 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

September is National Suicide Prevention Month. 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.

Additionally, AFSP provides opportunities for everyone to get involved with the organization and raise awareness for suicide prevention within their community, including 

creating a suicide prevention awareness and fundraising event

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

is Chief Medical Officer, American Foundation for Suicide Prevention, New York, NY.

2. Luxton DD, June JD, Comtois KA. Can post discharge follow-up contacts prevent suicide and suicidal behavior? A review of the evidence. 

Articles

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. 

Suicide: Myths, Media, and Difficult Discussions

Christine Moutier, MD, discusses the Centers for Disease Control and Prevention (CDC) report, 

Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12–25 Years Before and During the COVID-19 Pandemic — United States, January 2019–May 2021

If you are interested in more 2020 suicide data from the CDC, 

The Leading Causes of Death in the US for 2020.

Dr Moutier recommends these resources for learning more about suicide prevention:

Training for clinicians and health systems in suicide prevention

Clinical handbook on Suicide Prevention released June 2021

Suicide Prevention in the COVID-19 Era: Transforming Threat Into Opportunity

 by the Congressional Black Caucus Task Force on Black Youth Suicide

 is Chief Medical Officer, American Foundation for Suicide Prevention, New York, NY.

Videos

Recent data from the CDC shows a rise in suicide attempts in girls aged 12-17. What can psychiatrists do? 

Concerning Trends in Suicide

Many factors have come into play during the coronavirus 2019 (COVID-19) pandemic, not the least of which has been meeting the flood of challenges in the realm of mental health. Rather than paint a bleak picture, Christine Moutier, MD, presents the unique opportunities for clinicians in identifying risk and preventing suicide.

In this podcast, Moutier discusses her recent paper published in 

." Moutier is chief medical officer of the 

American Foundation for Suicide Prevention

Podcasts

The unique opportunities for clinicians in identifying risk and preventing suicide are discussed in this podcast.

Preventing Suicide in the Age of COVID-19

We are living in a pressing time of transition in our nation. Even while attitudes are opening up about mental health and suicide prevention, the rate of suicide continues to rise in the United States, in fact by nearly 30% over the past two decades.

 After a century of progress as a nation, overall mortality particularly in the middle years is increasing as a result of the so-called deaths of despair due to suicide, alcohol, opioids, and liver disease.

 In an era with greater technologic advances and potential connectivity, the science of suicide demonstrates that many forces are still active, including human experiences of isolation, struggle, loss, and unmet expectations, and concurrently, low mental health literacy. Although 94% of US adults believe mental health is equally important to physical health, most do not know how to identify changes in mental health that signal serious risk, or what to do in response, let alone have feasible access and mental health coverage anywhere near parity.

Additionally, overreliance on a sense of self-sufficiency and fear of judgment are barriers to achieving deeper connections in our relationships and fully integrating suicide prevention into actionable steps in our homes and communities. The truth is that interpersonal connectivity is a basic need for humans. When we lose that experience of connection, whether due to changes in culture and modern frenetic living or shame that drives people to hide their true internal experiences, then the prevalent experience of unaddressed mental health conditions and other types of suffering can lead to the problems we are seeing in the rising suicide rate.

We must be ready for the fact that all of us as members of the human condition will face incredible challenges, at times pushing beyond our own sense of capability in a given moment. Most will experience varying degrees of isolation. The full continuum of mental health spans a wide range from joy to terrible anguish, and ambivalence between hope and hopelessness (and many other risk factors for suicide) is fairly common human experiences. If we can learn to discuss these human experiences without shame, we can become more sophisticated at recognizing the potential avenues for effective intervention to lead a person in trouble down a healthier path. Additionally, by sharing these experiences more freely with trusted others, our sense of connectedness can lead to better health outcomes in many arenas including suicide risk reduction.

Imagine a society in which a common, basic understanding of neuroplasticity and epigenetics are fact, not fiction, informing a more compassionate, trauma-informed approach to K to 12 education and workplace wellness. With this basic, foundational knowledge of neuroscience, children and adults can be taught strategies that protect and enhance cortical brain development, prevention for psychiatric illness can start early, and suicide prevention can be built into every school and pediatric clinic. Envision a society in which front-line citizens (eg, first responders, teachers, health professionals, legal/financial advisors, probation/corrections officers, addiction counselors) are trained in basic mental health first aid and suicide prevention; in which we move beyond stigma related to distress or suicide loss; and in which the RAISE early prevention/intervention model is applied to prodromal or burgeoning mental illness with treatment and self/family strategies as part of recovery.

 Further, envision a society in which biomarkers for suicide and predictive analytics are further refined and scaled to national level so that every patient in primary care has the benefit of mental health screening and suicide preventive interventions, as they do for other leading causes of death (eg, cardiovascular disease, cancer, infectious diseases).

 Finally, envision a society in which health systems have become suicide-safer systems of care.

These advances are at various stages of progress. New recommended care standards were recently released for better detection and clinical care that reduces suicide risk.

 At the American Foundation for Suicide Prevention, we fund research, provide community education, and serve as a catalyst for cultural transformation and suicide rate reduction through initiatives like Project 2025.

 We remain hopeful because we see the seeds of change glimmering around the US. Through the leadership of our scientific community and our delivery mechanism for education, advocacy, and loss support through a chapter network in all 50 states, we see that suicide prevention is not only possible, but the foundation is being built. We must all work together in the field of psychiatry with partners of many types, including health system leaders, tech and corporate leaders, media, education, and policy makers, to mount the effective suicide prevention plan that is necessary to stem this rising tide.

In this Special Report, new developments and current thinking in suicide prevention are presented, including:

• Recommended language changes that can speed the eradication of stigma (eg, the recommendation to stop using the phrase “commit suicide” because suicide is a complex health outcome, not a moral failing)

• One physician’s powerful personal experience of suicide loss and lived experience that has led to newfound freedom

• Treatment modalities with evidence for reducing suicide risk in high-risk patient populations: cognitive behavioral therapy for suicidal cognitions and behaviors, dialectical behavior therapy for adults with borderline personality disorder and for adolescents with elevated suicide risk, among other modalities

• New methods in suicide prevention research aimed at better risk detection

• An approach to clinical suicide risk assessment that incorporates underutilized tools like the Reasons for Living Inventory

• Integration of suicide prevention practices into primary care

• A health system framework called Zero Suicide that specifically aims to better identify at-risk patients and provide the warm handoff and care, follow-up contact, and evidence-based treatment that can save lives

• Research about the impact of media and social media in particular related to mental health and suicide prevention

Suicide prevention is a complex challenge, but we remain resolute. The nation’s readiness for effective pro-mental health and suicide prevention strategies is growing like never before, and the scientific field of suicide has matured enough to provide answers. In this issue and the next issue, we share highlights from the growing science. We don’t have time to waste. Let’s speed the bench to bedside translation and work together to reduce suicide in the US.

Dr Moutier 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.

 Stone DM, Simon TR, Fowler KA, et al. Vital signs: trends in state suicide rates – United States, 1999-2016 and circumstances contributing to suicide – 27 states, 2015. 

 Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. 

 American Foundation for Suicide Prevention. National survey shows majority of Americans would take action to prevent suicide. September 12, 2018. 

 Dixon LB, Goldman HH, Srihari VH, Kane JM. Transforming the treatment of schizophrenia in the United States: the RAISE initiative. 

 Oquendo MA, Sullivan GM, Sudol K, et al. Toward a biosignature for suicide. 

 Walsh CG, Ribeiro JD, Franklin JC. Predicting risk of suicide attempts over time through machine learning. 

 Suicide Prevention Resource Center. Zero Suicide in Health and Behavioral Healthcare. 

 National Action Alliance for Suicide Prevention: Transforming Health Systems Initiative Work Group. Recommended standard care for people with suicide risk: making health care suicide safe. Washington, DC: Education Development Center, Inc.; 2018.

 American Foundation for Suicide Prevention. Project 2025. 

Even while attitudes are opening up about mental health and suicide prevention, the rate of suicide continues to rise in the United States.

Introduction: Turning Suicide Prevention Science Into Action

The global mortality toll for suicide exceeds that of homicide, war, and natural disasters combined.

 Furthermore, the rate of suicide in the US has been increasing over the past 15 years (

). Clearly, it is time to take action: as clinicians, we are in a unique position to help bend the curve and practice the most effective ways to saves lives and bring hope to those affected by suicide.

The good news is that people want to help. According to a Harris Poll conducted in August 2015, nearly 90% of Americans value mental health and physical health equally. People increasingly understand suicide as the tragic outcome of untenable suffering largely rooted in mental illness, and they want to help those at risk.

As the leading organization in the fight against suicide, the American Foundation for Suicide Prevention (AFSP) has set a goal, as part of our Project 2025 initiative, of reducing our nation’s suicide rate 20% by 2025. A growing body of research has given us strategies at population, community, and clinical levels that can be put into practice. It is our hope that more and more mental health professionals will utilize the latest proven modalities to reduce suicide risk. In addition, it is imperative that we work within our communities, and as a nation, to take a public health approach to combatting what is now the 10th leading cause of death in the US.

Suicide prevention: a public health perspective

Suicide prevention activities began in the US in the late 1950s (

). However, it wasn’t until the late 1990s that significant momentum and key milestones began to occur with marked acceleration in the past few years (

Legislative initiatives are sweeping the country. Likewise, public discourse on mental health and suicide prevention has become commonplace in many leading media sources. The Associated Press officially issued new media guidelines in the 2015 

, giving strong recommendations for safe and effective reporting on suicide-and notably urging a ban on the term “committed suicide” (see 

Over the years, AFSP has grown from a small grassroots research-funding organization in 1987 to a strong voice of advocacy in all 50 states-not only for those who have lost a loved one to suicide, but for people with their own “lived experience” of suicide. Alongside our efforts to create a culture that’s smart about mental health, AFSP is the largest private funder of suicide prevention research. (For more about AFSP and its work, go to 

A public health approach is essential if we hope to stem the rising tide of suicide. First, we must invest in science at a level that is commensurate with the morbidity and mortality toll on our nation (see 

). In addition to providing universal education and interventions to ensure that everyone is well versed in the basic common language of mental health, those who work in the public sector (eg, teachers, first responders, police) must recognize the signs of deteriorating mental health or people in crisis.

Children in kindergarten and first grade can be taught important self-efficacy skills. Techniques such as the Good Behavior Game

 have had beneficial results in terms of academic performance 15 years later, but also in terms of mental health and suicidal thinking. Skills can be taught far upstream to save a life much later.

Evidence-based treatments to effectively address suicide risk must be practiced and new techniques developed. Given the shortage of and misdistribution of mental health and even primary care providers in parts of our country, online resources should not be overlooked.

At the policy level, legislative reform must allow for true access to quality mental health care in every region of our country. Finally, measures must also be enacted to reduce access to lethal means for those times when individuals are at heightened risk for suicide.

Research does not allow us to predict who is at imminent risk for suicide in the short term-multiple risk factors converge to increase a person’s risk of suicide. No single event ever causes someone to take his or her life. Health factors, such as mental health conditions and substance use disorders; environmental factors, such as stressful life events and access to lethal means; and historical factors, such as previous suicide attempts or a family history of suicide, can converge to overwhelm an individual’s coping ability.

Fortunately, interacting with these risk factors-and offsetting them-are protective factors such as social support, connectedness, coping skills, cultural/religious beliefs, and problem-solving skills. These protective factors interact in a dynamic way with risk factors and real-time life events and psychosocial stressors to change a person’s risk level over time.

Some of these lifetime risk factors are more amenable to modification than others (

). If we can better understand how these risk and protective factors interrelate, we stand a greater chance of addressing the factors that increase risk, enhancing those that are protective, and thus decreasing the number of completed suicides.

Evidence has shown that restricting access to lethal means saves lives and drives down suicide rates for entire regions. Means matter, and the notion that people who are bent on suicide will find a way simply isn’t true the majority of the time. This point is borne out by several examples. Pesticides are the leading suicide method in Sri Lanka. However, the most highly human-toxic pesticides were banned in the mid-to-late 1990s. Consequently, suicide rates dropped 50% from 1996 to 2005.

In another telling example, domestic coal gas was the leading method of suicide in England and Wales before 1960. By 1970, because of natural changes in gas production, almost all domestic gas in the UK became nontoxic, and suicide rates dropped by roughly one-third.

In yet a third example, the Israeli Defense Forces found that 90% of suicides among soldiers were by firearm, many during weekend leave. In 2006, soldiers were required to leave weapons on base during weekend leave. Weekend suicides dropped significantly. Weekday suicides did not decrease but also did not rise to make up for the weekend decrease. As a result, the suicide rate decreased in this population overall by 40%.

These examples of policy/access changes that led to suicide reductions dispel the myth that people who are suicidal will find a way. The truth is that making lethal means less accessible during critical periods of distress saves lives. Clinicians can educate patients and families about storing lethal means during key times of crisis or distress, which empowers families and friends to act in a way that might save a loved one’s life.

Timing matters: the intense suicidal urge is very short-on a spectrum of minutes to hours. People who survived a serious attempt were asked about the time between the first thought of suicide during that crisis and the actual attempt. Close to 50% of attempts took place within 10 minutes; another 15% of attempts were fairly evenly spread between 11 minutes and 24 hours; the remaining 35% of attempts were made 1 day to 12 months later.

 For many, the period of intense danger lasts only minutes, so helping people to live through peak moments can be lifesaving. These issues of timing also highlight the importance of developing a safety plan well in advance of the crisis.

Findings consistently show that if a person can live through the high-intensity period of suicide risk, or if he survives an attempt, there is a very high likelihood of not re-attempting later in life. A review of 90 studies showed that among those who had made serious attempts, 23% made a subsequent nonfatal attempt during the next decade. But more importantly, 90% or more did 

It is well-known that over 90% of people who died by suicide were suffering from a mental disorder, although all too often undiagnosed, untreated, or undertreated. Furthermore, comorbidity of 2 or more psychiatric conditions is commonplace in cases of suicide. A mental disorder is diagnosed in 30% to 40% of people in treatment who die by suicide; 25% to 30% of people who take their lives tell a therapist or doctor about their distress and thoughts of suicide in the months preceding their death.

It is important to move away from over-reliance on suicidal ideation as the main or sole focus of the suicide risk assessment. Instead, it is vital to explore patients’ suicide risk and protective factors proactively; listen as patients discuss their reasons for living versus their reasons for dying; and help engage them in a therapeutic alliance that puts the patient on the side of staying alive.

The recommendations for pharmacotherapy are simple. First, maximize the management of the patient’s psychiatric condition(s); and second, consider medications that have suicide-specific indications.

Clozapine is the only medication with an FDA indication for suicide risk reduction in people with schizophrenia. Lithium has a strong evidence base for suicide risk reduction as well. In 2 meta-analyses of over 50 studies, lithium showed a 60% to 80% reduction in suicide deaths compared with placebo and other mood-stabilizing medications.

 The rate of suicide attempts was lowered even more significantly than rates of suicide. These findings held true for both unipolar depression and bipolar disorder. If your patient with a mood disorder is at risk for suicide, lithium should be considered.

There are a few other promising medications for suicide risk reduction that we continue to watch. These include ketamine and other NMDA receptor antagonists and partial agonists, which have received FDA breakthrough therapy designations signifying their potential to save lives in the case of life-threatening illness. More data are needed to verify efficacy, safety, dosing, and delivery options.

The research around particular psychotherapeutic modalities has been robust and is now burgeoning with new therapies. Among the better-established therapies for suicide risk reduction are dialectical behavior therapy (DBT) and cognitive behavioral therapy for suicidal patients (CBT-SP). For example, persons who received DBT were half as likely to make a suicide attempt.

 CBT-SP is also extremely effective in preventing repeat attempts in adults who recently attempted suicide.

Safety planning intervention (SPI) can be used in many different settings during or preceding a suicidal crisis. Therapists or peer specialists can facilitate safety planning, but the patient is empowered to identify and use his own customized and stepped levels of coping to avert a crisis.

 A mobile application for SPI has been developed so that patients can utilize their personalized safety plan in real time as needed.

 Another approach is the Collaborative Assessment and Management of Suicidality (CAMS), which has also been shown to be extremely helpful.

A plethora of online resources for suicide risk reduction, such as the DBT and mindfulness-based website (

 An online CBT-based insomnia tool, sleep healthy using the Internet (SHUTi), was developed by researchers from the Black Dog Institute to alleviate symptoms and prevent progression to major depression. Mood Gym, developed by eHub Mental Health at the National Institute for Mental Health Research, is a free online resource that has had positive results in some persons who do not have access to an in-person CBT therapist.

 harkens to its historical and linguistic roots-from a time when suicide was considered a criminal act. Many scientific fields such as neuroscience and epidemiology were in their infancy, particularly with regard to their inquiry into suicide. They now shed light on suicide as a culmination of complex factors, with anguish driven by mental illness as one of the main risk factors.

Thanks to a growing body of research, each day brings us new evidence-based ways to understand, assess, and address suicide risk. Clinicians have a powerful role to play in their work with patients. They can also make a substantial difference by educating their communities about mental health and the role that everyone has to play when it comes to preventing suicide. It is our hope at AFSP that by better equipping clinicians with the latest proven methods and strategies for clinical practice-and by adopting a well-warranted public health approach to suicide prevention-we can turn hope into action and achieve our mission of saving significantly more lives.

This article is based on Dr Moutier’s presentation at the 2015 Annual Conference of the 

 (NNDC). The NNDC, a partner of Psychiatric Times, develops and fosters connections among members to use the power of its network to advance scientific discovery, improve care, and drive the national conversation on depression and mood disorders through collaborative research efforts.

Dr Moutier is the Chief Medical Officer of the American Foundation for Suicide Prevention, a leading private funder of suicide-related research. (The grant review process utilizes 3 levels of peer review similar to that of the National Institute of Mental Health.) She reports that she is a consultant for Otsuka.

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http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/.

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http://www.air.org/topic/p-12-education- and-social-development/good-behavior-game

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