Too many have lost a loved one to suicide. Every 11 minutes, someone dies by suicide in the US, often without warning.
Suicidality has historically been regarded as a symptom of major depression and mental illness in general. During my training, when someone was at risk of suicide, we were taught to treat the underlying mental illness, and the patient would get better. However, in many cases that has proven to not be correct.
In fact, a large percentage of severely depressed patients never think about suicide, and more than half of suicides occur independently of a known mental health condition. Moreover, many of those who attempt or die by suicide do so without warning, particularly those under 20 years of age.
Depression alone is not a clear indicator for the proper understanding of the complexity of suicide. As one of America’s leading causes of death, it is imperative we understand the risk factors that lead to suicide and address them distinctly from concurrent mental health diagnoses or lack of them.
In many cases, those closest to the edge are often the ones who may seem furthest from it.
Addressing Suicide Independently
Suicidality results from a series of factors that can differ across individuals. A complex interplay of biological, clinical, neurological, and situational components. Chiefly, psychological pain, the burden of negative emotions including shame, guilt, fear, anxiety, loneliness, and angst, indicates suicidality as a behavior, as opposed to a symptom of depression.
Contrary to what one would think, the Crisis Text Line found that words such as ‘ibuprofen,’ ‘800mg,’ and even a pill emoji correlated more with suicide than words such as ‘depressed’ and ‘sad.’ The presence of hopelessness (lack of positive expectations), including difficulty in believing that there are non-suicidal alternatives to life problems, provides a more reliable predictor of risk than depression.
We continue to learn more about those at risk of suicide. Variations in DNA also play a part. A recent study involving more than 29,000 individuals with a history of suicide attempts identified a genetic predisposition to suicide. Sharing an underlying biology with known, non-psychiatric risk factors such as sleep disorders, substance abuse, and pain suggests a common architecture between suicide attempts and these risk factors, not mediated by psychiatric illness.
Furthermore, research has revealed structural and chemical changes in the brains of people who die by suicide, such as alterations in the prefrontal cortex, which controls decision-making, and lower levels of serotonin, a key mood regulator. These changes have been observed regardless of whether the individual had depression, anxiety, or did not have a diagnosed mental health disorder.
Importantly, these findings indicate that suicidality can occur independently of other mental health conditions, underscoring the need to approach suicidality as a condition with a distinct program of care.
Current Healthcare Is Missing the Mark on Suicide Prevention
Despite advances in understanding suicidality, our healthcare system isn’t well-equipped to deal with its complexity. Many primary care providers miss critical warning signs, particularly in patients who do not exhibit mental health symptoms. This is especially concerning given that nearly half of those who die by suicide have visited a doctor in the month preceding their death. Additionally, like my training, most mental health professionals do not have any or sufficient training on both assessing and treating people at risk of suicide.
For those who have been hospitalized due to suicidality, studies indicate that the risk of suicide increases (conservatively) 400% following psychiatric hospitalization, with risk peaking in the period immediately after discharge. Yet many people are discharged to a community that is ill-equipped to manage their condition.
Current diagnostic practices also overlook the mix of biological, psychological, and situational factors that contribute to suicide risk. Moving forward, routine screenings must evolve beyond explicit suicidal ideation, considering psychological distress, hopelessness, and biological predispositions.
Looking Ahead: Future Approaches to Suicide Prevention
Timely accessibility to clinicians specially trained in suicide is paramount.
Currently, only nine states mandate training in suicide assessment, treatment, and management for health professionals. While ensuring training will lead to better identification of those at risk, substantial training is needed to provide proper treatment. Suicide as a condition is a subspecialty that requires specific training; just like someone with an arrhythmia would be referred from a primary care physician to a cardiologist, someone at high risk of suicide should be referred to a clinician with sufficient training to both manage and reduce that risk.
Ensuring training across all clinicians would not only increase the availability of therapists nationwide to assist the huge numbers of suicidal individuals but also enable them to recognize the risk of suicidality in patients beyond depression.
Moreover, suicide prevention therapy must look to treat suicidality as distinct from other mental health diagnoses and focus on clinically validated care pathways, which have been shown to reduce attempts by 60% and deaths by 80% compared to treatment as usual (similar to the cardiology example cited above).
If healthcare is to provide effective assistance, suicide care, and intervention requires a more nuanced, comprehensive interpretation of risk factors beyond mood or affective disorders and a combined approach that enables access and provides an empathetic understanding of the mental pain experienced by individuals. It is only then that we will be equipped to truly ‘treat’ those at risk and reduce these needless deaths.
Neil Leibowitz, MD, JD, is Chief Medical Officer at Vita Health.
