Editor’s Note: J. John Mann, M.D., Ph.D., is professor of psychiatry at Columbia University College of Physicians and Surgeons and director of the Suicide Prevention Center. Jeffrey A. Lieberman, M.D., is chairman of psychiatry at Columbia University College of Physicians and Surgeons, past president of the American Psychiatric Association, the author of “Shrinks: The Untold Story of Psychiatry” (Little, Brown 2015), and hosts the podcast “Shrink Speak.” Follow him @DrJlieberman. The opinions expressed are their own.
The recent deaths of Kate Spade and Anthony Bourdain are a stark reminder that suicide takes far too many lives prematurely and unnecessarily.
The 10th leading cause of death in the United States and the second-leading cause of death in people age 10-34, suicide claimed nearly 45,000 American lives in 2016 alone. Unlike other major threats to public health such as heart disease, smoking-related conditions, infectious diseases and cancer, whose death rates have declined in the last few decades, suicide rates have dramatically increased.
According to the Centers for Disease Control and Prevention, death by suicide has risen 25% in the United States since 1999 – and risen by 30% in half of all US states – despite falling over the same period in most of the rest of the world.
A number of myths surrounding suicide continue to persist. Most serious is the belief that people take their own lives abruptly, with no warning. They usually don’t. In more than 90% of cases, suicide is an outcome of a pre-existing mental disorder and associated risk factors.
While a recent CDC report suggested that only half of those who die by suicide have a mental illness, we know from many other systematic reviews of suicide deaths that this is vastly underestimated, and it is closer to 90% of cases in which people who take their own lives have prior conditions, whether they have been diagnosed and treated by a mental health professional or not.
We also know that in the United States only about 25% of those who died by suicide were in psychiatric treatment at the time, suggesting that most suicides occur because their illness has gone untreated.
Another common myth is that the mere mention of the word suicide by friends and loved ones leads individuals to take their lives. But in reality, those harboring suicidal thoughts actually benefit from talking openly about their feelings. If you are concerned about someone’s emotional state, and wonder if they might be at risk for suicide, you should engage them and inquire.
Think of someone’s worrisome behavior (social withdrawal, lack of interest, taking risks, frequent intoxication) or ominous statements (I’d be better off dead, life isn’t worth living, taking stock of what they have done) as if they have a fever. You don’t know if it’s due to a common cold or flu, or due to a more serious infection that needs immediate treatment. So, you ask them and if needed, encourage them to go or take them to see a doctor.
The first source of help if they are not already in psychiatric treatment is their primary care provider. There are also suicide help lines (The National Suicide Prevention Lifeline number is 1-800-273-8255). If the situation is dire, then you should call 911 or take them to the emergency room of a hospital where they can be fully assessed and advised of the best course of action.
Suicide should not be an acceptable outcome for mental disorders. Proper treatment can reduce the risk of suicide. But ensuring that those who are at risk receive care will require a sustained effort both at the micro and macro levels.
We can slow and reverse the escalating suicide trends by applying proven methods of prevention and providing better mental health care. Like heart disease risk calculators used to monitor those vulnerable to heart attacks, suicide risk assessments and risk reduction strategies should be employed to reduce suicide threat levels. The Columbia Suicide Severity Rating Scale was developed for just this purpose. (Full disclosure: Mann receives royalties for the commercial use of the Columbia Suicide Severity Rating Scale.) It is used to assess risk by first responders, in emergency rooms and by schools to assess risk. The FDA recommends the use of questionnaires like the Columbia Suicide Severity Rating Scale to assess risk and outcomes in clinical trials testing new psychiatric medications.
In addition to a pre-existing mental disorder, other factors influence one’s risk of suicide, including, but not limited to: a family history of suicide, substance abuse, and stressful life events, such as marital discord or losing one’s job. Men die by suicide at more than three times the rate of women and men are not as good as women at seeking help. And older males and middle-age females are at the greatest risk of suicide, demographics that include both Kate Spade and Anthony Bourdain.
Media coverage of prominent suicides can also play a role. Latent suicidal thoughts can wax and wane until pushed over the threshold to carry out the ultimate act. In this context, media coverage that glamorizes suicide can tip the scales for people who are thinking about suicide and vulnerable to social messages. While many media outlets are sensitive to this issue and make attempts to highlight the mental illnesses that resulted in suicide and its preventability, too much coverage tilts the story in the wrong direction.
Stopping needless deaths will also require greater policy efforts. Federal support for suicide prevention and treatment has chronically been underfunded, even while incident rates have continued to climb. A 2012 National Strategy for Suicide Prevention led by the US surgeon general called for, among other things, greater training for mental health professionals in assessing suicidal thoughts and behaviors.
Yet the number of trained professionals remains inadequate. In addition, the capacity for assessment and screening must extend beyond hospitals, clinics and doctors’ offices to engage people in community settings such as schools, place of employment settings and religious organi