Short-circuiting the suicide cascade

The suicide rate in the United States continues to spiral upward, with seemingly no end in sight. More than 45,000 Americans take their own lives each year, 33 percent more than did so in 1999, according to the most recent federal data.

It’s a national public health crisis — one that researchers and clinicians have struggled to thwart because the triggers of suicide are so poorly understood. People may wrestle with suicidal thoughts for years, but not follow through. Depression and other mental health conditions are clearly risk factors, but such diagnoses aren’t linked to roughly half of all US suicides. Some prevention efforts, such as asking a patient to sign a “contract” to not commit suicide, have proved to be largely useless.

But there’s been some encouraging progress in recent years, both in understanding the suicidal thought process and in developing individual and societal interventions to better assist those caught in the crucible of such a crisis. Instead of encouraging people to sign no-suicide contracts, clinicians now are more likely to work with a patient to design a personalized prevention plan to use when suicidal thoughts flare. Clinicians and suicide prevention experts are tackling how suicide is portrayed in the media, working to debunk misunderstandings and trying to slow access to pills, guns and other means, particularly for individuals who have expressed suicidal thoughts.

“From a clinical perspective, we can do a lot better than just leaving people on their own to figure out how to deal with not killing themselves,” says Barbara Stanley, a clinical psychologist at New York City’s Columbia University. “We can give them strategies and skills.”

What turns thought to action?

Some 15 years ago, researchers began to view suicide as two distinct processes —suicidal thoughts, also called ideation, and the progression that can lead to an attempt. That shift in thinking has spawned research on when and how ideation leads to action, and the risk factors involved.

David Klonsky, a psychologist at the University of British Columbia, and Alexis May, then a graduate student and now at Connecticut’s Wesleyan University, posited that three steps tip the balance from ideation to action. They explore their Three-Step Theory, and several others with overlapping elements, as part of a look at suicidal ideation and attempts in the 2016 Annual Review of Clinical Psychology.

The first step — the psychological groundwork — is laid when someone is living with unremitting emotional or physical pain, which is further amplified if it’s overlaid by a sense of hopelessness: a feeling that there’s no way out. “Another way to think about step one,” Klonsky says, “is that it’s creating that desire to not want to be alive.”

The second step in the theory rests on the degree to which that pain and hopelessness is ameliorated by connectedness to others or to a broader community. Those ties might be rooted not just in personal relationships — a challenge in today’s America where loneliness appears to be on the upswing — but also connections to a job, a personal cause or even the outcome of the current football season.

If bleakness and disconnectedness align, a person becomes vulnerable to taking the critical third step: the leap from thoughts to action. Basic personality plays a role here: Someone less squeamish about blood and violence will have lowered sensitivity to inflicting pain and harm on themselves. But in large part, the leap to step three is a matter of practical capability — access to lethal means and the knowledge to use them. In America, that often means guns. “If someone is living with a firearm and they … know how to use it, their practical capability is very, very high,” Klonsky says.

Heightened practical capability can also figure in the emergence of apparently related suicides, such as the unsettling deaths this March involving survivors of the Parkland school shootings. Knowing that someone you know, or who appears similar to you, has committed suicide can make taking one’s own life seem more feasible, suicide prevention experts say.

A troubling influence

For this reason, experts were highly critical of the popular Netflix dramatic series “13 Reasons Why,” which first aired in 2017 and featured a teenage girl who, after her suicide, released 13 score-settling tapes describing the ways people in her life had failed her. Not only could other teens identify with the girl, but the program also showed the method in graphic detail, presenting suicidally inclined viewers with a means.

“That was a lot of the backlash with the show,” says Catherine Glenn, who studies self-injury risk factors in adolescents at the University of Rochester in New York. “That played out [the method] in almost a step-by-step fashion.” And hospitalizations for suicide attempts and suicidal thoughts did indeed increase after the show aired, according to a recent study in the Journal of Adolescent Health.

But there is a surprising safety net for all potential suicide victims: time. It’s on their side if they can be kept away from guns or other immediately lethal means. Research shows again and again that the window of peak suicide risk is narrow, frequently just an hour or so, and sometimes less than 20 minutes. “The choice to take one’s life is rarely a long-term stable choice,” Klonsky says. “It’s usually made in the moment of crisis that’s not as bad even five or six hours later.”

Keeping the window to life open

Still, clinicians are frequently faced with a longer-term dilemma: what to do if patients are considered suicidal — either because they’ve attempted suicide or admit to suicidal thoughts — but not ill enough to be hospitalized. How best to keep them safe in the weeks and months to come?

“By and large, if someone is in your office or in an emergency room, they at least have mixed feelings about killing themselves,” says Stanley. “As a clinician, you align with the part of them that wants to stay alive.”

Previously, and sometimes even today, patients who have expressed suicidal thoughts or attempted suicide have been asked to sign a contract promising not to try again. Research into this contractual approach has been limited, but what data exist don’t show benefit. There also are some practical reasons why this approach has proved to be a non-starter, Stanley says. Patients have described the paperwork as little more than a way to shield clinicians and clinicians’ employers against future liability. Plus, a contract by definition requires that both parties “have skin in the game,” Stanley points out. “For a no-suicide contract, the only person giving is the patient.”

Instead, clinicians have begun working with at-risk patients to create individual prevention plans. Working together, they design a concrete series of steps for recognizing a burgeoning suicidal crisis and heading it off.

Patients identify warning signs, such as drinking more, or spending a lot of time alone. With clinicians, they brainstorm coping strategies and ways to distract from or soothe their mood, such as doing chores or listening to music. For times when they need outside help, they list names of close friends, family members and mental health clinicians.

The plans are not a substitute for treating underlying risk factors such as depression or post-traumatic stress disorder, but they do provide something tangible to rely on during a person’s darkest moments, says Stanley, co-developer of one such approach called the Safety Planning Intervention. “When you’re in a suicide crisis, you’re not thinking straight — you don’t want to have to think.”

Stanley says she has many examples in which the plan made a difference — such as, one time, “somebody going to the George Washington Bridge, realizing that the safety plan was in his pocket, feeling it, and saying, ‘OK, let me try this first instead of jumping.’”

A recent study in JAMA Psychiatry of the Safety Planning Intervention reported that it cut short-term suicidal behaviors nearly in half. It looked at 1,640 patients getting care at Veterans Affairs emergency departments, finding that among 1,186 who completed a plan and got at least two follow-up phone calls shortly after hospital discharge, the rate of attempts or near attempts in the subsequent six months was 3 percent, versus 5.3 percent for 454 patients getting usual care, which was typically referral to a mental health clinician.

How guns make a difference

These prevention plans often also involve restricting access to suicidal means. Researchers affiliated with Means Matter, a Harvard School of Public Health campaign, have promoted this approach with strategies that include reducing access to dangerous or lethal doses of medications and storing guns away from at-risk individuals or, at a minimum, locking them up. The campaign is working with an array of gun owner groups and gun shops across the country to promote suicide prevention as a basic tenet of firearm safety.

One frequently cited study in the 2007 Journal of Trauma found that access to guns does make a difference. It compared a group of states with high rates of gun ownership to a second group with low ownership, and found suicides in the first group were nearly twice as high. Virtually all of that disparity was attributable to firearm suicides; there was scant difference in non-firearm suicides between the two groups. The pattern remained in a study published in 2013.

“When you try with a gun, you usually don’t get a second chance,” says Matthew Miller, one of the studies’ authors and a suicide researcher at Boston’s Northeastern University who has studied access to firearms.

While any discussion about gun restrictions can become a hot-button subject in the US, researchers can quickly check off numerous examples where blocking access to means has saved lives. When the United Kingdom discovered a less toxic form of gas to fuel ovens and heaters, the rate of suicides by domestic gas fell to nearly zero by the late 1970s. Similarly, banning the most highly toxic pesticides commonly used in Sri Lanka reduced that country’s overall suicide rate. And suicide barriers on bridges — such as the steel net now under construction beneath the Golden Gate Bridge — have reduced the incidence of suicide by jumping.

There’s good reason to be hopeful about interventions like these, particularly because the popular perception that someone contemplating suicide is nearly unstoppable is wrong, Miller says. A 2006 study he was involved with, based on a survey of 2,770 members of the public, found that 34 percent didn’t believe installing a barrier at the Golden Gate Bridge would avert even a single death. In other words, they believed that 100 percent of potential jumpers would have found another way. “That just shows you in some sense how fatalistic people are,” Miller says.

In reality, most people’s unsuccessful suicide attempts do not ultimately lead to a later death by suicide — a fact that offers hope. One analysis of 90 studies, which followed people who had been treated for self-harm, found that while some had gone on to attempt again, more than nine years later just 7 percent had taken their own lives.  

“If people have a suicidal crisis and don’t die,” Klonsky says, “they’re overwhelmingly likely to live a life that does not end in suicide.”