We're going about suicide prevention the wrong way

Suicide is rare among the general population. It is more common, but still rare, among people with serious mental illness. There are about 38,000 successful suicides per year (American Foundation for Suicide Prevention 2010). There are at least 380,000 attempts. The lifetime risk to those with schizophrenia is only 5%. (Hor and Taylor 2010). The lifetime risk to those with bipolar is only 10-15%. (Center for Disease Control and Prevention 2014). Of the 37.5 million Californians, only 3,823  (.01%) took their own lives, and 16,425 (.04%) were hospitalized for self-inflicted injuries in 2010. (California Mental Health Services Authority 2012).   

Advocates regularly overstate the prevalence of suicide and attempts among persons with mental illness in order to curry funding for their programs. At the high end, the National Alliance on Mental Illness claims, “More than 90% of youth suicide victims have at least one major psychiatric disorder.”  (National Alliance on Mental Illness (NAMI) 2013)  Mental Health America, a trade association for providers of mental ‘health’ services estimates “30% to 70% of suicide victims suffer from major depression or bipolar (manic-depressive) disorder” (Mental Health America n.d.).

Suicide is not always the irrational act of a sick mind.  Mental illness in people who commit suicide is often diagnosed after the fact. After someone takes his or her own life, we look for a cause. If they take their life after having had lost their spouse or job, gotten a bad grade in school, or received a new medical diagnosis we chalk it up to depression and put the suicide in the mental illness column. 

In spite of being overstated, it is clear that suicide disproportionately affects people with mental illness. Dr. E. Fuller Torrey looked at studies of the prevalence of suicide among the seriously mentally ill and studies of the prevalence of serious mental illness among those who suicide, two sides of the same coin, and in both cases found about 5,000 of the 38,000 suicides (about 14%) were in people with serious mental illness. This is still three times their presence in the general population.  (Torrey n.d.).

Suicide can not be reduced through advertising and public relations

Every suicide is a tragedy for the individual, their family and the community. Many of these suicides could be prevented if persons with mental illness were provided care. Instead of doing that, the industry is funding ineffective feel good campaigns targeted at the general public.

The mental health industry’s main tool in reducing suicide takes the form of public service announcements, brochures, hotlines, and speeches targeted to the general population. For example, in 2012, the California mental health industry banded together to spend $32 million in public funds for a TV, radio, billboard, online, mobile and print advertising campaign targeted at the general public to reduce suicide. (California Mental Health Services Authority 2012).

But there is little scientific evidence media campaigns reduce suicide and mounting evidence they don’t. The largest and most sound review of the issue was Suicide Prevention Strategies: A systematic review, published in the Journal of the American Medical Association.  (J. John, Alan and al. 2005). The authors found that “despite their popularity as a public health intervention, the effectiveness of public awareness and education campaigns in reducing suicidal behavior has seldom been systematically evaluated.” The report went on to note what the research does show: “Such public education and awareness campaigns, largely about depression, have no detectable effect on primary outcomes of decreasing suicidal acts or on intermediate measures, such as more treatment seeking or increased antidepressant use.”

“A 2009 study in the journal Psychiatric Services looked at 200 publications between 1987 and 2007 describing depression and suicide awareness programs targeted to the public and found that the programs “contributed to modest improvement in public knowledge of and attitudes toward depression or suicide,” but could not find that the campaigns actually helped increase care seeking or decrease suicidal behavior. A similar study in 2010 in the journal Crisis actually found that billboard ads had negative effects on adolescents, making them “less likely to endorse help-seeking strategies”. (Sanburn 2013)

Mental health industry sponsored suicide initiatives are often targeted at college students, a group least likely to commit suicide.  The 2011 National Survey on Drug Use and Health is one of the premiere epidemological surveys and found college students were less likely than other same aged adults to have serious thoughts of suicide (6.5 vs. 8.4 percent), make suicide plans (1.5 vs. 2.4 percent), or attempt suicide (0.8 vs. 1.8 percent). (SAMHSA 2012). The college targeted PR programs are no more effective than mass market anti-suicide PR campaigns. “Few such programs are evidence-based, reflect the current state of knowledge in suicide prevention, or evaluate effectiveness and safety for preventing suicidal behavior…A systematic review of studies published from 1980-1995 found that knowledge about suicide improved but there were both beneficial and harmful effects in terms of help-seeking, attitudes, and peer support.” (J. John, Alan and al. 2005)

Why are mass market media campaigns so popular in spite of the fact there is no evidence they work and evidence they don’t? Money. It is very easy and profitable for a mental health provider to write a brochure, produce a PSA, rather than try to reduce suicide. By putting their logo on the materials they increase their visibility and self-importance. As one researcher concluded, “The conflict between political convenience and scientific adequacy in suicide prevention is usually resolved in favor of the former. Thus, strategies targeting the general population instead of high-risk groups (psychiatric patients recently discharged from hospital, suicide attempters, etc.) may be chosen…especially if the desired outcomes also include a number of conditions frequently associated with suicidal behaviours (such as poor quality of life, social isolation, unemployment and substance misuse).” (Diego de Leo 2002)

How to reduce suicide

A high risk group those who want to reduce suicide should target are prisoners. Suicide in jail is three times more common than in the general population and thirty eight percent of those who committed suicide in jail in 2005-2006 had a known history of mental illness. (Hayes April, 2010). If the mental health industry worked to reduce incarceration of persons with mental illness, they could further reduce suicide.

 Another effective suicide prevention strategy is means removal: putting locks on guns, medicine cabinets and drawers containing knives. (Yip, et al. 2012). However, the mental health industry is unlikely to give up funds they can use to create TV ads (that feature their logo) in order to fund suicide means reduction. California did authorize the use of mental health dollars to fund a net under the Golden Gate Bridge. But that was largely a PR ploy to defuse criticism of massive waste in California’s Proposition 63 which is supposed to fund services for the seriously ill. Proposition 63’s author, California Senate President Pro Tem Darrell Steinberg noted “Proposition 63’s contribution to suicide prevention at the Golden Gate Bridge will probably become its most publicly recognizable benefit.” (Steinberg 2014) 

If the mental health industry insists on relying on communications as a path to reduce suicide, then those communications would be much more effective, and should be targeted at those of highest risk of suicide, not the general public.  It has long been known and ignored that those who are most likely to commit suicide are those who have previously attempted suicide, first degree relatives of those who completed suicide, and persons with serious mental illness, not the general public. (Tsuang 1983), These individuals, by name, are likely known to the mental health system as a result of their suicide or family histories. Intensive follow up of these individuals, rather than the general public, would be a much more efficient and effective way for the industry to reduce suicide caused by mental illness. As the executive director of the American Association of Suicidology (AAS) Lanny Berman told Time Magazine,

 “The general zeitgeist in the field is public education is good, and it’s better that people know about the problem and really know that prevention is possible. “But I don’t know that public awareness campaigns work for the people you most want to reach, the people who are already suicidal.”  If we know who’s most at risk, people like Jaffe and Berman argue, shouldn’t we target them in a smarter way? If a factory closes, for example, shouldn’t efforts be made to market suicide prevention services in that community? ...Berman… is concerned that SAMHSA is too focused on “upstream” measures like increasing overall awareness. “The bottom line is that the people most at risk are people who don’t get into treatment, and a public health approach shifts attention from high-risk patients to large populations of folks who might develop mental health problems,” he says.” (Sanburn 2013)

While the lifetime risk for suicide in people with schizophrenia is only 5%, we do know how to predict and prevent those suicides. The biggest risk factors are “number of prior suicide attempts, depressive symptoms, active hallucinations and delusions, and the presence of insight…a family history of suicide, and comorbid substance misuse. The only consistent protective factor for suicide was delivery of and adherence to effective treatment.” (Hor and Taylor 2010)

 If mental illness is a cause of suicide, then treating mental illness should reduce suicide. But as far as we know, no mental health provider is proposing to use suicide funds to treat the seriously ill. There is evidence they should.  A study in New York found Assisted Outpatient Treatment, reduced suicide attempts and physical harm to self 55%. (New York State Office of Mental Health 2005). The Treatment Advocacy Center compiled a list of studies suggesting suicide is more likely to occur in those individuals with schizophrenia and bipolar disorder who are not being treated or adequately treated and less likely in those that are treated:

• A Swiss 34-year follow-up study of 158 individuals with bipolar disorder reported that 18 of them (11 percent) had committed suicide. The suicide rate was more than twice as high among patients who had not been treated compared with those who had been treated (p = 0.04), a difference the authors called "spectacular."
Angst F, Stassen HH, Clayton PJ et al. Mortality of patients with mood disorders: follow-up over 34-38 years. Journal of Affective Disorders 2002;68:167–181.
•  In a study of suicide among psychiatric patients, it was reported that "42 of the 59 patients (71.1%) who were depressed in their last episode [of hospitalization] were not receiving adequate antidepressant or lithium carbonate medication at the time of suicide."
Roy A. Risk factors for suicide in psychiatric patients. Archives of General Psychiatry 1982;39:1089–1095.
•  A study in Kentucky found that only 2 of 28 individuals with schizophrenia who committed suicide had evidence in their blood of having taken antipsychotic medication. Thus, 93 percent of them were not being treated. Shields LBE, Hunsaker DM, Hunsaker JC III. Schizophrenia and suicide: a 10-year review of Kentucky Medical Examiner cases. Journal of Forensic Sciences 2007;52:930–937.
• A case control study of 63 individuals with schizophrenia who committed suicide and 63 individuals with schizophrenia who did not reported that "there were seven times as many patients who did not comply with treatment in the suicide group as there were in the control group."
De Hert M, McKenzie K, Peuskens J. Risk factors for suicide in young people suffering from schizophrenia: a long-term follow-up study. Schizophrenia Research 2001;47:127–134.
• Studies have suggested that some medications, especially clozapine and lithium, may decrease the incidence of suicide among individuals with severe psychiatric disorders.
Tondo L, Baldessarini RJ, Hennen J. Lithium and suicide risk in bipolar disorder. Primary Psychiatry 1999;6:51–56.
Müller-Oerlinghausen B. Arguments for the specificity of the antisuicidal effect of lithium. European Archives of Psychiatry and Clinical Neuroscience 2001;251(suppl):1172–1175.
• A study from Germany using a case-control methodology compared 27 inpatients with schizophrenia and 24 inpatients with affective psychoses, all of whom suicided, with their matched inpatient case controls who did not suicide.  The authors concluded that there is "a significantly increased risk" of suicide when medications are not used.
Gaertner I, Gilot C, Heidrich P et al. A case control study on psychopharmacotherapy before suicide committed by 61 psychiatric inpatients. Pharmacopsychiatry 2002;35: 37–43.

Conclusion

Suicide is horrible for those left behind. By spending suicide funds on what we know works we may be able to reduce suicide. By spending it on what doesn't work, we certainly can't.

Works Cited

American Foundation for Suicide Prevention. Suicide: Facts and Figures. 2010. https://www.afsp.org/understanding-suicide/facts-and-figures (accessed April 15, 2013).

California Mental Health Services Authority. California Mental Health Services Authority Launches Statewide Suicide Prevention Campaign. Dec 12, 2012. http://www.prweb.com/releases/prweb2012/12/prweb10229719.htm (accessed 12 28, 2013).

Center for Disease Control and Prevention. "Surveillance for Violent Deaths — National Violent Death Reporting System, 16 States, 2010 ." Morbidity and Mortality Weekly Report, January 17, 2014: 1-33.

Diego de Leo, Franzcp. "Why are we not getting any closer to preventing suicide?" The British Journal of Psychiatry 181 (2002): 372-374.

Hayes, Lindsay M. National Study of Jail Suicide: 20 Years Later. National Institute of Corrections, U.S. Department of Justice, Available at http://static.nicic.gov/Library/024308.pdf, April, 2010.

Hor, Kahyee, and Mark Taylor. "Suicide and schizophrenia: a systematic review of rates and risk factors." Journal of Psychopharmacology, November 2010: 81-90.

J. John, Mann MD, Apter MD Alan, and et. al. "Suicide Prevention Strategies A Systematic Review." The Journal of the American Medical Association (JAMA) (American Medical Association) 294, no. 16 (October 2005): 2064-2074.

Mental Health America. Suicide. http://www.nmha.org/go/suicide (accessed April 15, 2013).

National Alliance on Mental Illness (NAMI). Suicide Fact Sheet. January 2013. http://www.nami.org/factsheets/suicide_factsheet.pdf (accessed April 15, 2013).

New York State Office of Mental Health. Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment. Report to Legislature, Albany: New York State, 2005, 60.

SAMHSA. "Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings." Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration , Rockville, MD, 2012.

Sanburn, Josh. "Inside the National Suicide Hotline: Preventing the Next Tragedy." Time, September 13, 2013.

Steinberg, Darrell. Steinberg on vote for Suicide Barrier at Golden Gate Bridge. June 27, 2014. http://sd06.senate.ca.gov/news/2014-06-27-statement-steinberg-vote-suicide-barrier-golden-gate-bridge (accessed July 20, 2014).

Torrey, E.F. 5000 suicides a year are likely caused by mental illness, mainly untreated mental illness. . http://mentalillnesspolicy.org/consequences/suicide.html (accessed 4 15, 2013).

Tsuang, MT. "Risk of suicide in the relatives of schizophrenics, manics, depressives, and controls. T." Journal of Clinical Psychiatry 44, no. 11 (November 1983): 398-400.

Yip, Paul, Eric Caine, Saman Yousuf, and Shu-Sen Chang. "Means restriction for suicide prevention." Lancet 379, no. 9834 (June 2012): 2393 - 2399.