Suicide: Prevention, not Prediction

Most of us have been affected by suicide in some way. Whether we lost a mom or dad, a brother or sister, a significant other, a friend, a neighbor, a co-worker, or the lady who used to cut your hair; the majority of us have known someone who has taken their own life. There’s a flurry of emotion. There’s shock, anger, and sadness and everyone handles the loss a little bit differently. But usually there’s a central theme, a central question. Why?

But the truth is, after 60 plus years of research, we still don’t really know why. What we do know is that suicide attempts rarely come out of nowhere. People don’t just snap. There are warnings. There are certain factors, situations, or characteristics that some people who die by suicide share and, by the same token, there are some interventions or actions that seem to prevent people from killing themselves.

First, we need to understand how vast the suicide problem actually is. Suicide rates may have varied slightly over the years, but they have not decreased a significant amount in many decades. In fact, suicide rates have increased by an average of 45% over the last 60 years¹. Suicide is the leading cause of death globally² and is 1 of the top 3 leading causes of death of the most economically productive age group (15- to 44-year-olds)³.

Worldwide, nearly one million people suicide every year^{4, 5}, more than 40,000 in the United States alone⁶.  That’s one suicide every 15 minutes⁷. It’s estimated that there are roughly 25 suicide attempts for every completed suicide⁸. That’s about 25 million suicide attempts annually worldwide⁹; one attempt every 40 seconds¹⁰. Overall, suicide accounts for more deaths per year than homicide, car accidents, war, and AIDS combined¹¹.  About 14% of the US population has had or will have thoughts of suicide at some point in their lives, and almost 5% of the US population has had or will have made a suicide attempt at some point in their lives. That’s 1 in 20 people! One in 20 people will attempt suicide at some point¹² (70).

Obviously, attempting to identify those at risk of attempting suicide is vitally important to prevent loss of life. Suicide has been studied for many years with this exact goal in mind. As early as the late 1800s, theories of suicide were offered. Surely, with the thousands of research studies on risk factors and intervention strategies for suicide, we must be getting really good at predicting which individuals are going to exhibit suicidal behavior right? Wrong. Very, very wrong. Research-based risk factors have been determined to be only weak predictors of suicide. Moreover, the accuracy of clinicians in predicting who will attempt suicide has been found to be only slightly better than chance¹³.  It’s been found that assessing risk doesn’t necessarily result in accurate prediction.^14,15 When individuals are assessed for suicide risk, only about 3-5% of those who were in the “high risk” group completed suicide. On the other hand, about 50-60% of those who completed suicide were assessed to be in the “low risk” group¹⁶. The bottom line is we’re not good at predicting suicidal behavior¹⁷. One might ask what the value is of studying and identifying risk factors at all then? The value is not in trying to predict the behavior, but in managing the risk to attempt to prevent the behavior¹⁸. It’s not about prediction. It’s about prevention.

Let’s look at it a different way.  We know that there are certain circumstances that put us a higher risk for having a heart attack: smoking, high blood pressure, high cholesterol, and obesity, to name just a few. These are risk factors for having a heart attack. Not everyone who smokes has a heart attack. Not everyone with high blood pressure or high cholesterol has a heart attack. Not everyone who is obese has a heart attack. Yet there are plenty of people who don’t have any of these risk factors who do have heart attacks. Yet, we still try to avoid the risk factors. We do this to minimize the chances we will have a heart attack to the extent possible. We try to prevent it from happening. It is the same with suicidal behavior. We use research-based risk factors to minimize the chances that suicidal behavior will occur with the goal of prevention.

The next blog in this series on suicide prevention will examine key risk factors for suicidal behavior.

National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) or visit suicidepreventionlifeline.org/

References

1. Bertolote, J. M., Fleischmann, A., DeLeo, D., & Wasserman, D. (2004). Psychiatric diagnoses and suicide: Revisiting the evidence. Crisis, 25(4), 147-155. doi: 10.1027/0227-5910.25.4.147
2. World Health Organization. (2014). Preventing suicide: A Global imperative. Retrieved from http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&ua=1
3. Patton, G. C., Coffey, C. Sawyer, S. M., Viner R. M., et al. (2009). Global patterns of mortality in young people: A Systematic analysis of population health data. Lancet, 374, 881-892.
4. World Health Organization. (2012). Public health action for the prevention of suicide: A Framework. Retrieved from http://apps.who.int/iris/bitstream/10665/75166/1/9789241503570_eng.pdf
5. World Health Organization. (2014). Preventing suicide: A Global imperative. Retrieved from http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&ua=1
6. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. (2014). Web-based injury statistics query and reporting system (WISQARS). Retrieved from: https://www.cdc.gov/injury/wisqars/index.html
7. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. (2010). Web-based injury statistics query and reporting system (WISQARS). Retrieved from: https://www.cdc.gov/injury/wisqars/index.html
8. Goldsmith, S. K., Pellmar, T. C., Kleinman, A. M., & Bunney, W. E. (2002). Reducing suicide: A National imperative: Washington, DC: National Academy Press.
9. Crosby, A., Gfroerer, J., Ortega, B., & Parks, S. E. (2011). Suicidal thoughts and behaviors among adults aged ≥18 years-United States, 2008-2009. Washington, DC: US Department of Health and Human Services, Centers for Disease Control and Prevention.
10. World Health Organization. (2014). Preventing suicide: A Global imperative. Retrieved from http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&ua=1
11. World Health Organization. (2012). Public health action for the prevention of suicide: A Framework. Retrieved from http://apps.who.int/iris/bitstream/10665/75166/1/9789241503570_eng.pdf
12. Kessler, R. C., Borges, G., & Walters, E. E. (1999). Prevalence of and risk factors for lifetime suicide attempts in the national comorbidity survey. Archives of General Psychiatry, 56, 617-626.
13. Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. ,Huang, X., Musacchio, K. M., Jaroszewski, A. C., Chang, B. P., & Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A Meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187-232. doi: 10.1037/bu10000084
14. Paris, J. (2006). Predicting and preventing suicide: Do we know enough to do either? Harvard Review of Psychiatry, 14, 233-240. doi: 10.1080/10673220600968662
15. Roos, L., Sareen, J., & Bolton, J. M. (2013). Suicide risk assessment tools, predictive validity findings and utility today: Time for a revamp? Neuropsychiatry, 3, 483-495. doi: 10.2217/npy.13.60
16. Large, M., Kaneson, M., Myhles, N., Myles, H., Gunaratne, P., & Ryan, C. (2016). Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: Heterogeneity in results and lack of improvement over time. PLoS ONE 11(6): e0156322. doi: 10.1371/journal/pone.0156322
17. deBeurs, D., Kirtley, O., Kerhof, A., Portzky, G., & O’Connor, R. (2015). The Role of mobile phone technology in understanding and preventing suicidal behavior. Crisis, 36(2), 79-82. doi: 10.1027/0227-5910/a000316
18. Doyle, M. & Dolan, M. (2002). Violence risk assessment: Combining actuarial and clinical information to structure clinical judgments for the formulation and management of risk. Journal of Psychiatric and Mental Health Nursing, 9, 649-657. doi: 10.1046/j.1365-2850.2002.00535.x