients who mention suicide to the emergency room.

The UMass Memorial Health system, for instance, made changes based on the tenets of Zero Suicideopens in new window—the now predominant model, which calls for overhauling entire systems to address suicide instead of merely training individual practitioners. The UMass system now does universal screening of patients ages 12 and older, then stratifies them by risk level, with high-risk patients receiving evidence-based interventions. Safety planning, for example, is an easy intervention in which the patient and clinician work together to identify risk factors and warning signs plus ways of coping with them. A revamped electronic health record system helps ensure patients do not fall through the cracks as they transition to the appropriate level of care.

Even something as simple as calling patients after emergency room discharge can reduce suicide, Boudreaux has found. In a multicenter study that focused on adults with recent suicidal ideation or attempts, the researchers found that patients who received follow-up phone calls and discharge resources had 30% fewer suicide attempts than patients who received treatment as usual (JAMA Psychiatry, Vol. 74, No. 6, 2017opens in new window).

Limiting access to lethal means—especially firearms—is also key, said Michael Anestis, PhD, executive director of the New Jersey Gun Violence Research Center at Rutgers University. Firearms accounted for 53% of suicides in 2020, according to the CDC (Kegler, S. R., et al., Morbidity and Mortality Weekly Report, Vol. 71, No. 19, 2022opens in new window).

The demographics are changing, however. “There has been an unprecedented surge in firearm sales—not just in deep red states,” said Anestis. That means psychologists must broaden their idea of who is at risk beyond veterans and other traditional high-risk groups. People who bought firearms during the Covid-19 pandemic, Anestis has found, are more likely to report past-month, past-year, and lifetime suicidal ideation than people who have never purchased firearms or purchased them before the pandemic (JAMA Network Open, Vol. 4, No. 10, 2021opens in new window).

The next frontier is to train people outside of health care, such as military unit leaders and bartenders, to do lethal means counseling—assessing whether someone who is suicidal has access to firearms, prescription medicine, or other potentially lethal items and working with the person and family members to limit access to those items during a crisis. “Folks who die by firearm are less likely to engage with health care,” said Anestis. “Training others to have these conversations is a way to move upstream and shift societal norms.”

Other efforts aim to increase the amount of training on suicide that psychologists receive. The vast majority of psychologists and other mental health professionals are not routinely trained in suicide prevention, according to a policy paper by the American Foundation for Suicide Prevention (PDF, 229KB)opens in new window. As a result, a growing number of states are mandating such training as a condition for licensure. Eleven states now require training in suicide prevention or suicide assessment, management, and treatment, while an additional four states encourage such training.

New hotline numbers help ensure that individuals in crisis can connect with sources of help.

In July 2022, the National Suicide Prevention Lifeline changed its name to 988 Suicide and Crisis Lifelineopens in new window and introduced a 3-digit number designed to be as easy to remember as 911. Instead of dialing the old 10-digit number, callers who are suicidal or experiencing other mental health crises can now dial 988 to connect with trained counselors at crisis centers nationwide. In the first week after the new number’s launch in July, the lifeline saw a 66% increase in volumeopens in new window compared to calls to the old number in the same week in 2021, according to the lifeline’s administrators.

“When someone’s in distress, they’ll get specialized mental health help related to suicide prevention instead of having to go to the emergency room,” said Harkavy-Friedman of the American Foundation for Suicide Prevention, which advocated for 988’s creation and now lobbies for increased funding.

Other efforts focus on connecting particularly high-risk populations with help. Physicians, for example, are at higher risk of suicide than those in other professions. Even before the stressors brought on by the Covid-19 pandemic, 1 in 15 physicians had considered taking their own lives in the past year (Lawrence, E. C., Mayo Clinic Proceedings, Vol. 96, No. 8, 2021opens in new window). To help change that, the Physician Support Lineopens in new window at 888-409-0141 offers confidential physician-to-physician support to medical students and physicians.

The AgriStress Helplineopens in new window, developed by a nonprofit group called the AgriSafe Network, provides 24-hour support to another high-risk group—farmers and ranchers. Specially trained crisis support specialists use a “care navigation” process to get callers in Missouri, Pennsylvania, Texas, Virginia, and Wyoming the assistance they need, whether it is a risk assessment, emotional support, or referrals to help in their communities. All callers receive a follow-up call within 24 hours.

Another specialized service is the Trans Lifelineopens in new window, which provides peer support for the trans community. Run by and for trans individuals, the lifeline goes beyond direct services to include advocacy to combat oppressive systems.

The National Maternal Mental Health Hotlineopens in new window, sponsored by the U.S. Health Resources and Services Administration, provides free support in English and Spanish at 833-9-HELP4MOMS before, during, and after pregnancy.

[Related: Prevention hotlines for specific issues]

Given the shortage of mental health professionals, there has also been a move to train nonprofessionals to intervene. About six million people over the past two decades have learned the Question, Persuade, and Refer (QPR) gatekeeper intervention developed by Paul Quinnett, PhD, executive chairman of the QPR Instituteopens in new window, which aims to make QPR as common as CPR.

“QPR is an intervention that lances a psychic boil and allows pain to dissipate by sharing it with a compassionate other person,” said Quinnett. “There’s a common myth that if you ask someone about suicide, it puts the idea in their head; but research shows just the opposite: Asking produces relief and lowers anxiety and stress.”

The institute has now developed advanced training aimed at creating a new workforce of certified crisis responders who can offer help in rural areas, developing countries, and other places where clinicians are scarce.

Once new research comes to fruition, individuals contemplating suicide will be able to get help from technology, too.

Most suicide interventions are not accessible when people need them most, points out Daniel Coppersmith, a doctoral candidate in psychology at Harvard University (Psychiatry: Interpersonal and Biological Processes, online first publication, 2022opens in new window). New technology is making it possible to deliver such interventions at the very time individuals need them.

Earlier technological innovation led to the use of smartphones for momentary ecological assessments, which revealed that individuals’ suicide risk can change rapidly. “We need interventions that can accommodate and adapt to the rapid nature of those changes,” said Coppersmith. The next generation of smartphone tools are the just-in-time adaptive interventions Coppersmith and others are developing. These technologies assess risk, whether by sending users a smartphone survey or passively monitoring data like their physical activity through wearable sensors. If these data reveal heightened suicide risk, the technologies make strategies from evidence-based practices like safety planning or cognitive behavioral therapy easily accessible.

Such interventions are still a work in progress, said Coppersmith, who predicts that the technology could be available within five years. “There’s a lot of discussion, debate, and excitement,” he said. “This is where the field is hoping to go.”