Can suicide be prevented?BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7557 (Published 07 November 2012) Cite this as: BMJ 2012;345:e7557
- Douglas Kamerow, chief scientist, RTI International, and associate editor, BMJ
Thirty years ago, my youngest sister, then 27 years old, jumped off a roof in New York and fell to her death. That anniversary and a new report from the US surgeon general have got me thinking about suicide prevention.
Suicide is a big public health problem. It is the 10th leading cause of death worldwide, accounting for about one million deaths a year.1 In the United States there were over 38 000 suicides in 2011.2 Men are 3-4 times as likely as women to kill themselves, though women attempt suicide much more often.
Risk factors for suicide have long been known. Psychiatric disorders are present in around 90% of people who kill themselves, and more than half of those who die by suicide meet criteria for a current depressive disorder. Other leading mental disorders associated with suicide include substance misuse, schizophrenia, and personality disorders. The problem, of course, is that while the vast majority of people who kill themselves have a mental disorder, only a relatively small proportion (4% of depressed people, for example) of those with mental disorders die by suicide. One of the challenges of suicide prevention is identifying those at greatest risk.1
The strongest single risk factor for suicide is a history of suicide attempts or other self harm, present in around 40% of completed suicides.1 Much has been published about the epidemiology of this risk factor (the risk is higher in men and older people who have harmed themselves, for example), and there is debate over the importance of suicidal intent in previous attempts in assessing the future risk of suicide.
A final important risk factor for suicide is access to the means to kill oneself. Because impulsiveness is also associated with suicide, ready access to a lethal means—a gun, a large quantity of poison, a nearby bridge—can be seen as a facilitator and even an independent risk factor for self inflicted death.
All of which leads to the question of how to prevent suicides.
The history of suicide prevention activities in the US dates back at least 50 years to the first suicide prevention centers in the 1950s, followed by the crisis intervention programs of the 1960s, and the formation of multiple suicide prevention associations in the 1970s and beyond.3 Federal agencies have funded countless studies, programs, and centers on suicide prevention. Much of this work culminated in an extensive report from the US Department of Health and Human Services in 2001,4 which summarized the state of the art and, in 11 goals and 68 separate objectives on awareness, intervention, and methodology, plotted a course to reduce suicides.
Since then many of the 2001 recommendations have been implemented: better training, more awareness, more resources, and more research. The suicide rate, however, has not budged; in fact, it has gone up a bit. In 2001 it was around 10.5 suicides per 100 000 people. In 2010 it had risen to over 12 per 100 000.3
Which brings us to the new report. At the end of September the surgeon general and the National Action Alliance for Suicide Prevention released an update to the national strategy for suicide prevention.3 It updates the prior report’s contents with new goals and objectives that focus more on coordinating and integrating services across individual, clinical, and community settings. It is informed by the (still relatively meager) evidence for what works in suicide prevention.5
It says all the right stuff. Integrate suicide prevention activities across multiple sectors. Inform public communications with findings from research. Develop evidence based programs for community and clinical prevention programs. Reduce access to lethal means. Improve surveillance. Create a research agenda and fund it.
No one could object to these goals and aspirations. Forgive me, though, if I am a bit cynical about whether any or all of this will be accomplished soon. The objectives are broad and often nebulous. There are few named population targets and no specific deadline dates.
If we are to prevent yet another report 10 years from now that just reorganizes and updates the same objectives, it seems to me that we have to get very specific and focused. Looking at exactly who kills themselves and how they do it might help narrow things down a bit.
We know that a history of previous suicide attempts and serious mental disorders are huge risk factors. Let’s make sure that these people are protected and followed carefully. We know that more than half of the people who commit suicide saw a doctor in the previous month.6 Let’s conduct the necessary trials to know whether screening in primary care for suicidal intent makes a difference. We know that (in the US) more than half the people who kill themselves do it with a gun.7 Let’s redouble efforts to keep guns out of the hands of populations at risk, as a gun safety matter, not a gun control issue.
Ten years from now I would love to mark the 40th anniversary of my sister’s death with something in addition to sadness and frustration: a reduction in the national suicide rate.
Cite this as: BMJ 2012;345:e7557
DK is a former US assistant surgeon general. He is the author of Dissecting American Health Care (www.kamerow.com/Dissecting_American_Health_Care.html).