Hotlines Aren’t Enough to Help People at Risk of Suicide

By | December 15, 2018

By CARA ANGELOTTA MDCara Angelotta, suicide prevention, health policy

Contrary to popular belief, the risk of suicide does not increase around the holidays. But, according to the Centers for Disease Control and Prevention, annual suicide rates in the U.S. have risen nearly 30 percent since 1999.

Much of the media coverage following the high-profile suicides of Kate Spade and Anthony Bourdain has followed recommended best practices to reduce risk of suicide contagion or “copycat” suicides by including warning signs a person may be at risk of suicide due to depression and contact information for the national hotline for suicide prevention. This overly simplistic approach implies that we can prevent all suicides by reaching out to loved ones in emotional distress and advertising the existence of mental health treatment.

As a psychiatrist who treats individuals hospitalized for acute suicide risk, I am concerned that much of the media coverage has belied the complexity of suicide. While we do not yet fully understand why suicide rates are rising, we do know that suicide is a complex public health problem that will require a multifaceted approach to reduce deaths. Increased awareness of depression as a treatable medical illness is an important but insufficient response to the suicide epidemic.

Risk factors for suicide extend beyond depression and suicidal ideation, which is the psychiatric term for contemplating suicide. Substance abuse (in particular alcohol and prescription drugs like opioids and benzodiazepines), prior suicide attempts, a history of psychiatric hospitalization, psychotic illnesses, personality disorders, and a family history of suicide are among the many psychiatric factors that are associated with an increased risk of completed suicide.

Social stressors, like financial distress and relationship problems, and medical problems, like traumatic brain injuries and physical pain, also increase suicide risk. Given the varied profile of individuals who die by suicide, a one size fits all approach of increased awareness of depression treatment will not be effective in reducing the rising rates of suicide.

Given that most people with suicide risk factors will not attempt suicide and many more people contemplate suicide than complete suicide, accurate prediction of individual suicide risk is challenging at best. The results of a recent study in the American Journal of Psychiatry suggest that electronic medical records may be utilized to help clinicians flag those at highest risk of future suicidal behavior.

Advertising suicide hotlines is a good start to reducing the risk of suicide for some vulnerable people, but psychiatric treatment alone is unlikely to solve the suicide epidemic. According to a World Psychiatry report, although the use of mental health treatments in the U.S. has increased since the early 1990s, largely driven by increases in antidepressant medication use, there is no evidence for any corresponding reduction in mental illness among U.S. adults in this same period. In a study of U.S. suicide deaths, nearly 25 percent of individuals received a mental health diagnosis in the four-week period prior to suicide.

While treatment, in its current state, is not a panacea for all individuals at risk of suicide, there must be high quality, evidence-based mental health treatment readily available for those that call suicide hotlines. There is a nationwide shortage of psychiatrists. Psychiatric treatment is often difficult to access with insurance and even harder to access without insurance or the means to pay directly for care. Mental health treatment also varies substantially in quality.

In addition to access to high-quality treatment, public health measures to reduce access to lethal means of suicide are important. According to the CDC, a firearm was used in nearly half of completed suicides in the United States between 1999 and 2016 for which data were available to analyze. Reducing access to guns has reduced suicide rates in other countries. Within the United States, state laws that limit access to handguns, like gun locks, universal background checks, and waiting periods for gun purchases, have been associated with reduced suicide rates.

Kindness, reaching out, and reduced stigma are necessary responses to suicide. Individuals have a role in suicide prevention, but society must make sweeping changes to solve this growing problem. The best means to reduce suicide on a population level will also involve commonsense public health approaches, expanded access to a full spectrum of high quality care provided by well-trained professionals, and increased funding of research to improve suicide risk prevention and mental health treatment.

Cara Angelotta MD is a forensic psychiatrist, Assistant Professor of Psychiatry at Northwestern University Feinberg School of Medicine and a Public Voices Fellow with The OpEd Project.