We are living in a time of urgency: suicide is a global, leading cause of death with a staggering loss of 800,000 lives each year. Suicide cuts across high- and low-income countries, with lower and middle-income countries bearing the largest burden (80% of all suicides) but with it continuing to be a serious problem in high-income countries as well. In recent years, the World Health Organization (WHO) and the United Nations have adopted actions plans focused on mental health and suicide prevention, and have set goals to reduce the rate of suicide by varying degrees: 10% by 2020 in the case of WHO, and 33% by 2030 in the case of the UN Sustainable Development Goals. Presently, 40 countries have enacted national strategies to prevent suicide, several of which are proving effective, with reductions in suicide rates in many countries such as China, Denmark, England, Switzerland, the Philippines and South Korea. Though the absolute number of suicides globally continues to increase, a recent study accounting for population growth, found the global rate of suicide has dropped by 32.7% over the past 27 years.
In the US, even as attitudes evolve regarding mental health and suicide prevention, the national rate of suicide has risen 33% over the past two decades with a societal price tag of $70 billion annually. Overall mortality, particularly in the middle years, is increasing as a result of the so-called “deaths of despair” due to suicide, alcohol, opioids, and liver disease. Although 94% of American adults believe mental health is equally as important as physical health, most do not know how to identify changes in mental health that signal serious risk, nor what to do in response. Suicide was declared a public-health crisis in the US as long ago as 1999 by the Surgeon General. Many factors are involved, including human experiences of isolation, struggle, loss and unmet expectations; low mental-health literacy; and a separate and unequal system of care with limited treatment access for those with mental health and substance use disorders. Although the suicide prevention field is still fairly young, a growing body of suicide prevention research indicates there is a reason for hope – and that suicide can indeed be prevented on a general population basis. But to stem the rising tide of what is currently the 10th leading cause of death in the US, the science behind suicide prevention must grow in order to translate into effective solutions we can put into practice and bring to scale in communities throughout the country.
Fighting suicide at local and national level
Firstly, it is critical that we invest in suicide prevention science at a level commensurate with its mortality toll (see figure below). Suicide is complex, but like most health-related leading causes of death, it has multiple risk factors we know converge to increase mortality. These include genetic loading, neurophysiological functions in the brain, environmental factors both distant and current, social determinants, biological variants of the stress response on cognition, issues like impulsivity and aggression, and access to lethal means. Fortunately, just as the field of oncology has and continues to answer key questions related to cancer – its causes, prevention and treatment – suicide prevention scientists have reached consensus on scientifically based, population-level solutions in response to these risk factors. These solutions have been replicated and are quite clear. They include public education on mental health and suicide, community approaches such as addressing access to lethal means during periods of risk, and clinical interventions that effectively target suicide risk.
Implementation of these strategies through local community-based initiatives are at a nascent stage, and a focused national effort through health systems, educational and workplace settings has yet to launch. We must, therefore, educate policymakers on the specific, effective strategies we know have demonstrated reductions in mortality and increased access to care. On a fundamental level, the Mental Health Parity and Addiction Equity Act of 2008 (Federal Parity Law), which requires insurers to cover treatment for mental health and substance use disorders no more restrictively than treatment for illnesses of the body, such as diabetes and cancer, must be fully enforced to make sure people can get the help they need. This and other efforts will light a path forward for federal and state policy solutions, in accordance with the growing public demand related to mental health and suicide prevention.
Greater understanding and awareness of mental health and suicide prevention throughout communities are proven to reduce the rates of suicide in those communities. Imagine a society in which a common, basic understanding of neuroplasticity and epigenetics are fact, not fiction, and serve to inform a more compassionate, trauma-informed approach to K-12 education and workplace wellness. Prevention for psychiatric illness can start early, suicide prevention can be built into every school and paediatric clinic, and children and adults can be taught strategies that protect and enhance cortical brain development.
Similarly, envision a society in which:
• Front-line citizens (e.g., first responders, teachers, health professionals, legal/financial advisors, probation/corrections officers, addiction counsellors) are trained in basic mental health first aid and suicide prevention
• We move beyond the shame sometimes associated with psychological distress, suicide attempts and suicide loss
• Medication-assisted treatment (MAT) is embraced as the gold standard of care for Opioid Use Disorder and is readily available in states across the nation
• Biomarkers for suicide and predictive analytics are further refined and scaled to a national level, giving every patient in primary care the benefit of mental health screening and suicide preventive interventions, as they do for other leading causes of death (cardiovascular, cancer, infectious)
• Health systems have become suicide-safer systems of care
There is a reason for hope. New recommended care standards were recently released for better detection and clinical care that reduces suicide risk. At the American Foundation for Suicide Prevention, research funding, community education and support for those who have attempted and/or lost loved ones to suicide serve as catalysts for cultural transformation. In addition, the suicide rate reduction is being demonstrated through initiatives like AFSP’s Project 2025, which has the bold goal of reducing the annual rate of suicide in the US by 20% by the year 2025, using a dynamic systems-model approach to determine evidence-informed actions to take to achieve that goal. The seeds of change are glimmering around the globe, and a hopeful foundation is being built upon an expanding awareness of this public health issue. New resources like WHO’s toolkit for engaging communities in suicide prevention are being launched. Stigma-reducing education like Mental Health First Aid is being taught around the world, from India to Ireland. In the US, the nation’s readiness for effective pro-mental health and suicide prevention strategies is growing like never before, and the scientific field of suicide has matured enough to provide answers on what we as a nation, and in communities throughout the country, can do to lower the rate of suicide throughout the country. We don’t have time to waste. We must all work together with partners of many types across sectors – health systems, business, labour, agriculture, law enforcement, media, education and policy – to mount an effective suicide prevention plan that is necessary to stem this rising tide.
Suicide prevention is a complex challenge, but we remain resolute. Let’s speed the scale-up of effective solutions and work together to reduce the suicide rate across nations, and further spread the sense of hope necessary to save lives.
5 ways communities can prevent suicides
• Host educational training such as Mental Health First Aid and Talk Saves Lives™ for frontline citizens and healthcare professionals.
• Invite local AFSP chapter to provide suicide prevention education and education on lethal means, especially among communities with higher gun ownership.
• Provide local media with guidance on safe reporting strategies, and hold them accountable for promoting messages of hope, help-seeking and resilience.
• Integrate mental health care and suicide prevention practices into primary care, and bring Safety Planning and SafeSide Primary Care Training to local health systems.
• Spread awareness of local mental health providers that specialize in treatment modalities that reduce suicide risk (especially in high risk individuals): cognitive behavioural therapy for suicidal people (CBT-SP), dialectical behaviour therapy (DBT) for adults and adolescents with elevated suicide risk, attachment-based family therapy (ABFT), and collaborative assessment and management of suicidality (CAMS).
Credit: Christine Moutier And Patrick J. Kennedy for World Economic Forum, 15 May 2019.