 is Chief Medical Officer, American Foundation for Suicide Prevention, New York, NY. Dr Moutier reports no conflicts of interest concerning the subject matter of this Special Report.

Christine Yu Moutier, MD

Chief Medical Officer for the AFSP, is excited to be attending APA's Annual Meeting in New Orleans. What is she looking forward to? Find out here.

Current Trends in Suicide Research and Prevention

, on Saturday May 21 at 4:00 PM - 5:30 PM CDT. 

is chief medical officer of the American Foundation for Suicide Prevention, New York, NY.

Videos

Christine Yu Moutier, MD, is excited to see you at the APA Annual Meeting in New Orleans! 

Current Trends in Suicide: APA Preview With the Chief Medical Officer of the AFSP 

The American Academy of Pediatrics and American Foundation for Suicide Prevention (AFSP), together with experts from the National Institute of Mental Health, created an educational resource to support pediatric health clinicians and other health professionals in identifying strategies and key partnerships to support youth at risk for suicide: the Blueprint for Youth Suicide Prevention.

™ sat down with Christine Yu Moutier, MD, the Chief Medical Officer for the AFSP.

 (PT): The Blueprint for Youth Suicide Prevention is the first major interdisciplinary effort to infuse suicide risk reducing strategies into pediatric care and youth community settings. How do you want this to help child and adolescent psychiatrists and mental health professionals? How can child & adolescent psychiatrists support this initiative?

The Blueprint provides steps for primary care pediatric health providers—ideally working alongside child and adolescent psychiatrists and other mental health professionals—to engage in suicide preventive actions in the health care settings where children and teens receive routine health care. Pediatricians are very trusted resources for families and medical settings are well-positioned to identify changes in mental health and screen for common conditions such as depression, anxiety, substance use problems, and eating disorders. All of these current efforts can be extended to specifically screen for suicide risk and provide education, support, and resources to patients and families.

Suicide is the second leading cause of death in youth and young adults, aged 10 to 24 years and many young people that die by suicide visit a health care provider in the months or weeks prior to the death—

38% of adolescents had contact with a health care system within the 4 weeks before their death

34% of people 15 years of age and older had contact with a health care provider in the week before their death

That is why health care systems are a critical setting to identify youth at-risk for suicide and coordinate suicide prevention strategies that can have a dramatic impact on saving lives. The Blueprint for Youth Suicide Prevention can help psychiatrists and other mental health professionals address youth suicide prevention via care delivery, identify and remove common barriers for patients who need care and support, as well as implement strategies for integrating suicide prevention within the larger health care system.

Health system leadership and staff can protect youth mental health by considering the following clinical suicide prevention approaches:

-Risk identification, screening, and assessment;

-Indicated interventions, including safety planning and lethal means counseling for youth with suicidal ideation or behavior;

-Treatment such as the use of medications, more health care visits, or referral to evidence-based suicide risk reducing treatment; and

-Recovery including support systems that help individuals maintain progress, encourage posttraumatic growth, and find meaning and purpose.

PT: We know that minority youth are at an increased risk for suicide. In the Blueprint, a key takeaway is that health equity is critical to suicide prevention. Can you tell us more about that? Furthermore, what is the difference between equity and equality?

 In recent years, we have learned so much about the ways structural racism and health inequities have been long affecting the mental health and suicide risk of minoritized communities. For example, 

 shows experience(s) with discrimination impacts youths’ risk for suicidal thoughts and access to developmentally and culturally responsive mental health services is limited in many communities, clinics, and schools.

 Yet there is little research that explores suicidal thoughts, behaviors, and risk factors among LGBTQ2S+, American Indian, Alaska Native, Black, and Latinx communities nor the impact racism, historical or intergenerational trauma has on suicidal ideation.

Clinical suicide prevention efforts are needed to provide comprehensive, effective, and culturally appropriate care to youth populations, including: 

child welfare system or who have experienced family disruption

, and youth with special care needs such as 

Health equality assumes everyone can attain or reach their full potential if given the same resources when it comes to their health. However, we know that people are not at the same starting line and need different supports to reach their optimal health at a personal, community, and system level. That is why it is even more crucial we strive to achieve health equity. This involves reducing long-standing socioeconomic, cultural, and other barriers for medically underserved communities to receive the comprehensive, effective, and culturally appropriate care and treatment they need.

PT: Right now, there is a lot of legislation targeting the LGBTQ+ community (the “Don’t Say Gay” bill in Florida, and the anti-transgender directive in Texas). Do you think legislation like this will have an impact on rates of LGBTQ+ suicide? Are the upward trends of suicide in youth similar for LGBTQ+ youth as they are for cis youth?

 At the American Foundation for Suicide Prevention (AFSP), we are concerned. For many years, AFSP has funded research related to LGBTQ2S+ experiences and their potential impact on both suicide risk and protection. We also have taken strong positions in the policy arena when research supports a connection to suicide risk, such as our work across many states to ensure that conversion therapy is not accessible to minors. AFSP stands with the consensus of every major health organization and supports bans on practicing conversion therapy on minors.

Suicide most often occurs when stressors and health issues converge to create an experience of hopelessness and despair. For LGBTQ2S+ youth in particular, stigma, prejudice, and discrimination can increase the likelihood of stress, depression, traumatic experiences, violence, and serious mental health concerns. Conditions like depression, anxiety, and substance problems, especially when unaddressed or when people lack access to quality mental health care, pose a greater risk for suicide.

During the pandemic, we have seen more pro-mental health and suicide prevention legislation pass at federal and state levels, thanks to the 40,000 volunteer field advocates with AFSP and our colleague organizations like NAMI, MHA, Jed Foundation, and Trevor Project all raising our voices together. This reflects investments in research demonstrating effective strategies, combined with the voices of people with lived experience and suicide loss, clinicians and people from all walks of life joining in the incredible mental health and suicide prevention movement. However, it is our individual and collective responsibility to continue supporting the mental health and wellbeing as well as prevent suicide amongst LGBTQ2S+ youth, especially in light of legislation like Don’t Say Gay that restrict discussion of sexual orientation and gender identity in public schools and are harmful to LGBTQ2S+ youth mental health.

PT: The Blueprint stresses the importance of a collaborative care, multi-layered model. Will you talk a little more on why it is imperative that psychiatrists, primary care physicians, teachers, parents/guardians, and all clinicians caring for the child need to work together to prevent suicide?

Suicide risk involves a complex set of factors at the individual, community, and societal levels. Child and adolescent psychiatrists as well as other mental health professionals understand the unique ways in which mental health impacts various stages of development in youth. This expertise can be extended beyond the clinic through a team-based, collaborative, and integrated care model by engaging schools and local communities in youth suicide prevention initiatives.

Youth face barriers in their school and local community due to a variety of social factors, community resources, as well as systemic racism and discrimination. They also face barriers when it comes to mental health support. That is why it is crucial for schools and community partners to work together to understand the resources and care systems available in their local community so pediatric health clinicians can best support mental health amongst youth based on where they live, learn, work, and play.

PT: In screening young patients for suicide, risk may be difficult to properly gauge with a parent/guardian in the room, as the patient may be less open in their responses. If the parent/guardian refuses to leave the room, what would you recommend to the screening psychiatrist?

There are strategies clinicians are well versed in, in order to have private 1:1 conversations with children and teen patients. This issue is very relevant to sensitive conversations about suicidal thoughts and feelings surrounding this level of distress. The need for a nuanced approach to these sensitive conversations is addressed in the Youth Suicide Prevention Blueprint as seen in the section on 

PT: How is screening for suicide via telehealth different than in person including how it should be done as well as the efficacy of the screening?

Many communities lack sufficient access to mental and behavioral health support. When traditional in-person mental health care appointments are unavailable, clinicians can help individuals and families consider alternative options like telehealth. Telehealth is an effective, convenient alternative to in-person screening, as it is mobile-friendly and uses multiple languages, interpreters, and assistive technologies to facilitate visits. It also has similar reliability and accuracy to in-person screening.

The patient, their family, and provider should determine together if telehealth is the appropriate modality for screening, if in-person is preferred, or if a hybrid approach will meet the child’s mental health care needs based on the nature or complexity of the child’s mental health condition, comfort level with telehealth, and ease of access.

For those who may not have access to telehealth capabilities, other resources such as a school psychologist, social worker, and/or other community-based resources are available. That is another reason why teachers, parents/guardians, and clinicians working together is imperative to preventing youth suicide.

Speaking of telehealth resources, all pediatricians should be aware of a wonderful resource available in many states, thanks to the incredible dedication of Pediatric Mental Health Care Access (PMHCA) Programs, sometimes referred to as Child Psychiatry Access Programs (CPAPs). These are programs that provide timely training and support to pediatric primary care clinicians (PCCs) and other clinicians related to detection, assessment, treatment, and referral of behavioral health conditions within their practice. This support is provided as part of a peer-to-peer, telehealth-based consultation model—PCCs can connect with off-site child/adolescent behavioral health professionals by phone, video call or email/web-based consultation. You can find more information on increasing access to behavioral health care via telehealth 

PT: We have all heard the myth that bringing up topics like suicide will “put the idea in their heads.” Can you talk about why that is untrue? Do myths like this encourage stigma?

 People may think if “I ask if someone if they are suicidal, I will put the thought in their head” or “I’m going to increase risk,” because they have heard of the concept of suicide contagion, which stems from unsafe messaging that sensationalizes suicide and details suicide methods through media, social media, or other key moments of messaging. However, asking how an individual is feeling and if they are having thoughts of suicide in an open, caring manner has clearly not been shown to increase risk, and actually is thought to open up potentially game-changing dialog that may be the first step in getting professional treatment. When you ask someone about suicidal thoughts directly, it provides them with the opportunity to share what may have been not disclosed. And often times, suicidal thoughts being held in secret and never having the opportunity for processing, support or treatment, is thought to lead to worse outcomes including suicide risk.

In the past, before a body of scientific research led to an understanding of what drives suicide risk, many myths prevailed. This led to stigma and erroneous views of suicidal behavior resulting in harshly punitive ideas and judgment of people who experience suicidal thoughts, attempt suicide, or ultimately lose their lives to suicide. Now that a multidisciplinary group of scientific fields are shedding light on the actual drivers of suicide risk, cultural views are changing and bringing an understanding that while complex, suicide is a health issue.

PT: This Blueprint was developed at the Virtual Summit on Youth Suicide Prevention. Is there anything you’d like to highlight from the Summit?

 The Youth Suicide Prevention Summit was an incredible convening of over 100 experts including pediatricians, suicide experts, youth organization and school leaders, people with lived experience, and researchers over 3 days! It was moving in the level of engagement and dedication shown across every sector of society from health to education to juvenile justice. We also held 2 subsequent convenings—1 focused on the role of government agencies some of whom had never seen themselves as having a role in suicide prevention, and 1 focused on equity and minoritized youth, both of which had extremely high levels of engagement and sense of urgency. We are so grateful to ALL who gave of their time and expertise in developing the Blueprint, and those who will engage in the implementation of these potentially life saving actions.

To see more of Dr Moutier’s thoughts on suicide, see 

Breaking the Trend: New CDC Data on Suicide

1. Suicide: Blueprint for Youth Suicide Prevention. American Academy of Pediatrics, American Foundation for Suicide Prevention, National Institute of Mental Health. 2022. Accessed March 9, 2022. 

https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/

2. Ahmedani BK, Simon GE, Stewart C, et al. 

Health care contacts in the year before suicide death.

3. Laanani M, Imbaud C, Tuppin P, et al. 

Contacts with health services during the year prior to suicide death and prevalent conditions a nationwide study.

4. Madubata I, Spivery LA, Alvarez GM, et al. 

Forms of racial/ethnic discrimination and suicidal ideation: a prospective examination of African-American and Latinx youth.

5. The Congressional Black Caucus. Ring the alarm: the crisis of Black youth suicide in America. Emergency TaskForce on Black Youth Suicide and Mental Health. Accessed March 15, 2022. 

https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf

6. American Indian and Alaska Native populations. Suicide Prevention Resource Center. Accessed March 15, 2022. 

https://sprc.org/scope/racial-ethnic-disparities/american-indian-alaska-native-populations

7. Vargas SM, Calderon V, Beam CR, et al. 

Worse for girls?: gender differences in discrimination as a predictor of suicidality among Latinx youth.

Risk factors of suicide and depression among Asian American, Native Hawaiian, and Pacific Islander youth: a systematic literature review.

9. Estimate of how often LGBTQ youth attempt suicide in the U.S. The Trevor Project. March 11, 2021. Accessed March 15, 2022. 

https://www.thetrevorproject.org/research-briefs/estimate-of-how-often-lgbtq-youth-attempt-suicide-in-the-u-s/

10. Fontanella CA, Hiance-Steelesmith DL, Phillips GS, et al. 

Widening rural-urban disparities in youth suicides, United States, 1996-2010.

11. Ivey-Stephenson AZ, Crosby AE, Jack SPD, et al. 

Suicide trends among and within urbanization levels by sex, race/ethnicity, age group, and mechanism of death — United States, 2001–2015.

Suicide and suicide attempts in children and adolescents in the child welfare system.

13. Abram KM, Choe JY, Washburn JJ, et al. Suicidal thoughts and behaviors among detained youth. 

https://ojjdp.ojp.gov/sites/g/files/xyckuh176/files/pubs/243891.pdf

14. Rybczynski S, Ryan TC, Wilcox HC, et al. 

Suicide risk screening in pediatric outpatient neurodevelopmental disabilities clinics.

Articles

The Chief Medical Officer for the AFSP sat down with Psychiatric Times to talk about the new Blueprint for Youth Suicide Prevention. 

The Blueprint: Strategizing and Partnering to End Youth Suicide

The Centers for Disease Control and Prevention (CDC) recently released new data on suicide deaths between 2019 and 2020. Christine Moutier, MD, chief medical officer for the American Foundation for Suicide Prevention, sat down to talk with 

Psychiatric Times (PT): Suicide deaths decreased by 3% overall. What might have caused this downswing?

 The overall US suicide rate declined for the second year in a row after a 2-decade period of increasing rates. From 2018 to 2019, there was a 2.3% decrease, and in 2020, we saw another 3% decrease. This break in the rising trend for the overall rate is good news, and there is reason to believe that scaling up effective suicide prevention efforts in community and clinical settings can have a powerful preventive impact. However, even though the total number of 

 decreased by 3% overall, those declines in rate were not the case for minoritized young adults during 2020. The pandemic has had a disproportionate impact, accentuating preexisting health and socioeconomic disparities within certain demographic groups, including young males as well as American Indian, Alaska Native, Black, and Latinx communities.

While we do not know the exact contributors to the overall reported declines in suicide deaths presented in this newest data set, research shows us that prioritizing and having open, honest conversations about mental health on the individual and national levels, implementing practices that reduce suicide risk in clinical and community settings, reducing access to lethal means, and seeking help early and when indicated, can reduce 

 of 21 higher-income nations international colleagues published in April in 

suicide deaths during the early months of the pandemic

 either stayed the same or dropped below prepandemic levels.

 Therefore, there seem to be consistent trends at least across higher-income nations in terms of a protective impact during the early months of the pandemic on suicide rates, as I had discussed could be the case in an 

 I published last year before this data was available.

We also may not understand the entire impact of COVID-19 on suicide deaths for the longer term, as suicide mortality data takes time to collect and analyze in a meaningful way, research into the specific drivers and protectors of risk takes time, and the pandemic is not over. Additionally, we know there can be a time lag in the manifestation of distress even months after the acuity of a traumatic or stressful period is over.

PT: July had the highest number of suicides in 2020. As we look to 2022, what can clinicians do to help prevent another summertime increase?

 There may have been factors specific to 2020 at play, in light of the fact that March and April are typically the time of year when suicide rates are highest. It may have been that the early months of the pandemic from March to June, when the lockdown period was occurring, may have conferred a psychological girding of sorts with communal cohesion and feeling of being in it together that may have protected against the sudden changes in routines, employment, and sense of certainty. That said, clinicians should prioritize suicide prevention not only in the spring or summertime, but all year round! On an individual level, there a few steps clinicians can take to reduce suicide risk, including:

-Incorporate routine suicide and mental health screening/rating scales into their practice.

-Use the Safety Planning Intervention and Lethal Means Counseling as an ongoing practice with all patients who have any level of suicidal ideation or suicide risk factors.

-Become familiar with Counseling on Lethal Means, and practice this with patients during periods of increased suicide risk.

-Increase the frequency of outpatient visits or communication during periods of increased risk.

-Involve the patient’s family in supportive actions to every extent possible with patient permission (for example, with helping make the home environment safe of lethal means).

-Have a referral list ready to go for CBT-, DBT- or CAMS-specific suicide risk-reducing forms of therapy.

-Learn the data related to treatments including medications and suicide prevention. You can read more 

-Use AFSP resources to help patients and families learn more (eg,

-Advocate with the leadership of your health care organization to make suicide prevention a priority of the health system.

This data is also a call to action for initiatives such as the

 American Foundation for Suicide Prevention’s

 to embrace stronger evidence-based suicide prevention practices. For example, primary, behavioral care, and emergency departments are critical settings where coordinated suicide prevention strategies can have a dramatic impact on saving lives. Basic screening and suicide risk-reducing care steps, educating providers about suicide prevention, and collaborating with key accrediting professional organizations can improve the acceptance and adoption of screening and preventative intervention as the standard of care.

PT: Suicide deaths for males aged 25 to 34 increased by 5%. Why do you believe men in this age group have been hit particularly hard?

 Suicide is complex, risk is dynamic, and an individual’s personal risk factors—combined with precipitants such as evolving experiences with 

, depression, anxiety, economic stress, suicidal ideation, and access to lethal means—may lead to periods of increased risk. The overall increase in suicide rates for males 25 to 34 was only true among Black, Hispanic, and American Indian/Alaska Native males; suicide rates among white males actually decreased. While we do not know the exact contributors to the specific increase in suicide deaths amongst males aged 25 to 34 in these populations, it could be attributed to several factors including:

-Young adult men in tribal communities and communities of color experience disproportionate economic, employment, and social stress or trauma.

-Continued societal pressures of toxic masculinity encourage men to be stoic and to not admit struggles they may experience with their mental health.

-Males generally seek help for mental health support less often than their female counterparts.

-Substance use and alcohol dependence to self-medicate—which can increase risk of suicide—is typically higher amongst males.

-Suicide attempts among males typically involve more highly lethal means than among females.



PT: Women overall experienced declines in rates of suicide. Do you believe the pandemic impacted men and women differently, and could that be a part of this decrease? Were women doing more for their mental health over the pandemic?

 It is notable that for all racial/ethnic groups of females over age 35, there were significant declines in suicide rates. However, for youth and young adult females, suicide rates remained level or trended toward nonstatistically significant increases. It has been clear throughout the pandemic that the overall impact on the population’s mental health has been significant and experiences such as depression, anxiety, and suicidal thoughts have been more prevalent. It is important to keep in mind that COVID-19 and associated mitigation efforts such as physical distancing do not alone cause suicide, and that there are known risk factors that increase risk such as isolation, hopelessness, lack of accessing mental health support and treatment; these risk factors are clearly experienced differently by individuals based on genetic, family, cultural, and other health and environmental factors that may sort out differently by gender to some extent.

We do know that women generally have higher rates of depression and suicidal thoughts and are more likely to attempt suicide, while males are more likely to die by suicide. They also tend to express their vulnerability and connect with peers more often and are more likely to seek help for their mental health.

The takeaway from this data is that we need to be paying attention to suicide regardless of age or gender. For young girls and women who are experiencing distress, isolation, 

, disordered eating, or body image issues, it is obviously extremely important to offer support and find treatment that is effective. And in general, if there is someone in your social life or among your patients who may be struggling with their mental health at a higher level of acuity, now is the time to plan for more frequent contact, to consider suicide-specific interventions such as safety planning, or a referral to CBT, DBT, or family therapy.



PT: Suicide deaths may have decreased for white and Asian males, but they increased for Black, American Indian/Alaskan Native, and Hispanic males. The CDC stated that the COVID-19 pandemic increased many of the risk factors associated with suicidal behavior, particularly for these groups. Why do you think these groups were hit so hard?

 As the COVID-19 pandemic has highlighted, we are far from having achieved any level of equity related to many key social determinants of health such as education, economic opportunities, and access to mental health care. The LGBTQ, American Indian, Alaska Native, Black, and Latinx communities continue to face longstanding socioeconomic, cultural, and other barriers—and critical to preventing suicide, getting the mental health care, support, or services they need. Systemic racism as well as historical barriers and inequities have also led communities to face 

, loss, and bias for an extended period of time over generations, which also can contribute to increased suicide risk.



PT: Is there anything psychiatrists and clinicians can do to help Black, American Indian/Alaskan Native, and Hispanic males in particular?

 Customized suicide prevention efforts are critically important and more likely to be effective if they are developed by and for populations with evaluation of what is effective. When implementing suicide prevention efforts, it is important for psychiatrists and clinicians to consider the following:

-Efforts should be informed by experiences based on various aspects of identity and their intersectionality—such as race, ethnicity, education, physical and mental health, gender/sexual identity, and religion.

-Partnerships should include diverse representation of mental health care providers and community stakeholders including people and family members with lived experience.

-More research is needed to better understand the specific risk factors and prevention strategies that work for each community.

-Create tailored communication of suicide prevention information, programming, and resources.

-Maintain an open and ongoing dialogue about mental health and suicide prevention with feedback from community stakeholders.



PT: Tracie Jade, the executive director of the Boris Lawrence Henson Foundation, states that “Trust is probably the No. 1 reason why specifically African Americans do not go to therapy.”

 Do you agree? If so, how can clinicians help foster trust?

 In addition to historical injustices, racism, and trauma African Americans have faced, longstanding mental health concerns and limited access to appropriate and culturally competent mental health care may all contribute to the community’s distrust of the medical system.

On an individual level, clinicians can help foster trust by expressing inclusive messages of solidarity, continuing in this effort as a longstanding priority, sharing 

 for the Black and other BIPOC communities as well as creating an environment where open, honest, and culturally sensitive conversations about mental health can be had to better understand their patients’ mental health.

 On a more systemic level, our health care system needs to increase diversity in the mental health care workforce as well as within the suicide research field. At AFSP, we are prioritizing diversity and culturally sensitive and inclusive strategies that recognize the impact history, trauma, and ongoing culture can have on mental health. Please see specific 

 AFSP has placed on diversity, equity, and inclusion.

Suicide: Myths, Media, and Difficult Discussions

Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries.

2. Chuck E. Global suicide rates did not increase at the beginning of the pandemic, study finds. 

. April 14, 2021. Accessed December 7, 2021. 

https://www.nbcnews.com/news/us-news/global-suicide-rates-did-not-increase-beginning-pandemic-study-finds-n1264079

3. Moutier C. Suicide prevention in the COVID-19 era: transforming threat into opportunity. 

. October 16, 2020. Accessed December 7, 2021. 

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2772135

4. Phillips K. Chance the Rapper unpacks why Black men are 'so guarded' about their emotions. NBC News. Updated November 11, 2021. Accessed December 7, 2021. 

https://www.nbcnews.com/news/nbcblk/chance-rapper-unpacks-black-men-are-guarded-emotions-rcna4336

5. American Foundation for Suicide Prevention. Mental health resources for underrepresented communities. Accessed December 7, 2021. 

https://afsp.org/mental-health-resources-for-underrepresented-communities#black-community

6. American Foundation for Suicide Prevention. Supporting diverse communities. Accessed December 7, 2021. 

https://afsp.org/supporting-diverse-communities 

The Chief Medical Officer for the American Foundation for Suicide Prevention sat down to talk with Psychiatric Times about the new data on suicide deaths between 2019 and 2020.  

Christine Moutier, MD, Chief Medical Officer for the American Foundation for Suicide Prevention, shared recent survey data and the latest suicide prevention techniques with 

Psychiatric Times: Youth suicide has been getting a lot of media attention lately. As the Chief Medical Officer for the American Foundation for Suicide Prevention, would you say youth suicide is increasing? Why or why not?

 from the Centers for Disease Control and Prevention (CDC), youth suicide rates had been rising from 2007 through 2018. In 2019, we saw the first decreases in rates in over a decade, when youth rates decreased by 5.2% from 2018 to 2019. And then for 2020, during the pandemic, although we do not yet have finalized 2020 suicide data from the CDC, preliminary numbers on the total US suicides (across all age groups) show a further decrease by 5.6% when compared to 2019. However, certain populations (ie, youth and young adults, as well as historically marginalized communities) may be disproportionately impacted by the pandemic and may be experiencing different suicide-related trends than the general population. We need more data to identify trends among youth suicide mortality during the pandemic. It is also worth noting there are fluctuations in suicide rates of all age groups over time.

PT: According to reports, the proportion of mental health–related emergency department (ED) visits among adolescents aged 12 to 17 years increased 31% in 2020 compared with that during 2019. Do you expect to see another rise in the coming years?

 looked at trends in emergency department visits for suspected suicide attempts by age group and sex during 3 time periods during the COVID-19 pandemic. Key findings included:

- During February and March 2021, when compared to the same time period in 2019, there was a 39% increase in ED visits for suspected suicide related concerns among youth aged 12 to 17 years.

- The increase for females aged 12 to 17 years was 51%.

- The increase for males aged 12 to 17 years was 4%.

- Young individuals (aged 18 to 24 years) did not see a similar increase as adolescents.

It is important to note these are not mortality data, but rather ED presentations for “suspected suicide attempts,” meaning likely self-harm (some of which is nonsuicidal), suicidal ideation, and suicide attempts. In general, many suicide attempts never come to medical attention, and some are never disclosed even to peers or parents.

It is also relevant that suicidal behavior is generally more prevalent among girls than boys, while boys suicide death rates are higher than girls. Presenting to the ED for suicidal concerns could be reflective of both higher rates of distress among the 12- to 17-year-old girl population but also could also be a measure of increased help seeking behavior. Average ED visit rates for mental health concerns and/or risk factors for suicide attempts could have potentially increased as adolescent females have been spending more time at home due to physical distancing and remote schooling, allowing them to express mental health distress and talk more about suicidal thoughts and behaviors than ever before, prompting adult figures in their lives to take them to the ED. When help seeking behaviors increase, suicide risk is generally mitigated.

Again, this data does not mean there was an increase in suicide deaths. The takeaway from this finding is that we need to pay attention to our youth regardless of age, gender, race, or ethnicity. We know some youth have higher rates of suicidal thoughts and behaviors (prepandemic), (eg, LGBTQ youth, youth who engage in bullying behaviors, and concerning trends in Black and Latinx youth) and so keeping in mind that there are known higher risk factors that were present before the pandemic is an important consideration.

If there is a young individual in your life and/or if you have pediatric/adolescent patients, now is the time to engage them in open, authentic conversations to understand where a child is with their mental health, and—if necessary—help them get support or treatment customized to their needs. It may be reasonable to utilize mental health services at an earlier stage of symptoms or concern, given the protective effect for suicide risk that mental health treatment and support affords.

PT: Girls aged 12 to 17 are especially at risk, with suspected suicide attempt ED visits 50.6% higher in early 2021. What advice would you give to mental health professionals treating girls in this age group?

 The difference in suspected suicide attempts between adolescent males and females could be attributed to the possibility that adolescent females disclose suicidal ideation or behavior more than adolescent males. It is also possible that there are differences between the pandemic’s impacts on mental health and suicide risk between the genders. The pandemic’s potential impact on family and parental stress, coping and mental health, social distancing, remote schooling, and other factors may be impacting girls in some unique or disproportionate ways compared with boys. This could relate to how boys and girls are socialized differently, possible differences in baseline social dynamics between girls and boys’ social networks, possible differences in how screen time, social media and video game engagement impacts youth, and their developmental needs being differently disrupted in some way.

PT: How would you like to see emergency psychiatric care evolve in the future to cope with the problem of youth suicide?

 The CDC’s data from syndromic ED surveillance speaks to the importance of improving suicide preventive care both during and after ED visits. There are evidence-based steps and tools for clinicians and health systems, detailed in the National Action Alliance for Suicide Prevention’s 

Recommended Standard Care for People with Suicide Risk

, that can be implemented in routine medical care for patients, including universal screening for suicide risk, safety planning, lethal means counseling, and providing caring communications that bridge transitions in care.

 All of these steps are included in an app called 

 codeveloped by AFSP and the American College of Emergency Physicians (ACEP).

It is critical to strengthen care transitions so once individuals leave the ED they do not fall through the cracks, but instead have a seamless transition that keeps them safely recovering well after the suicide attempt or suicidal crisis. It has been shown that caring contacts and follow up with patients after their visit to the emergency department, including 6 to 12 communications over the course of 18 months in addition to treatment as usual, can reduce subsequent suicide attempts by 40% to 60%.

 Key resources to assist in strengthening care transitions include 

Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care

Suicide is a complex public health problem so we must ensure 

suicide prevention is infused into community-based settings

 as well as health systems to carry out prevention activities and interventions that are effective and culturally appropriate.

PT: What are some of the myths surrounding youth suicide?

 For many complex health issues throughout history, misinformed views tend to promulgate, leading to a multitude of negative effects, deeply stigmatizing the experiences where these health issues are involved. Without science, untruths and stigma continue to thrive.

In the past, before a body of scientific research led to an understanding of what drives suicide risk, many myths prevailed about suicide. These myths not only shaped stigmatized and erroneous views of suicidal behavior but resulted in harshly punitive ideas and judgment of those who experience suicidal thoughts, who attempt, or who ultimately lose their lives to suicide. Now that a multidisciplinary group of scientific fields are shedding tremendous light on the actual drivers of suicide risk, cultural views are changing, bringing an understanding that, while complex, suicide is a health issue.

One myth that may still have echoes in the current day is the erroneous idea that certain individuals are bent on suicide, and therefore very little can be done to change course once someone becomes suicidal. Today, scientific research in a broad range of domains—from neuroscience to clinical research to epidemiology and community/public health interventions—shows that despite its complexity, suicide is 1) a health-related outcome and 2) can be preventable.

Another common misunderstanding might be related to conflation between suicide contagion and asking about suicidal thoughts. One might think if “I ask if someone if they are suicidal, I will put the thought in their head” or “I am going to increase risk,” because they have heard of the concept of suicide contagion, but asking in an open, caring manner will not increase risk. When you ask someone about suicidal thoughts directly, it provides them with the opportunity to share what may have been not disclosed and therefore not been addressed. Whereas suicide contagion stems from unsafe messaging that sensationalizes suicide and details suicide methods through media, social media, or other key moments of messaging, such as during the postvention period after a suicide has occurred.

PT: You recently participated in a World Suicide Prevention Day Facebook Live Event. Can you share with us what you thought were some of the most important discussions of the day?

 for World Suicide Prevention Day on September 10, and we heard from musicians, celebrities, and experts that elevated the conversation about supporting one another; the power of safe, effective self-disclosure by a number of influencers; and about some important initiatives going on in suicide prevention. For example, a conversation between AFSP’s CEO Bob Gebbia and policy makers highlighted the important opportunity for transforming our national crisis response system with the implementation of 988, which will go live July 2022. I spoke with our partners at the American Academy of Pediatrics and the National Institute of Mental Health about our national youth suicide prevention blueprint, which will be released in early 2022. It will engage pediatricians in the important role they have to play in preventing youth suicide.

PT: One of the other panels you attended was on music and mental health. Do you think music is integral in mental health care, and why? How can psychiatrists leverage the powerful effects of music to help their patients?

 The music industry is engaging with the topic of mental health and suicide prevention in some very positive ways. For example, AFSP has partnerships with Audacy, a global radio network, as well as Universal Music Group, which is hosting opportunities for musicians to discuss mental health and coping as a way to inspire their followers to become more proactive about their own mental health. Music can also be a beneficial outlet for individuals who are experiencing depression or struggling with their mental health, as it provides an opportunity to process overwhelming emotions as well as communicate how they are feeling through safe and creative expression. Sometimes music resonates with listeners, lets them know that they are not alone in how they are feeling, or alone in what they are going through. That can provide immense comfort.

Music is a fantastic tool for improving patient outcomes, and research has shown us it can be extremely beneficial in treating mental health conditions like depression. Psychiatrists should consider incorporating music as a topic for example related to a patient’s Safety Plan for internal coping, as a way to distract from suicidal thoughts, and to tap into healthier coping strategies.

PT: The Netflix drama “13 Reasons Why” put the spotlight on youth suicide in the media. Do you think shows like that help youth recognize they are not alone and should seek help?

 The portrayal of suicidal struggles and suicide is complex, and research shows that viewers respond to entertainment content in a variety of different ways. The same content that can lead to increased awareness and interest, and even empathy in many, can also lead to worsening of mood, anxiety, or self-image, or even increased suicide risk for others who are vulnerable or struggling. Research also shows that for individuals who have certain vulnerabilities—either related to their present mental health, or past experiences, especially trauma—some of those individuals have a special susceptibility to identification with others they see struggling in similar ways. If the vulnerable individual sees a fictional character struggling and then dying by suicide, especially when portrayed graphically or in a manner that glorifies the death or the decedent, the vulnerable viewer can become more at risk of imitating this suicidal behavior.

The Annenberg Inclusion Initiative, in collaboration with AFSP, released 

a study in 2019 on the portrayal of mental health

 and suicide in film and television, which found that it is sparse (1.7% of speaking roles appearing in film and 7.1% on television, versus 20% of the American public who we know have a diagnosable mental health condition), and portrayals tend to be extremely distorted, showing a grave misunderstanding of mental health and the experiences patients have living with psychiatric illnesses. This misrepresentation includes frequent derogatory name calling, inaccurate linkage to violent behavior, and an overall lack of understanding about the experiences of individuals with mental health conditions. We know most people with mental health conditions live full lives, but this is not shown in most television programs or in movies.

PT: If a patient starts discussing shows, music, or other media around suicide, should clinicians consider that a warning sign?

 Absolutely, I would hone in and explore that further. It is possible that it is an avenue for them to begin discussing their own suicide risk factors such as past trauma, family history of suicide, or prior suicidal thoughts or attempt. Exposure to another’s suicide or to graphic or sensationalized accounts of suicide is a risk factor too. If a patient starts discussing their exposure or accounts of suicide in shows, music, or other media, I would encourage asking about their connection to the content or artist and probing for possible suicide risk factors. Consider it an appropriate time for a reassessment and formulation of suicide risk. To learn more about how to do that, Drs Pisani, Stahl, and I cover that in our recently released clinical handbook, 

PT: September is National Suicide Prevention Month. What are some ways people psychiatrists and other mental health clinicians can get involved this month to help put a stop to suicide?

 In observance of National Suicide Prevention Month, there are a multitude of ways everyone including psychiatrists and other mental health clinicians can help prevent suicide, including:

- Adding crisis resource numbers to your patient resources, to your own cell phone, and encouraging loved ones to do the same, so that it is ready when/if you need it.

- Considering additional training in Safety Planning, Lethal Means Counseling, and other brief risk reducing interventions.

- Encouraging your health system’s leadership to engage in system-wide suicide prevention policies and practices.

- Advocating for mental health and suicide prevention policies at the national, state, or local levels that ensure everyone in your community has access to mental health care, suicide prevention training, and funding for local crisis resources.

- Getting involved with your local AFSP chapter and helping transform your community into one that is smart about mental health, where everyone has support when they need it.

The Chief Medical Officer for the American Foundation for Suicide Prevention sat down to talk with Psychiatric Times about a number of important topics in suicide. 