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Published On April 5, 2018

CLINICAL RESEARCH

Why Doctors Must Solve the Suicide Problem

As despair deaths reach historic levels in the United States, interventions at health care checkpoints may be the best way to bring them down.

Between 1999 and 2014 the rate of suicide in the United States increased an alarming 24%. In 2016, the last year for which data was collected, the rate crept up another 1.2 percentage points, and suicide is the tenth leading cause of death in the country. The problem is clear, but gaining support for solutions has been hard to come by, says Christine Moutier, chief medical officer of the American Foundation for Suicide Prevention, the largest private funder of suicide research in the country.

Moutier helped launch Project 2025, an ambitious AFSP program that aims to reduce suicides by 20% in the next seven years. The bulk of the program focuses on roles that physicians and health systems can play. The most promising way forward, she believes, is to help clinicians identify patients at risk and provide care that can slow this epidemic.

Q: How did you get involved in suicide prevention?

A: When I was a dean at the University of California San Diego School of Medicine, we lost 13 faculty physicians to suicide over 15 years. That got us asking questions: What drives up suicide risk, especially for physicians? Can risk spread in a community? Can suicides be prevented? Our investigations helped shape a suicide prevention program at the school that is now in its tenth year.

Q: Why does Project 2025 focus on the role of physicians?

A: The data show that, nationally, quite diverse groups are at high risk—middle-aged white males and females, veterans, active-duty military, LGBT populations, the geriatric population, young Native American males and Latina teenagers. Trying to target all these groups separately is really challenging. We realized that the greatest opportunity is to employ evidence-based interventions in the settings where clinicians encounter all these at-risk groups: in emergency departments, primary and behavioral health clinics, and correctional facilities.

Q: How did you come up with a national strategy?

A: We gathered a panel of 25 experts that included scientists, clinical and policy experts, people who have experience of attempted suicide, and the survivors of those who have died by suicide. Together we surveyed the literature. We looked for what approaches clearly work to reduce suicides, if you can expose enough at-risk people. We found, for example, that treating someone who shows up in the ER after a suicide attempt with proven approaches—such as cognitive behavioral therapy—reduces repeat attempts and hospitalizations by about 50% for the following 12 to 24 months.

We specifically sought out interventions that could feasibly be implemented, either regionally or, ideally, at a national level.

Q: How is that different from past approaches?

A: The most common prevention approach has been community education and raising awareness, but measuring the impact of education on suicide rates is difficult—and talking about suicide in graphic or sensationalized ways can encourage contagion. Other approaches have included screening, but not necessarily with an emphasis on follow-up care.

Q: What kind of training can help a clinician prevent suicide?

A: Clinicians can learn how to think about suicide prevention as a continuous quality and safety practice, always running in the back of their minds. You make it a priority to recognize changes in risk that a patient faces over the continuum of care. When you identify that someone is at risk, or if the risk has recently increased, you focus on helping that person stay alive. You involve families when possible, and you employ safety planning and counseling about lethal means as part of every encounter. All these steps are known to reduce risk.

As basic as it is, you can also follow up by phone or another method. That has been robustly shown to reduce suicide rates for at-risk patients, particularly following discharge from the ER or a psychiatric unit.

Q: Suicide rates climbed a bit in 2016. That seems like a curveball in Project 2025’s goals, doesn’t it?

A: One likely possibility contributing to rising rates is that as the stigma associated with suicide goes down, the more often coroners and medical examiners will correctly label suicide deaths. Based on a limited amount of data, it is estimated that 10% to 15% of suicides are not called suicides. We are also committed to helping end that stigma. So even if the actual rate stays the same or begins to fall, it may look like it’s climbing for a period of time.

It’s also important to note that at the federal level, funding for suicide prevention research remains far too low. The total federal annual allocation for suicide-related research, including National Institutes of Health and other funders, is approximately $50 million, versus in the hundreds of millions to billions for many other leading causes of death. We do believe that if we use those dollars wisely and scale up the key interventions that have been proven to reduce suicide risk, we can begin to move the needle.