Changing the Narrative on Suicide Prevention: A Conversation With AFSP’s Christine Yu Moutier, MD

CLINICAL CONVERSATIONS

September 10, 2025, is World Suicide Prevention Day. This day of recognition was established in 2003 by the International Association for Suicide Prevention and the World Health Organization in order to raise awareness and establish worldwide commitment to preventing suicides.¹ This year’s theme is “Change the Narrative.” In recognition of this important day, Psychiatric Times sat down with Christine Yu Moutier, MD, the chief medical officer of the American Foundation for Suicide Prevention (AFSP), to raise awareness on important clinical issues related to suicide and help change the current narrative.

Psychiatric Times: According to the Centers for Disease Control and Prevention, nearly 50,000 individuals died by suicide in 2023.² What patients are most at risk?

Christine Yu Moutier, MD: There are multiple populations at increased risk for suicide based on a number of clinical, social, and environmental factors, which include social determinants of suicide risk.³ Patients often have intersectional identities and layered biological and historical risk factors, so it is important to consider patients as holistically as possible. Those at risk include:

• Individuals with mental health conditions like depression, substance use disorders, bipolar disorder, schizophrenia, and/or anxiety disorders—often co-occurring—are at higher risk.
• Those with less well known physical health conditions such as chronic pain, inflammatory conditions, cancer, and even common chronic conditions like heart disease and diabetes, have higher risk. The additional risk conferred by physical health problems is often mediated by depression, but also via psychological responses and physiological processes that also impact the brain.
• Individuals with experiences like justice system involvement, loss, divorce, financial crisis, exposure to parental mental illness, substance abuse or family suicide, can all increase risk. As with all risk factors, it is rarely these events on their own, but rather in concert with other common underlying risk factors like depression or trauma, that elevate suicide risk.
• Patients with a history of previous suicide attempts and self-harm, a family history of suicide, and/or generational trauma.
• Patients with access to lethal means. Living in a firearm-owning home elevates suicide risk by multiple-fold (3-4 fold for adolescents, 8-fold for men, and up to 35-fold for women).⁴
• Veterans and active-duty military members who experience depression, posttraumatic stress disorder, bipolar disorder, substance use disorder—whether or not they experienced combat.
• LGBTQ+ individuals who face social discrimination, rejection, and violence. It is not any aspect of identity that elevates risk, but rather the impact societal values and structural prejudices have on various populations that lead to experience(s) of greater trauma.
• Youth and adolescents who have experienced childhood abuse, neglect, or trauma, as well as bullying. Adverse childhood experiences can produce changes in neurodevelopment, in addition to acute experiences like bullying that can serve as a precipitating factor preceding suicide. This does not mean that bullying is a sole cause for suicide, but can activate suicide risk when underlying risk factors are present.
• Older adults have the highest risk of all age groups, overtaking middle-aged American rates in 2018. Consider the 5 Ds of suicide risk for older adults: depression, deadly means, disease, disconnection, and disability.⁵ Depression is not a natural part of aging, and clinicians can play a key role in addressing and advocating for modifiable changes like connections to social services and peer programs for older adults who are homebound and live on their own, have lost self-sufficiency, as well as experience chronic illness, pain, or cognitive impairment.

PT: About 50% of suicides in 2023 were via firearm.² How can clinicians approach the conversation with patients about firearm safety?

Moutier: No one takes their life for a single reason, but risk is greater when a firearm and other lethal means are present and accessible. This poses significant suicide risk for families, particularly for younger individuals. For example, research shows that approximately 50% of suicide deaths among 18- to 20-year-olds, and nearly all suicides by those under 18, involve a family member's firearm. For women, about one third of firearm suicides involve a spouse or partner's firearm.

Since a suicidal crisis cannot be predicted, it is not enough to simply remove firearms during times of increased risk. Clinicians can share 3 pieces of advice with firearm owners and those that live in households with firearms to help prevent suicide.

1. Store firearms securely, removing ammunition and changing safe codes. Temporarily storing firearms outside the home during the period of mental health deterioration or suicide risk is even better.
2. Engage family and peers when possible to keep an eye out for suicide warning signs. Help them learn about how they can support a loved one’s mental health because family is a critical aspect to preventing suicide. Educate them about making the home environment safe by storing guns locked and unloaded. There are also resources available to guide individuals on how to support a loved one who is struggling—take AFSP’s programs like Talk Saves Lives and Finding Hope, for example.
3. If you are worried about someone in distress, have a conversation with them and connect them to mental health treatment or crisis resources like 988. During a crisis, you can work collaboratively with the person in distress, their loved ones, and other trusted resources like a clinician to help them remove firearms from their home until the period of suicidal crisis resolves.

Research shows that most individuals in suicidal crisis who do not have easy access to a lethal suicide method like a firearm usually do not engage another way to kill themselves. For that reason, removing access to firearms allows time for both the moment of intense suicidal crisis to pass, and also for someone to intervene with potentially lifesaving mental health support and resources.

The most important point to take away is that patients are not averse to conversations about firearms when approached with principles of cultural humility. Training on Counseling on Access to Lethal Means (CALM) is available for free.⁶

PT: Individuals aged 85 and older had the highest rates of suicide in 2023.² What does this say about our care for the older population? What can we be doing to encourage mental well-being in our older adults?

Moutier: Individuals aged 85 and older face unique mental health challenges compared with the general population, like coping with chronic or serious illness, losing family and loved ones, and a loss of self-sufficiency. In addition to these risk factors being overlooked, underrecognized, and undertreated, ageism and stigma prevent older adults from seeking care. On the flip side, there is a shortage of geriatricians, geropsychiatrists, or other health professionals trained in suicide and mental health screening, diagnosis, and treatment for the geriatric population.

The health care system must improve access to mental health care to prevent suicide in older adults by training more providers in geriatric mental health, integrating behavioral health into primary care settings, and advocating for Medicare parity in mental health coverage. Medicare has also begun providing payment for suicide preventive care such as screening, risk assessment, and safety planning.⁶

There are steps we can all take to support the mental health of older adults in our lives, including:

• Staying connected with loved ones, whether that is in person or via phone or video calls or participating in family gatherings.
• Recommending low-impact physical activities like walking or tai chi and/or creative hobbies like art, music, or writing.
• Supporting brain health like doing puzzles or playing board or card games together.
• Encouraging participation in community, mentoring or volunteering programs, or getting involved in the local senior center.
• Having supportive, honest conversations with loved ones that open up dialogue about grief, loss, and fears. You can also help identify support groups or spaces where older adults can have these conversations.

PT: Approximately 30% of individuals with treatment-resistant depression attempt suicide at least once in their lifetime, compared with about 15% of those with nonresistant depression.⁷ How can we target this particular group of patients?

Moutier: For individuals with treatment-resistant depression, electroconvulsive therapy and several forms of transcranial magnetic stimulation have been found to be helpful in reducing suicide risk.⁸ There are a few medications or classes of medication clinicians can consider for suicide prevention:

• Lithium is one of the oldest treatments used in modern psychiatry, but it has been and still is underutilized. It has a suicide-preventive effect in the long-term treatment of both depression and bipolar mood disorders. However, it also can lead to significant adverse effects, which need to be closely monitored through bloodwork screening.
• Ketamine is still being investigated to understand longer term outcomes, but it has been found to lead to rapid reduction of depressive symptoms and suicidal ideation. Esketamine is FDA-approved with an indication for treatment-resistant depression and may also have short-term suicide risk reducing properties. On August 11, 2025, intravenous ketamine was given a fast-track designation by the FDA for the treatment of suicidal ideation in patients with depression including bipolar depression.⁹ This would be the first FDA indication of ketamine to directly address suicide risk, and only the second ever suicide related FDA indicated medication (clozapine is currently the only suicide related FDA indicated medication for patients with schizophrenia).
• Antidepressant augmentation or clinical diagnostic reevaluation are recommended when depression is not responding to first and second-line treatment trials. Consider adding or changing type of psychotherapy.
• Never worry alone. Get a second opinion from a colleague you respect and always discuss challenging cases with mentors/colleagues you trust.
• Limit quantity of medications when risk is elevated, especially for medications with narrow therapeutic index.

PT: Recent cuts to 988 have made easily accessible suicide prevention resources more complicated, especially for LGBTQ+ youth. What advice do you have for your fellow clinicians in helping this vulnerable group?

Moutier: Recent cuts to 988 for LGBTQ+ youth were not just a political decision, they are a public health failure. The services were not symbolic, they were built on evidence and evaluated for its specific, intended impact as a specialized part of 988. Since the program’s launch in 2022, these services connected more than 1.3 million LGBTQ+ youth in crisis with counselors trained to understand their specific risk factors, trauma, and strengths. For many, this was their first—and only—experience with person-centered care.

The argument from federal officials is that “all counselors are trained to help everyone.” But general training is not enough and it is not a substitute for training and care that is specifically designed with cultural competence to improve outcomes. LGBTQ+ youth are not simply “everyone”—they face unique disparities in mental health outcomes and access to care. That is why I advise clinicians to continue helping LGBTQ+ youth with culturally competent care. It is not a radical concept; it is a well-documented and effective approach for supporting high-risk populations like LGBTQ+ youth and saving lives. Culturally competent care improves access, engagement, and outcomes. When people feel seen, they are more likely to reach out, disclose with greater depth and vulnerability, adhere to care plans, and return to health professionals. Research shows that LGBTQ+ individuals face significantly higher rates of psychological distress yet often delay or avoid care due to fear of discrimination or previous negative experiences. Cultural competence directly counters this and is exactly why the 988 LGBTQ+ service was created from the beginning.

Abruptly removing these services in the midst of a mental health crisis for LGBTQ+ youth is both dangerous and deeply out of touch with clinical best practice. Culturally competent care is not about politics. It is about public health. It is about risk. It benefits high-risk groups, like LGBTQ+ indiivduals, by reducing barriers and strengthening engagement.

PT: In your opinion, what should clinicians be doing in general to stem the tide of suicide?

Moutier: Clinicians play a pivotal role in suicide prevention and there are several evidence-based strategies they can adopt or continue to implement to save lives. Some include the following:

• In patient care, consider not only psychiatric illness but also suicide risk as its own clinical target.
• Conduct suicide risk assessments in an ongoing manner over time.
• Empathically listen without judgment to patients’ suicide “narrative.” This allows for greater understanding on both your and their part of the patient’s unique drivers of risk.
• Increase frequency of visits or communication during periods of elevated risk.
• Consider the Psychiatric Advanced Directive as a way to engage the patient’s wishes for their treatment, should their mental health deteriorate and impede their ability to make decisions in their usual manner. This is an underutilized tactic for addressing treatment planning that upholds patient autonomy and can potentially reduce suicide risk by engaging the patient’s wishes outside of periods of higher risk.
• Review and adjust medications on an ongoing basis, and limit the quantity of medications, when appropriate.
• Consider adding psychotherapy in addition to medication.
• Communicate with other clinicians in split-treatment arrangements.
• Obtain consultation and discuss challenges with colleagues so you are not bearing the burden of worrying alone and to obtain creative, additional strategies for the treatment plan.
• Help establish a safe home environment by addressing lethal means and working with family, when possible, to ensure follow through on the steps to improve home safety.
• Have open, authentic conversations with a patient and/or their family members about their mental health and/or suicide risk. It not only builds a better understanding of their individual experience(s) but also reduces stigma. These conversations also make it easier to collaboratively develop safety plans with patients and counsel them on reducing access to lethal means like firearms and medications.
• Implement the collaborative care model or key elements of it, into primary care practices to help effectively reduce suicidal thoughts and attempts.
• Get more suicide prevention training as new interventions are being developed and standards or care continue to evolve. AFSP has a new virtual clinical suicide prevention 101 training called Clinical Approach to Preventing Suicide: An Introduction (for more information, email programs@afsp.org). It is a 1.5-hour presentation, offered either in-person or virtually, designed to provide an introductory overview of the clinician’s role in preventing suicide among patients, and covers risk and protective factors, warning signs, screening tools, brief interventions, and treatment options. The program, led by health care professionals authorized to prescribe medication, is based on research and designed for clinicians who serve adults aged 18 and older, as well as those in training such as PA students, nurse practitioner students, or physician residents. Participants will be able to:
  • Describe a model for understanding the risk and protective factors of suicide.
  • Enumerate the warning signs of suicide risk.
  • Identify at least 2 evidence-based screening tools for assessing suicidal risk.
  • List the key components of a patient-driven, collaborative safety plan.
  • Identify treatment options for patients at risk of suicide.
  • This program aims to foster awareness and understanding among health care providers about treatment options tailored to individuals at risk of suicide, facilitating informed and compassionate care.

PT: World Suicide Prevention Day is about hope. What words of encouragement do you have for your peers? Are you hopeful that we can reduce the rates of suicide?

Moutier: Mental health professionals are doing some of the most vital, courageous, and compassionate work there is. Every conversation you have with a patient, all the care, empathy, and time you spend listening to patients, and holding onto your own anchors for staying hopeful—even while working with the most challenging patients who suffer—can save lives. Prevention work has its challenges because not every life can necessarily be saved—as is true for other complex health outcomes like cancer or heart disease, even with best practice care—and the medium term impacts of prevention efforts can be harder to measure. Taking care of your own mental health and staying present in your time with patients does create a lifeline of hope, resilience and recovery for people who are struggling. Thank you for showing up on the good days and the hard days.

Even in the face of challenging times, I remain hopeful. Suicide prevention at the population level relies on a long-game strategy with continued research, implementation, and advocacy. If increases in investments continue, a strong, sustained, and fully implemented public health approach can be achieved. They could also lead to rates declining.

This requires all of us—not just mental health professionals—from primary care and health system redesign to universal education in schools and community settings and specially trained peers with lived experience. On an individual level, connection is key in addition to individualized, increasingly personalized strategies in safety planning, medication, and therapy. Suicide risk can be reduced at any stage along the continuum of care from upstream to acute risk, and we all serve multiple roles in our lives, from clinician to community member to family member. In each of our roles, we can bring suicide prevention principles based in science to life. Learn more at afsp.org.

PT: Thank you!

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

References

1. About World Suicide Prevention Day. International Association for Suicide Prevention. Accessed September 10, 2025. https://www.iasp.info/wspd/about/

2. Suicide data and statistics. Centers for Disease Control and Prevention. March 26, 2025. Accessed September 10, 2025. https://www.cdc.gov/suicide/facts/data.html

3. Na PJ, Shin J, Kwak HR, et al. Social determinants of health and suicide-related outcomes: a review of meta-analyses. JAMA Psychiatry. 2025;82(4):337-346.

4. Studdert DM, Zhang Y, Swanson SA, et al. Handgun ownership and suicide in California. N Engl J Med. 2020;382(23):2220-2229.

5. Van Orden KA,Buttaccio A, Conwell Y. The 5D indicators of suicide risk in older adults who are lonely. Ann N Y Acad Sci. 2025;1548(1):181-193.

6. Mental health care (outpatient). Medicare. Accessed September 10, 2025. https://www.medicare.gov/coverage/mental-health-care-outpatient

7. Kern DM, Canuso CM, Daly E, et al. Suicide-specific mortality among patients with treatment-resistant major depressive disorder, major depressive disorder with prior suicidal ideation or suicide attempts, or major depressive disorder alone. Brain Behav. 2023;13(8):e3171.

8. Ludwig J, Marcotte DE, Norberg K. Anti-depressants and suicide. J Health Econ. 2009;28(3):659-676.

9. Kuntz L. FDA grants fast track designation for NRX-100 for suicidal ideation in patients with depression, including bipolar depression. Psychiatric Times. August 11, 2025. https://www.psychiatrictimes.com/view/fda-fast-track-designation-for-nrx-100-for-suicidal-ideation-in-patients-with-depression-including-bipolar-depression