Suicides confront us with our limits when trying to save lives. They pose many what ifs...?: What if I could have said something to him? What if I heard what she was trying to tell me? What if we only had known how desperate she felt? What if he were not so alone?
The nation has made many attempts to prevent suicide -- from promoting two national strategies to funding community programs for youth prevention -- yet the overall rate has climbed 17.5 percent since 1999. In 2011, there were 39,518 suicides, our tenth leading case of death. Suicide was the second leading cause among youth and young adults, 15 to 34 years old, and an increase of 29.1 percent since 1999 among men and women, 35 to 64 years old, has driven the overall national rise.
Preventing suicide when someone stands at the edge of the cliff is a daunting task, ultimately challenging us to think differently. Many have promoted looking for "warning signs," but the vast majority of persons with such signs -- depression and distress, family tensions, alcohol or substance use, increasing isolation, and even suicidal thoughts -- never die by suicide. (Thankfully!) Among 100,000 persons with clinically significant depression (aka, major depression), perhaps 500 to 600 will kill themselves in the coming year -- a terribly high number and nearly 50 times the national average. But more than 99,000 will live. We don't know how to distinguish one from another.
Moreover, many persons who kill themselves provide few signals that they intend to die. Those who knew them, including family members and medical professionals, often say, "I never saw it coming." And it isn't for lack of trying. Sometimes those who kill themselves have long expressed distress and suffering, and their demeanor during the days before death apparently did not differ greatly from other days. At other times, people did not share their innermost thoughts, no matter what others may have asked.
A third barrier is geographic. We place our mental health services in hospitals, clinics, and practitioner offices. But many people never go to such places. Rather, they can be found (if someone were looking) in family court seeking orders of protection, or awaiting trial in criminal court for violent offenses, or in jail, or in front of a judge pleading their DUI arrest. There are many other places across our communities, and now through social media, where we can encounter persons who have life trajectories that will bring them to adverse outcomes, including suicide, death from drug overdose, fatal motor vehicle injury, or as a victim of homicide.
Until recently, suicide was viewed principally as a mental health problem, where it was felt that effective treatment of persons' psychiatric conditions or psychological issues would alleviate their suicidal thoughts and plans. However, many of us have viewed it as a fundamental public health problem as well as a mental health challenge.
Let's use heart disease as an analogy. Fifty years ago, hospitals around the nation built intensive care units to reduce cardiac deaths, only to find that three out of four persons died before they ever arrived at a hospital. For most who die by suicide, their first attempt is their last. Eventually, heart disease researchers, clinicians, and policy makers pursued public health approaches to foster prevention, encouraging persons to change their lifestyles in order to stop smoking, to exercise, and to work with their physicians to treat common problems, such as high blood pressure, long before someone might become "a case." It is time that we learn from them!
Colleagues and I think of suicide, at once, as a quintessentially individual event, much like a heart attack, and as a population level outcome that reflects the impact of life adversities and environmental factors (much like cardiac risks) that potentially are amendable to change long before someone comes to the edge of the cliff. For example, both men and women involved in intimate partner violence have heightened rates of suicide or attempted suicide, and their antecedent risks. Colleagues have been working with the National Domestic Violence Hotline to develop new approaches for training responders to explore with callers, typically victims in acute distress, whether they have suicidal thoughts or plans. Many do.
Men in the middle years who attempt and die by suicide often have a background of having been involved in domestic assaults. While it may be difficult to generate sympathy for perpetrators of such violence, many of these men were themselves victims of abuse during childhood. Following a wife or partner being granted an order of protection, they may become intoxicated and bereft of social support. Finding ways to intervene early with distressed couples potentially offers a window of opportunity benefitting women, men, and the next generation. The courts and the criminal justice system, more generally, potentially can serve as public health settings suited to engaging vulnerable persons when they may be more amenable to change.
Much of the advance in heart disease prevention came from changing cultural norms involving health and lifestyle. In a similar vein, we need to create a culture of safety to save lives in the U.S. This particularly relates, with respect to suicide, to deaths involving firearms and drugs. While the Second Amendment clearly allows individual ownership of guns, it is incumbent on us to find a way of building alliances among responsible persons to create safe environments in homes and in communities. If we can as a nation address deeply ingrained problems associated with tobacco use and nicotine addiction, key contributors to heart disease, we certainly should have the ability to develop broadly collaborative "safe home" coalitions that promote safe storage of firearms and potentially lethal prescriptions drugs, and public policies that limit gun ownership by persons having high-risk backgrounds, such as documented family violence or unstable mental health -- in addition to felony convictions.
The surging rise in deaths from prescription medications and street drugs during the past decade has been linked to increases in suicide. Frequent rulings of so-called "accidental" or "unintentional" death reflect a lack of knowledge about a person's last minute intentions, even in the context of clear patterns of life-threatening, deliberate self-intoxication. Whether masked suicides or self-harm without an intent to die, we must develop collective efforts that seek to change life trajectories by influencing culture, communities and families, as well as treating individuals in our current health and mental health systems. The "war on drugs" has failed, repeatedly. It is timely to consider public health approaches that use moral authority, policy changes, and treatment to stem this rising tide.
I think of efforts to bridge mental health and public health perspectives as forging a field of "public health and preventive psychiatry." Whatever name used to label such efforts, we urgently need to explore novel ways of developing and implementing effective strategies to prevent suicide and other premature deaths.