Improving Suicide Prevention and Treatment

The suicide rate in the United States is about the same today as it was in the 1950s. The rate has increased and decreased at times for reasons that are known and unknown.

Higher antidepressant prescription rates seem to be correlated with modest reductions in suicide rates, whereas higher per capita alcohol consumption is related to a higher national suicide rate.

Other factors like lower per capita income and lack of availability of medical services favor higher suicide rates.

About 40,000 people died by suicide in 2011, with rates increasing among middle-aged men and women.1 Equally disturbing, suicide is the second leading cause of death among those aged 15 to 34 years.

Clearly, we need to do better at suicide prevention. About 20% of all suicides see a mental health professional within 30 days of their suicide, and almost twice that number see primary care physician or internist. Most people who commit suicide in the United States have an untreated mood disorder. We need to improve the diagnosis and treatment of mood disorders.2 Importantly we need to train nonpsychiatrists to do this.

Suicide prevention involves risk assessment and targeting aspects of both stressors, such as an acute episode of major depression, and the diathesis or predisposition, which includes mood regulation including pessimism, and reactive aggressive traits or decision-making.3

Mood regulation can be improved by cognitive therapy. Depression can be treated with antidepressants. The impact of access to lethal means, such as guns and alcohol, are fundamental considerations in suicide risk management. Alcohol should be removed from the home of suicidal outpatients, as should guns. Medications should be locked up.

Use of antidepressants to treat major depressive episodes is the single most effective suicide prevention measure in Western countries. Even when antidepressants are used, the dose and duration of treatment are frequently inadequate.

Drugs used to treat other mental illnesses are also being looked at for suicide prevention.4 For example, clozapine and lithium have been examined for use in the prophylaxis of suicide attempts.

In addition to better managing mood disorders, there are instruments or rating scales that can be used to assess suicide risk by measuring past suicidal behavior and current suicidal ideation.

One example is the Columbia Suicide Severity Rating Scale (C-SSRS), which is used by the FDA in the evaluation of all psychotropic medications and can also be easily used by clinicians in clinical practice.

The more lethal a past suicide attempt and the presence of current suicidal ideation with a specific plan and intent — meaning the patient feels they may act on the thoughts of suicide — all heighten the risk for suicide.

A family history of suicide or a nonfatal suicide attempt is also a risk factor, because the predisposition to suicidal behavior is transmitted in families and is partly heritable.

We have shown that reduction in the severity of suicidal ideation and occurrence of suicidal behavior in depressed adults is largely determined by the degree of improvement in depression.

Psychiatrists and other mental health professionals should measure the degree of improvement in depressive symptoms to optimize treatment response.

Systematic assessment of suicide risk at the first clinic visit and at follow-up visits can help detect patients who are at greater risk. In the future, we expect biological tests will supplement clinical risk assessment.5

J. John Mann, MD, is the vice chair for research in the Department of Psychiatry at Columbia University. He is also director of research and director of the Molecular Imaging and the Neuropathology Division at the New York State Psychiatric Institute. Mann will be presenting on this topic at the 2014 U.S. Psychiatric & Mental Health Congress on September 22 in Orlando, Florida.


  1. Centers for Disease Control and Prevention. Suicide and self-inflicted injury. National Vital Statistics Report. 2011; 63(3).
  2. Mann JJ, et al. Suicide prevention strategies: a systematic review. JAMA. 2005; (294):2064-2074.
  3. Heeringen K and Mann JJ. The neurobiology of suicide. Lancet Psychiatry. 2014; (1):63-72.
  4. Griffiths JJ, et al. J Prev Med. “Existing and Novel Biological Therapeutics in Suicide Prevention.” 2014; 47(3S2):S195-S203.
  5. Mann JJ, et al. Can biological tests assist prediction of suicide in mood disorders? Int J Neuropsychopharmacol. 2006; (9):465-474.