Implementing Evidence-Based Approaches to Reducing Rates of Suicide

As data continue to show increases in the rates of suicide in the United States, healthcare systems are grappling with addressing the issue in an effective and sustainable way. The American Journal of Managed Care^® (AJMC^®) recently spoke with C. Edward Coffey, MD, affiliate professor of psychiatry and behavioral sciences at the Medical University of South Carolina, about evidence-based strategies to reducing suicide.

AJMC^®: How has the prevalence of suicide changed over recent years? And what are some of the drivers behind these changes?

Coffey: The news is not good. In this country, the suicide rate has increased steadily by 33% in the past 16 years. It’s increasing both in men and in women.

We don’t really know, scientifically, the answer to why these rates have increased. There are many, many hypotheses. There’s of course an epidemic of opioid abuse, and certainly some of those opioid deaths could be, in part, suicides. It’s been speculated that there is an angst in the country at large related, in part, to social and economic issues; economic disparities are getting wider and wider, and the gaps between the haves and have nots are growing. We don’t know if there’s a direct line, but it isn’t a stretch that these sorts of things are impacting people’s lives in a very significant way.

Perhaps most importantly is the availability of guns. Most suicides are a result of death by gun, and as the availability of guns increases so to does death by gun—homicide and suicide. I think all these factors contribute

AJMC^®: Looking at youths and young adults in particular, have you seen rates change in recent years?

Coffey: With regard to our country’s youth, the news is not good here either. I think earlier this year, the CDC reported that the overall death rate for children between the ages of 10 and 19 years has begun to increase by about 12% from 2013 to 2016. The increase alone is bad enough, but what’s striking about this increase is that it’s a reverse direction. For years, youth death rates had been going down, so it’s a reverse of the direction.

This increase in death rate is being driven primarily by an increase in injury deaths. The CDC defines injury as suicide, homicide, or unintentional accidents. Among those 3 buckets, it’s the suicide and the homicide rates that have skyrocketed. To give you an example, from 2007 to 2016, suicide rates have increased by 56% in youth, and homicide rates half that by about 27%. The numbers themselves are striking, but these numbers come after years of great progress in reducing youth death rates, so it’s really concerning. It’s reaching a crisis proportion.

As I mentioned before the issue of firearms, it seems a little bit easier to draw a straight line between the availability of firearms and these deaths in our kids. Firearms are involved in about almost 90% of all homicides and over 40% suicides, and suicide is the predominant cause of firearm death in this country.

AJMC^®: There’s been some research suggesting a rise in mental health issues among adolescents and young adults and that social media might play a part in this. Do you agree?

Coffey: It is hard to say. There’s observational or correlational studies and so we have to look at them and try and understand them, but they’re not definitive in terms of cause and effect. I think it’s possible, and I think such effects could be contributing to this overall sense of angst in the country.

My focus has been more on the weapons availability and trying to make it more difficult for people, adults or kids, to act on this suicidal impulse. That really is the big opportunity, and it is the one we leverage very effectively.

We can speculate on a number of things that might be causing distress, like social media and others; it’s the easy availability the weapons that I think is the problem.

AJMC^®: What are some evidence-based approaches to reducing suicide, and how does that play into the work you have been doing?

Coffey: There are 2 evidence-based approaches to reducing suicide. One is rapid access to definitive diagnosis and treatment of any underlying mental disorder. There is no question that suicide is a grave concern in patients with major mental illness, and I say major mental illness on purpose. It’s not just depressive disorders that carry a very high suicide rate; suicide rates are increased at about the same level in all of the major mental disorders, so not just the mood disorders like depression or bipolar, but also disorders like schizophrenia or substance misuse and some of the anxiety disorders. And if you take those disorders and mix in substance misuse, then you’ve got a real deadly situation.

When we think about interventions to reduce suicide, we don’t want to limit our focus to just those patients with depression or another mood disorder, it’s all of these major mental disorders that carry about the same elevated risk.

The second evidence-based approach is restriction of lethal means—making it hard for somebody to act on their suicidal impulse. We know, for example, when this event takes place, it’s usually in the setting of a person who’s stressed and their impulse control is impaired. If we can make it hard to carry out the act, we can buy some time and then that impulse will subside and maybe that person can get to definitive help.

In our country, the most common approach to suicide is to guns. So, if we want to bend this needle tomorrow, if we want to reduce the rates tomorrow, the quickest thing we could do would be to ensure safe gun ownership.

AJMC^®: Does there also need to be tailored approaches for different groups of people?

Coffey: I think these 2 strategies will work for everybody but the way we implement the strategies may need to be customized for some groups. So, the approach to diagnosing and treating mental disorders does need to be customized for the individual and their beliefs and their values. Secondly, the whole means restriction, likewise, needs to be customized. For example, it’s one thing to restrict a businessman’s access to a gun, it’s another to restrict a veteran’s access. Those 2 are very different, and we have to approach these difference in a smart and respectful way so we can ensure safety.

AJMC^®: Do you think there needs to be increased access to treatment for patients with mental health disorders, as well as a strategies to reduce stigma surrounding these disorders?

Coffey: Absolutely. You’re not going to rapidly diagnose and treat anything if the patient doesn’t have access to healthcare. So now, we get into the whole discussion of the mental health care system. Our healthcare system in general is fragmented and disintegrated, and you move to the mental health care system and it’s even more fragmented and further complicated by stigma. All of these factors provide barriers to getting that rapid access to definitive diagnosis and treatment.

It’s going to take a while to fix that. All of these issues are very important, but we’re not going to fix them today. We’re going to have to chip away at them, and it’s going to take some time. The stigma surrounding mental health today is a lot better than when I was starting out in the field 30 years ago.

If we want to do something quickly now to change the direction of the way things are going, the quickest thing we could do is focus on means restrictions. When I was in Detroit, I was talking about our work with an auto executive and describing how we had gotten very good progress with focusing on means restriction, and he said what we were doing is a lot like what’s happened in the auto industry in regards to traffic deaths.

He said back in the 1950s and 1960s, a lot of people were dying on the roads and both the cars and roads were unsafe. Part of the issue was driving while impaired, but we didn’t talk much about it then. So, one approach to reducing traffic deaths was, correctly, to conduct an education campaign and change our laws so that people don’t drive while impaired. But that doesn’t happen in 1 day, or 1 week, or 1 year. It takes decades for that to happen to change the culture.

The other thing the automakers did was make the cars safer. They put in seatbelts and airbags, they created windshields that don’t shatter on impact. So, while we’re trying to teach people to drive safer and we’re trying to change the culture around driving while impaired, we didn’t wait for that to be our only step. And the automaker said that’s what we’re doing by focusing on the means—trying to make the environment safer while trying to change the issue of mental health and mental health care.

We need to employ both strategies, but the timeline for 2 is going to be very different, I think.

AJMC^®: Does this also require collaboration between the medical community and regulators?

Coffey: It’s a public health issue; it’s like the measles outbreak we have going on, it’s like the HIV/AIDS epidemic we’re dealing with. It’s public health, and it means we all have to get involved. We need the healthcare system, we need the community, we need the government to participate and be part of the solution.

We had pretty good success in Detroit and elsewhere working with the community on this issue. For example, we had patients who might not have been willing to temporarily give their gun to a neighbor or a relative but were willing and comfortable handing it over to their gun club for a few months until they were feeling better. It’s these kinds of partnerships that can happen.

The third strategy that I think is not necessarily evidence based but I think has made a huge difference is our starting belief that we could eliminate every suicide, and this is where vision zero comes in. A fundamental belief that it is possible to eliminate every suicide. That sounds like common sense, but unfortunately, for a long time, there has been a belief in healthcare that some suicides might not be preventable. While I think that’s possibly true, our team took the approach that said we going to try and not let it happen today.

So, we got the patients and family very involved in this discussion around suicide and around the importance of means restriction and we got very focused on ensuring a strong safety plan for those individuals, and I think that was the secret sauce to the success we achieved in Michigan.