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Preventing suicide in all the wrong ways

Preventing suicide in all the wrong ways

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It's Suicide Prevention Week and advocates are busy conducting suicide awareness campaigns. But there is not evidence that awareness reduces suicide. More effective suicide prevention approaches are being ignored.

Suicide is rare among the general population. It is more common, but still rare, among people with serious mental illness. There are about 38,000 successful suicides per year (American Foundation for Suicide Prevention 2010). There are at least 380,000 attempts. The lifetime risk to those with schizophrenia is only 5%. (Hor and Taylor 2010). The lifetime risk to those with bipolar is only 10-15%. (Center for Disease Control and Prevention 2014).

Mental health advocates regularly overstate the prevalence of suicide and attempts among persons with mental illness.  At the high end, the National Alliance on Mental Illness claims, “More than 90% of youth suicide victims have at least one major psychiatric disorder.”  (National Alliance on Mental Illness (NAMI) 2013)  Mental Health America, a trade association for providers of mental ‘health’ services estimates “30% to 70% of suicide victims suffer from major depression or bipolar (manic-depressive) disorder” (Mental Health America n.d.).

But suicide is not always the irrational act of a sick mind.  Mental illness in people who commit suicide is often diagnosed after the fact. After someone takes his or her own life, we look for a cause. If they take their life after having had lost their spouse or job, received a bad grade in school or received a new medical diagnosis we chalk it up to depression and put the suicide in the mental illness column. 

In spite of being overstated, it is clear that suicide does disproportionately affect people with mental illness. Dr. E. Fuller Torrey looked at studies of the prevalence of suicide among the seriously mentally ill and studies of the prevalence of serious mental illness among those who suicide, two sides of the same coin, and in both cases found about 5,000 of the 38,000 suicides (about 14%) were in people with serious mental illness. This is three times as high as the general population.  (Torrey n.d.). 

Suicide can not be reduced through awareness advertising and public relations

Every suicide is a tragedy for the individual, their family, and the community. Many of the truly mental illness related suicides could be prevented if persons with mental illness were provided care. Instead of doing that, the mental health industry’s main tool in reducing suicide takes the form of public service announcements, brochures, hotlines, and speeches targeted to the general population. For example, in 2012, the California mental health industry banded together to spend $32 million in public funds for a TV, radio, billboard, online, mobile and print advertising campaign targeted at the general public to reduce suicide. (California Mental Health Services Authority 2012).  But those charged with overseeing the funds, refuse to measure rates of suicide to see if the funds are having an impact. Instead they measure tangential issues like “attitudes” and number of presentations made. The money is wasted.

There is little scientific evidence media campaigns reduce suicide and mounting evidence they don’t. The largest and most sound review of the issue was Suicide Prevention Strategies: A systematic review, published in the Journal of the American Medical Association.  (J. John, Alan and al. 2005). The authors found that

despite their popularity as a public health intervention, the effectiveness of public awareness and education campaigns in reducing suicidal behavior has seldom been systematically evaluated.

The report went on to note what the research does show:

Such public education and awareness campaigns, largely about depression, have no detectable effect on primary outcomes of decreasing suicidal acts or on intermediate measures, such as more treatment seeking or increased antidepressant use.

A 2009 study in the journal Psychiatric Services looked at 200 publications between 1987 and 2007 describing depression and suicide awareness programs targeted to the public and found that the programs “contributed to modest improvement in public knowledge of and attitudes toward depression or suicide,” but could not find that the campaigns actually helped increase care seeking or decrease suicidal behavior. A similar study in 2010 in the journal Crisis actually found that billboard ads had negative effects on adolescents, making them “less likely to endorse help-seeking strategies”. (Sanburn 2013)

Mental health industry sponsored suicide initiatives are often targeted at college students, a group least likely to commit suicide.  The 2011 National Survey on Drug Use and Health is one of the premiere epidemiological surveys and found college students were less likely than other same aged adults to have serious thoughts of suicide (6.5 vs. 8.4 percent), make suicide plans (1.5 vs. 2.4 percent), or attempt suicide (0.8 vs. 1.8 percent). (SAMHSA 2012). The college targeted PR programs are no more effective than mass market anti-suicide PR campaigns.

Few such programs are evidence-based, reflect the current state of knowledge in suicide prevention, or evaluate effectiveness and safety for preventing suicidal behavior…A systematic review of studies published from 1980-1995 found that knowledge about suicide improved but there were both beneficial and harmful effects in terms of help-seeking, attitudes, and peer support.” (J. John, Alan and al. 2005)

Why are mass market media campaigns so popular in spite of the fact there is no evidence they work and evidence they don’t? Money. It is very easy and profitable for a mental health provider to write a brochure, produce a PSA, rather than try to reduce suicide. By putting their logo on the materials they increase their visibility and self-importance. As one suicide researcher concluded, “The conflict between political convenience and scientific adequacy in suicide prevention is usually resolved in favor of the former. Thus, strategies targeting the general population instead of high-risk groups (psychiatric patients recently discharged from hospital, suicide attempters, etc.) may be chosen…especially if the desired outcomes also include a number of conditions frequently associated with suicidal behaviors (such as poor quality of life, social isolation, unemployment and substance misuse).” (Diego de Leo 2002)

How to reduce suicide

One effective suicide prevention strategy is means removal: putting locks on guns, medicine cabinets and drawers containing knives. (Yip, et al. 2012). However, the mental health industry has largely been unwilling to give up funds they can use to create TV ads featuring their logo in order to fund suicide means reduction. California did authorize the use of mental health dollars to fund a net under the Golden Gate Bridge. But that was largely a PR ploy to defuse criticism of massive waste in California’s Mental Health Services Act (MHSA) fund which is supposed to fund services for the seriously ill. (Mental Illness Policy Org. August, 2013) California Senate President Pro Tem Darrell Steinberg claimed “Proposition 63’s contribution to suicide prevention at the Golden Gate Bridge will probably become its most publicly recognizable benefit.” (Steinberg 2014).

It is also known and ignored that those who are most likely to commit suicide are those who have previously attempted suicide, first-degree relatives of those who completed suicide, and persons with serious mental illness. (Tsuang 1983), These individuals, by name, are likely known to the mental health system as a result of their suicide or family histories. Intensive follow up of these individuals, rather than the general public, would be a much more efficient and effective way for the industry to reduce suicide. Time Magazine reported on this in an interview with Lanny Berman, executive director of the American Association of Suicidology (AAS):

The general zeitgeist in the field is public education is good, and it’s better that people know about the problem and really know that prevention is possible. But I don’t know that public awareness campaigns work for the people you most want to reach, the people who are already suicidal.”  If we know who’s most at risk, people like Jaffe and Berman argue, shouldn’t we target them in a smarter way? If a factory closes, for example, shouldn’t efforts be made to market suicide prevention services in that community? ...Berman… is concerned that SAMHSA is too focused on “upstream” measures like increasing overall awareness. “The bottom line is that the people most at risk are people who don’t get into treatment, and a public health approach shifts attention from high-risk patients to large populations of folks who might develop mental health problems,” he says. (Sanburn 2013)

While the lifetime risk for suicide in people with schizophrenia is only 5%, we do know how to predict and prevent those suicides. The biggest risk factors are “number of prior suicide attempts, depressive symptoms, active hallucinations and delusions, and the presence of insight…a family history of suicide, and comorbid substance misuse. The only consistent protective factor for suicide was delivery of and adherence to effective treatment.” (Hor and Taylor 2010)

As far as we know, no mental health provider is proposing to use suicide funds to treat the seriously ill. There is evidence they should.  A Kendra's Law study in New York found Assisted Outpatient Treatment, reduced suicide attempts and physical harm to self 55%. (New York State Office of Mental Health 2005). The Treatment Advocacy Center compiled a list of suicide studies suggesting suicide is more likely to occur in those individuals with schizophrenia and bipolar disorder who are not being treated or adequately treated and less likely in those that are treated.

  • A 34-year follow-up study of 158 individuals with bipolar disorder reported that 18 of them (11 percent) had committed suicide. The suicide rate was more than twice as high among patients who had not been treated compared with those who had been treated (p = 0.04), a difference the authors called "spectacular."
 (Angst F 2002)
  • A study in Kentucky found that only 2 of 28 individuals with schizophrenia who committed suicide had evidence in their blood of having taken antipsychotic medication. Thus, 93 percent of them were not being treated. (Shields LBE 2007)
  • A case control study of 63 individuals with schizophrenia who committed suicide and 63 individuals with schizophrenia who did not reported that "there were seven times as many patients who did not comply with treatment in the suicide group as there were in the control group."
 (De Hert M 2001)
  • A case-controlled study compared 27 inpatients with schizophrenia and 24 inpatients with affective psychoses, all of whom suicided, with their matched inpatient case controls who did not suicide.  The authors concluded that there is "a significantly increased risk" of suicide when medications are not used. (Gaertner I 2002)

If the mental health industry insists on relying on communications as a path to reduce suicide, then those communications would be much more effective if they were targeted at those of highest risk of suicide, not the general public. Prisoners are a high-risk group. Suicide in jail is three times more common than in the general population and thirty eight percent of those who committed suicide in jail in 2005-2006 had a known history of mental illness. (Hayes April, 2010). If the mental health industry worked to reduce incarceration of persons with mental illness, they could further reduce suicide.


To reduce suicide we should stop funding what doesn’t work and start funding what does. The Helping Families in Mental Health Crisis Act (HR-3717) proposed by Representative Tim Murphy (R-PA) along with 96 bipartisan co-sponsors takes a step in this direction by ensuring mental illness spending is driven by evidence and through funding various anti-suicide initiatives.

Works Cited

American Foundation for Suicide Prevention. Suicide: Facts and Figures. 2010. (accessed April 15, 2013).

Angst F, Stassen HH, Clayton PJ et al. "Mortality of patients with mood disorders: follow-up over 34-38 years." Journal of Affective Disorders 68 (2002): 167-181.

California Mental Health Services Authority. California Mental Health Services Authority Launches Statewide Suicide Prevention Campaign. Dec 12, 2012. (accessed 12 28, 2013).

Center for Disease Control and Prevention. "Surveillance for Violent Deaths — National Violent Death Reporting System, 16 States, 2010 ." Morbidity and Mortality Weekly Report, January 17, 2014: 1-33.

De Hert M, McKenzie K, Peuskens J. "Risk factors for suicide in young people suffering from schizophrenia: a long-term follow-up study." Schizophrenia Research 47 (2001): 127-134.

Diego de Leo, Franzcp. "Why are we not getting any closer to preventing suicide?" The British Journal of Psychiatry 181 (2002): 372-374.

Gaertner I, Gilot C, Heidrich P. "A case control study on psychopharmacotherapy before suicide committed by 61 psychiatric inpatients ." Pharmacopsychiatr 35 (2002).

Hayes, Lindsay M. National Study of Jail Suicide: 20 Years Later. National Institute of Corrections, U.S. Department of Justice, Available at, April, 2010.

Hor, Kahyee, and Mark Taylor. "Suicide and schizophrenia: a systematic review of rates and risk factors." Journal of Psychopharmacology, November 2010: 81-90.

J. John, Mann MD, Apter MD Alan, and et. al. "Suicide Prevention Strategies A Systematic Review." The Journal of the American Medical Association (JAMA) (American Medical Association) 294, no. 16 (October 2005): 2064-2074.

Mental Health America. Suicide. (accessed April 15, 2013).

Mental Illness Policy Org. "California’s Mental Health Service Act: A Ten Year $10 Billion Bait and Switch." New York, NY, August, 2013.

National Alliance on Mental Illness (NAMI). Suicide Fact Sheet. January 2013. (accessed April 15, 2013).

New York State Office of Mental Health. Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment. Report to Legislature, Albany: New York State, 2005, 60.

SAMHSA. "Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings." Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration , Rockville, MD, 2012.

Sanburn, Josh. "Inside the National Suicide Hotline: Preventing the Next Tragedy." Time, September 13, 2013.

Shields LBE, Hunsaker DM, Hunsaker JC III. "Schizophrenia and suicide: a 10-year review of Kentucky Medical Examiner cases." Journal of Forensic Sciences 52 (2007): 930-937.

Steinberg, Darrell. Steinberg on vote for Suicide Barrier at Golden Gate Bridge. June 27, 2014. (accessed July 20, 2014).

Torrey, E.F. 5000 suicides a year are likely caused by mental illness, mainly untreated mental illness. . (accessed 4 15, 2013).

Tsuang, MT. "Risk of suicide in the relatives of schizophrenics, manics, depressives, and controls. T." Journal of Clinical Psychiatry 44, no. 11 (November 1983): 398-400.

Yip, Paul, Eric Caine, Saman Yousuf, and Shu-Sen Chang. "Means restriction for suicide prevention." Lancet 379, no. 9834 (June 2012): 2393 - 2399.

Photo by 1800 copy via Flickr.


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I suffer from major depression and borderline personality disorders, Its rather difficult to live with, why? I mean I'm 51 of age and a male, had it for 10 years, will it go away?

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When this article's title came up in my feed I was so excited. I thought, "Finally, a publication about dealing with the root causes of depression and suicide." But instead of dealing with these, this article, like countless others, shrugs off the ways our culture increases suicide risks because it's so much easier either to tell the suffering to call a hotline or to put up a fence to hem them in at the edge of a cliff. I suppose that's much, much easier than, together as communities, rebuilding a gentler and more just culture far more people want to stay alive to keep experiencing.

No wonder the incidences of depression and suicide keep increasing despite every expert's published opinion about how to solve these problems.

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I understand your point, but I believe you expect too much, and are excessively condescending as a result

As somebody who has thought about suicide before, you should know that a general "solution" to suicide is just not feasible, at least not at the moment. Yes, it's much easier to make a fence, to create a hotline, but the fact of the matter is that we don't have a better option yet. Suicide is generally a case-by-case basis, with the emotions leading up to it being any mixture of guilt, anger, depression, etc. There just is no solution that can solve even a majority of problems. Furthermore, I (again, personally! Your opinion may not be the same.) am too cynical to really have an improved outlook on life due to a general program. On the other hand, personal programs for everyone at risk aren't feasible either, due to the excessive resources required for such an undertaking, resources that would probably be impossible to obtain.

So, yes, it's not perfect, but Rome wasn't built in a day. For now, let's just start with what we can do to physically restrict suicide, buying ourselves time to get where we want to be.

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If I am condescending, I am entitled to be. Why? Because instead of letting people like me who have been suffering terribly for decades choose a relatively painless way out, and despite the US' deplorable health care system and too often moribund mental health system--all exacerbated by third-world-like conditions that dog the chronically poor (not my words but those of the UN's own rapporteur on human rights on his latest visit to the US), mental health "experts" keep tossing about the same ineffective, insulting non-solutions for many of us. Many of us don't need "therapy" or a new way of thinking. We need a justice system that works for the poor, too. We need job guarantees instead of, to quote a senior Amazon rep recently in response to beleaguered warehouse workers begging for more humane conditions, "No one has any right to a job [in the US]." We need safe, habitable, affordable housing instead of the commodification of a legitimate survival resource leading to what the US government itself acknowledges: that nowhere in the US is there sufficient affordable housing. We need alternatives to homelessness instead of mushrooming laws making homelessness illegal and obliging the harassment of the homeless. We need access to health care instead of myopic solutions still way beyond people's financial abilities. We need a government that cares about the population instead of maintaining individual politicians' power and buying the support of super-powerful corporate representatives.

And we need the entitlement to do with our own bodies what WE see fit instead of people who aren't even financially responsible for our survival having the gall to tell us what we should feel and endure. Mental health could publish more on and lobby to change the conditions research for decades in the US and abroad has repeatedly linked to plummeting mental health outcomes. And it could, minimally, recognize that those it cannot "save" should be entitled to the dignity of choice instead of absurd labels that impugn and debase, thereby invalidating the choices we consistently do make for ourselves. So long as any industry imposes its own values and beliefs on others and obstructs our decisions about our own private lives--the lives we're told we solely are responsible for--that industry is worthy of condescension.

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Imagine a prison camp where the captives are tortured. These poor souls live in torment, trying to escape, similar to many who live in physical or mental agony in our everyday world.

Now, imagine someone so evil that he says, "we can't stop the torture, so let's prevent the captives from escaping!" That's what this article promotes.

We shouldn't be stopping means of escape until after we have figured out how to prevent people from being in anguish. It is cruel--and downright evil.

The goal shouldn't be merely "suicide prevention"--the goal should be making it so people don't have that desire, but supporting it if that's their choice.

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I completely agree with you. But I suppose that wouldn't work for governments. The lowly "essential workers" who do the jobs no one really wants to for just enough to keep doing them for the rest of their lives--many of these might choose a painless way out to a lifetime of painful poverty. Governments depend on these workers' taxes and their economy-driving consumption. And until machines surpass human brain-power (the way they surpassed human/animal muscle power with the industrial revolution), corporations would loose their low-wage, low-or-no benefits laborers. Who'd stock the shelves for, care for the children or elders of, deliver packages to... the high-paid workers?

Loved your analogy: "Now, imagine someone so evil that he says, 'we can't stop the torture, so let's prevent the captives from escaping!' "

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This article may have had some of the answers I needed but it doesn't have a lot of them. I to was looking forwards to reading this article and was disupointed because it was just like every other article I have read. I wanted to see the proof suicide hotlines don't work, I don't want to go to article to article trying to fine a answer they mention but never support or tell that much about it. This article has just been telling me what I all ready know, their are people out there that have the answers but no one is trying to get those answers.

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What an odd answer, but perhaps in this day and age we should not be surprised by it. Even if you make a valid sweeping point about society, what you are talking about would take multiple volumes to address, and would not just involve a mental health professional but countless others from other fields. Here's the truth you do not seen to want to face: There is no magic pill to fix society because humans are essentially flawed and diverse. You might do better with your own emotional issues if you accepted that as a first principle, and work on yourself, first. Putting it all on society is just punting responsibility and accountability for the hard PERSONAL and INDIVUDUAL work it takes to get through these issues---and that's why the numbers for these types of issues are increasing - we have stopped raising kids to be resilient, and they turn unto adults with your world view: society is to blame---fix society because I can't cope in it. That assessment may seem a but harsh, but my own life experience suggests it's pretty fair overall. Good luck to you. Peace, out.

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This was a great read,I will say this much though that part about there being a big correlation between those who tend to commit suicide and those seeking treatment well that has to do with the sort of individuals mindsets who are not seeking treatment and does not prove to me that what goes for treatment most of the time is actually acceptable!

As for reduction to keep this weapon and that weapon of those suicidal, well when you have someone whose determined and brainy good luck with that!

Otherwise I agree with a lot of this and believe it's true. Yeah in theory if you make things more convenient for treatment and difficult for the sick to obtain blah blah blah. I say this as someone whose definitely insane underneath the cleverness!

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Most suicide prevention sites/articles miss the elephant in the room. Suicide and declining mental health are strongly linked to stressors like homelessness, joblessness, chronic isolation, chronic pain... So, if we want to help many people NOT think seriously about suicide, we ought to be reshaping our culture so many vulnerable people never get to a point where suicide seems such an attractive alternative to staying alive.

Therapy is great for people who want it. But it doesn't put a roof over people's heads. It doesn't provide people meaningful (to them) work that brings in enough cash to survive while saving for emergencies. It doesn't offer the legions of working poor job security in a country where executives of the world's largest corporations point out workers "have no right to a job." It doesn't mitigate the well-documented ancillary costs of poverty (significantly higher exposure to all kinds of pollution and other daily stresses). It doesn't grant the poor and other disenfranchised people who most desperately need the help of the legal system access to the courts (A recent US academic publication found there are FEWER than a single attorney for every 10,000 below-the-poverty-level US citizens). And it doesn't bring isolated people who aren't deemed likable-enough-for-friendship the critical companionship so many researchers have been pointing out is vital to physical and mental health.

Suicide is not the result of just "mental illness" (a vague term biomedical scientists and physicians have yet to characterize reliably). Instead of hoisting the preventive responsibilities onto the shoulders of those already overly-encumbered, the rest of us can rebuilt the safety networks--including reinvesting in being there for other community members--that catch people long before they become so desperate suicide seems like the best choice.

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This is essentially more of I wrote to one of your acolytes above: this answer is interesting but still peculiar, but perhaps in this day and age we should not be surprised by it. Even if you make a valid sweeping point about society, what you are talking about would take multiple volumes to address, and would not just involve a mental health professional but countless others from other fields. Here's the truth you do not seen to want to face: There is no magic pill to fix society because humans are essentially flawed and diverse. You might do better with your own emotional issues if you accepted that as a first principle, and work on yourself, first. Putting it all on society is just punting responsibility and accountability for the hard PERSONAL and INDIVUDUAL work it takes to get through these issues---and that's why the numbers for these types of issues are increasing - we have stopped raising kids to be resilient, and they turn unto adults with your world view: society is to blame---fix society because I can't cope in it. That assessment may seem a bit harsh, but my own life experience suggests it's pretty fair overall. Good luck to you. Peace, out.

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While you're entitled to your opinions about how society works or what constitutes "good" parenting, in a society that truly respects personal autonomy, people would be free to do with their bodies and personal lives as they see fit. Your all-caps notwithstanding, telling someone they're suicidal because they don't have the right coping skills or aren't doing the right work to have the (right) opinions of others isn't necessarily going to change the way people feel. If we own ourselves, regardless what others think about the jobs we pursue or the arts we enjoy or the religion we practice or ... our conclusions about life's value to us, we ought to be free to decide about and pursue or not any of these personal interests. We ought to be free to decide for ourselves if we want to keep living in society--whether it's perfect or flawed.

Countries and courts all over the world are beginning to change on the matter of end of life decision-making. I think it's just a matter of time before we have the right to make such a private decision for ourselves. None of us should HAVE to care what others think about such a personal choice. We should be free to make the decision for ourselves. It's on this basis, among others, that this article misses the mark.

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Thank you for this well-informed and carefully documented post.


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