Provisional data from the Centers for Disease Control and Prevention (CDC) on suicide deaths for the year 2020 were published in the Journal of the American Medical Association (JAMA). According to the new data, deaths by suicide declined from 47,511 to 44,834 (5.6%) between 2019 and 2020.1 Suicide has reportedly decreased from the tenth to the eleventh leading cause of death as COVID-19 became the third leading cause of death.
We spoke to Dr Christine Yu Moutier, Chief Medical Officer of the American Foundation for Suicide Prevention (AFSP), about this provisional data.
Do the CDC data make you optimistic?
Dr Moutier: I remain optimistic that protective mental health measures are having a positive impact amid a time of collective distress and there’s a readiness to engage and implement effective suicide prevention strategies widely. The silver linings of the pandemic, including a continued sense of community cohesion, a more normalized dialogue around mental health and help seeking, increased treatment seeking, telehealth services and access to mental health care, and increased policies and investments in mental health services and suicide prevention, could indeed continue to contribute to preventive impacts.
For example, the AFSP Project 20252 aims to positively impact our culture surrounding mental health and suicide prevention by mobilizing institutions and individuals to embrace stronger evidence-based suicide prevention practices and research, drive suicide prevention policy, and increase open-mindedness around mental health with the goal of reducing the suicide rate by 20 percent by the year 2025.
While the most recent data from the Centers for Disease Control and Prevention (CDC) is encouraging from an overall population health level, the COVID-19 pandemic and its lasting effects on our nation’s mental health is far from over. It’s important to understand the following:
- COVID-19 and associated mitigation efforts such as physical distancing do not alone cause suicide. Suicide is complex, risk is dynamic, and an individual’s personal risk factors combined with precipitants such as evolving experiences with isolation, depression, anxiety, economic stress, and suicidal ideation, and access to lethal means may lead to periods of increased risk.
- This decrease in suicides may not be true for all groups in which the pandemic has had a disproportionate effect on particular populations, including youth and young adults as well as LGBTQ, American Indian, Alaska Native, Black and Latinx, and other minority communities.
- We may not understand the entire impact of COVID-19 on suicide deaths for another year or longer as suicide mortality data takes time to collect and analyze in a meaningful way. Additionally, we know there can be a time lag in the manifestation of distress even months after the acuity of a traumatic or stressful period is over.
How can clinicians continue embracing evidence-based suicide prevention strategies? In their practice, how can clinicians drive suicide prevention policy and increase open-mindedness around mental health and suicide?
Dr Moutier: I think every clinician can do a few things that are within their purview in order to reduce suicide risk of their patients:
- Incorporate routine suicide and mental health screening/rating scales into your practice.
- Use the Safety Planning Intervention in an ongoing way with all patients who have any level of suicidal ideation or suicide risk factors.
- Become familiar with Counseling on Lethal Means and practice this with any patients during periods of increased suicide risk.
- Increase the frequency of outpatient visits or communication during periods of increased risk.
- Involve the patient’s family in supportive actions to every extent possible with patient permission. For example, with helping make the home environment safe of lethal means.
- Have a referral list ready to go for CBT, DBT or CAMS– specific suicide risk reducing forms of therapy.
- Learn the data related to medications and suicide prevention.
- Utilize AFSP resources to help patients and families learn more, eg, After A Suicide Attempt, After Suicide Loss, How to Have a Real Convo.
- Advocate with the leadership of your health care organization to make suicide prevention a priority of the health system.
The onus of suicide prevention has to be a shared responsibility with health systems and leadership really taking the lead.
Some of the rationale for incorporating suicide screening and practice in clinical settings follows:
31% of people of people die by suicide visit an emergency department in the year prior to their death and up to 45% of people who die by suicide visit their primary care physician in the month prior, yet most mental health professionals do not receive education in mental health and training in effective suicide prevention practices is still in early stages of implementation. However, there are new ways to identify and support patients who are at risk, such as asking about suicidal ideation as part of a routine health screening or screening for signs of crisis in an emergency room, can have a dramatic life-saving impact.
Proactive steps clinicians can take to drive suicide prevention strategies and policy in their practice include:
- Implementing routine screening procedures by asking patients about thoughts of suicide or self-harm
- Instituting safety planning upon patient admission
- Developing a streamlined suicide risk assessment and care coordination tool
- Expanding utilization of best-practice suicide prevention models; and
- Expanding education of suicide/mental health care in medical and behavioral settings
Clinicians can also increase open-mindedness around mental health and suicide in their practice by asking their patients about suicidal thoughts and suicide risk factors without judgment and with an open mind. You will not increase a patient’s risk of suicide by talking to them directly. In fact, it could save their life. Being clear with your patients and their families that they can talk about struggles and engage in supportive, active listening with one another can help them be more open about their mental health and increase their willingness to work with you to determine the best course of action. Remind your patients and their family members that experiencing serious challenges is a normal part of life and that you’ll continue to support them.
Research shows that when primary care and health systems embrace mental health as integral components of primary care and health care delivery, many health outcomes improve. Individual suffering and disability improve, and families, schools, and workplaces benefit when individuals can live and function to their healthiest potential. There are also enormous economic benefits3 for prioritizing mental health promotion and prevention.
Christine Yu Moutier, MD, is the Chief Medical Officer for the American Foundation for Suicide Prevention (AFSP). Her clinical handbook, Suicide Prevention, was published in May 2021 by Cambridge University Press.
- Ahmad FB, Anderson RN. The leading causes of death in the US for 2020. JAMA. Published online March 31, 2021. doi:10.1001/jama.2021.5469
- PROJECT 2025 A nationwide initiative to reduce the annual rate of suicide in the U.S. 20 percent by 2025. AFSP. https://project2025.afsp.org/
- McDaid D, Park AL, Wahlbeck K. The economic case for the prevention of mental illness. Annu Rev Public Health. Published online January 2, 2019. doi:10.1146/annurev-publhealth-040617-013629a