The rate of suicide in the United States increased 28 per cent from 1999 to 2016, according to a report last week from the Centres for Disease Control and Prevention. You would think that we were in the midst of a suicide epidemic, an alarming prospect that was underscored by the deaths recently of both Kate Spade and Anthony Bourdain.But the truth is that things have been this bad — and worse — many times in our history. The prevalence of suicide has fluctuated over time, often rising during periods of social strife; it was 17.4 per 100,000 in 1932, during the Great Depression.The real question is why society has made so little progress in dealing with the public health crisis of suicide. In fact, the suicide rate last year is nearly the same as the rate a century earlier.In US alone, suicide is the 10th leading cause of death. Yet last year, the National Institutes of Health spent more money researching dietary supplements than it did suicide and suicide prevention. Any other disease that comes close to killing as many Americans as suicide does, like HIV and heart disease, gets marquee recognition as a public health menace and major federal research funding.
As a result, we have seen the rates of death from heart disease and HIV plummet over time. Not so for suicide. The simple reason suicide has been neglected for so long is stigma. It is a human behaviour that terrifies most people. Suicide is wrongly seen as a character or moral flaw — or even a sinful act. It is viewed as something shameful that must be hidden.But suicide is a medical problem that is almost always associated with several common and treatable mental illnesses, like depression, anxiety and impulse and substance abuse disorders. It is estimated that more than 90 per cent of those who die by suicide have a diagnosable mental disorder. This means that, in theory, suicide should be preventable if we can deliver the right treatment to people who have these psychiatric illnesses.
Unfortunately, it’s hard to know which treatments are most effective at preventing suicides because most studies of mental health interventions specifically exclude suicidal subjects. (This is because ethics boards are typically reluctant to allow people at this kind of risk to receive a placebo treatment.) One notable exception is a Johns Hopkins study of a group of Danish patients showing that deaths by suicide were about a quarter lower in people who had six to 10 talk therapy sessions.There is good reason to believe that if more people had access to such simple but high-quality treatments, we would see a drop in suicide. (Sceptics will point out, correctly, that suicide rates have been rising despite a growing number of people taking antidepressants. I would respond that there is more to the effective treatment of depression than just taking antidepressants.)
Still, a big challenge is that suicidal people often conceal their symptoms. Although Spade’s husband, for example, knew that she struggled with a mood disorder, he said: “There was no indication and no warning that she would do this. It was a complete shock.” Many people are also reluctant to ask friends and loved ones who seem distressed whether they are thinking about suicide, for fear that somehow inquiring about it could incite suicide. But research shows otherwise.
Dr. Madelyn Gould, a psychology professor at Columbia, and colleagues screened a group of high school students about their moods. Subjects exposed to questions about suicidal feelings or thoughts were no more likely to report thinking about suicide after the survey than those who were not asked these questions. The implication is that we should not be afraid to ask people we are concerned about if they are feeling suicidal.
In fact, we need to talk more openly about suicide, to help people see it as the treatable medical scourge that it is.
But we can do far more. There is emerging evidence that we can identify and even prevent suicidal feelings and behaviour with some new tools. Dr Matthew Nock, a professor of psychology at Harvard, and his colleagues developed a gamelike mobile app called Therapeutic Evaluative Conditioning that is designed to condition people to have an aversion toward suicidal or self-injury behaviours. Nock found that, when people with a history of suicidal ideation and self-injurious behaviours like cutting had access to the app for a month, the intervention decreased their suicidal plans by 45 per cent and self-injurious behaviour by 37 per cent.
The US military hopes to make progress in reducing suicide among soldiers by using a computer program to identify those at highest risk. Researchers looked at the medical records of all soldiers who were psychiatrically hospitalised and found they could use clinical and demographic variables to identify those most likely to commit suicide after being discharged. They speculated that the military might consider “targeting expanded posthospitalisation interventions” to these soldiers.
One small promising study of suicidal soldiers found that 40 per cent of those who received traditional treatments went on to attempt suicide again. But only 14 per cent of those who received brief cognitive behavioural therapy — a treatment designed to reduce beliefs and assumptions that increase vulnerability to suicidal thinking and behaviour, like hopelessness, guilt and shame — made a subsequent suicide attempt.
We should declare war on suicide — just as we’ve done with other public health threats like HIV and heart disease — and give it the research and clinical funding needed to beat it.
— New York Times New Service
Richard Alan Friedman is an opinion writer and professor of Clinical Psychiatry at the Weill Cornell Medical College.
