Breaking the Trend: New CDC Data on Suicide

Q&A

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^TM about the new information.

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

Christine Moutier, MD: 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 US suicide deaths 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 suicide deaths.

A study of 21 higher-income nations international colleagues published in April in Lancet Psychiatry¹ found that suicide deaths during the early months of the pandemic either stayed the same or dropped below prepandemic levels.² 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 invited JAMA commentary I published last year before this data was available.³

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?

Moutier: 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 here.

-Use AFSP resources to help patients and families learn more (eg, After an Attempt, Surviving a Suicide Loss, Have a #RealConvo).

-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 (AFSP) Project 2025 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?

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

Moutier: 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, bullying, 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?

Moutier: 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 trauma, 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?

Moutier: 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.”⁴ Do you agree? If so, how can clinicians help foster trust?

Moutier: 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 resources 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.⁵ 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 strategies AFSP has placed on diversity, equity, and inclusion.⁶

To see more of Dr Moutier’s thoughts on suicide, see Suicide: Myths, Media, and Difficult Discussions.

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

References

1. Pirkis J, John A, Shin S, et al. Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries. Lancet Psychiatry. 2021;8(7):579-588.

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