Suicide is the 10th-leading cause of death in the United States, overall. For people ages 35 to 54, it ranks fourth, and for 10- to 34-year-olds, second.
Over the decades, suicide rates have climbed and fallen and climbed again. Between 1999 and 2017, the suicide rate increased 33%, according to the U.S. Centers for Disease Control and Prevention (CDC) (see March Monitor, "Worrying Trends in U.S. Suicide Rates"). Meanwhile, health-care providers still struggle to identify those at risk and to intervene. Yet suicide researchers say that situation is starting to change.
Within the field of psychology, experts are bringing their unique skills to bear on the problem of suicide. Basic scientists are exploring brain changes and risk factors associated with suicidal ideation and behavior. Applied scientists are seeking new ways to identify those at risk. Clinical researchers are testing new therapeutic interventions, and clinicians on the front lines are helping deliver those treatments to people who are struggling. Meanwhile, psychologists working in advocacy roles are drawing from the latest research to educate the public and promote policies proven to reduce suicide rates. And many psychologists in the suicide field have skills that extend across other subfields of psychology, enabling them to act simultaneously as clinicians, researchers and educators.
"Our field is unique in the opportunities it provides to engage in all sorts of activities: research, clinical work, teaching, influencing policy. You can do it all in one lifetime," says psychologist Jill Harkavy-Friedman, PhD, vice president of research at the American Foundation for Suicide Prevention (AFSP).
"In the suicide field, psychologists are really partnering across three arms: science, services and policy," adds Joan Asarnow, PhD, a clinical psychologist and professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles’s David Geffen School of Medicine, whose work focuses on suicide prevention and interventions in youth. "We need basic science to inform our treatments. And on the other end, we need to find ways to get these [prevention and treatment] approaches into our communities."
To be sure, it’s a multidisciplinary effort, involving psychiatrists, emergency room physicians, social workers, public health experts, pediatricians, school counselors, teachers and many others. But psychology is notable for its wide-ranging expertise—and that diverse expertise is a natural fit for the field of suicide prevention.
Increasingly, psychologists are banding together with others both inside and outside the field to tackle the problem of suicide prevention, says Cheryl King, PhD, a psychologist at the University of Michigan whose research focuses on improving suicide-risk assessments and evaluating interventions to reduce risk in youth. When she began her work three decades ago, the research was somewhat piecemeal, she says. No longer. "We were always concluding our sample sizes were too small, our statistical power was too limited, further research was needed. Now there are a lot of big teams working on this," she says. "Psychologists who study suicides are members of a growing community of researchers who often collaborate with others on interdisciplinary research teams."
Improving suicide-risk prediction
Suicide is an ancient problem, but within psychology, it’s a fairly young field. Historically, most suicide research has come from psychiatry departments, since people with suicidal thoughts and behaviors are often hospitalized in psychiatric settings, says Joe Franklin, PhD, an assistant professor of psychology at Florida State University who studies interventions for suicide and self-harm. But over the last three decades or so, more and more psychologists have gotten involved.
One area in which that teamwork is paying off is in the area of suicide-risk prediction. Many risk factors are associated with increased suicide risk, including depression, anxiety, sociodemographic factors and substance use. But not everyone who has depression or uses drugs or alcohol has suicidal thoughts. To better understand risk, Franklin, with his former postdoctoral adviser Matthew Nock, PhD, a professor of psychology at Harvard University, and colleagues analyzed 365 studies of suicide-risk factors over the last half century. "I’m a big proponent of going back to that basic science to ask, ‘What do we really know about what causes suicide?’" Franklin says.
Not nearly enough, according to their analysis. Franklin and his colleagues found that after 50 years of research, prediction of suicidal behavior was still only slightly better than chance (Psychological Bulletin, Vol. 143, No. 2, 2017). "We’ve been moving in circles in suicide research, and we aren’t where we want to be in terms of suicide prediction," he says.
Such findings reinforce what clinicians on the ground have long recognized, says King: "Single risk factors just don’t predict suicide well." Still, the analysis has been an important and influential finding for the field, and has given a fresh push to efforts to better predict who is at risk.
To better understand how risk factors interact, Franklin and his colleagues applied machine learning to the electronic health records of more than 5,000 adults who had a history of self-injury. They developed an algorithm that predicted suicide attempts based on combinations of risk factors including demographic data, previous diagnoses, medication history and past health-care utilization (Walsh, C.G., et al., Clinical Psychological Science, Vol. 5, No. 3, 2017). "Machine learning can take us from near-random guessing to a prediction that’s about 80% correct," Franklin says.
King is also harnessing technology to improve suicide-risk assessment among adolescents. Her team has developed an adaptive screening tool that adjusts to the individual. "The questions posed to youths depend upon their responses to previous questions, so different youths get different sets of questions to get the best prediction possible," she says. In the National Institute of Mental Health (NIMH)-funded Emergency Department Screen for Teens at Risk for Suicide study, King and her collaborators are testing the screening in 14 pediatric emergency departments nationwide. If testing is successful, she plans to work with implementation experts to put the tool into use. "Our interest is in getting this new teen suicide-risk screen out into the field," she says.
From lab to clinic
Basic research is informing our understanding of suicide in other ways as well, including efforts to understand genetic signatures and brain activity associated with suicidal behaviors. For example, psychologists at Carnegie Mellon University are looking for neurocognitive markers associated with suicidal ideation and attempts. The researchers used fMRI to look at the neural patterns of 17 people with and 17 people without suicidal ideation as they thought about concepts including death, cruelty and praise. Using machine-learning techniques to assess the participants’ neural patterns, the researchers were able to determine with 91% accuracy those who had suicidal ideation and those who did not. What’s more, among those with suicidal thoughts, the algorithm differentiated with 94% accuracy those who had made suicide attempts from those who had not (Just, M.A., et al., Nature Human Behaviour, Vol. 1, 2017).
Elsewhere, psychological scientists are exploring new ways to model suicidal behavior in order to understand what might make someone act on a suicidal impulse. "It’s just hard to do experimental suicide research, logistically and ethically," says Franklin. But he and others are beginning to use virtual reality (VR) to test how various factors might affect the likelihood of self-harm. Franklin developed a VR scenario in which people can virtually jump from a height or shoot themselves, and tested it among participants who did not have a history of suicidal thoughts (Behaviour Research and Therapy, online 2018). He plans to use the system to study how factors such as social rejection might influence the way people behave in those virtual scenarios. "We can’t directly study the causes of suicidal behavior, but we can directly study the causes of virtual suicidal behavior," he says.
At the clinical end of the spectrum, psychologists are also working to improve outcomes for people at risk of suicide. That effort has seen significant advancement in recent years, says psychologist Ivan Miller, PhD, a professor of psychiatry and human behavior at Brown University. "Until about 15 years ago, there really wasn’t an awful lot of empirically oriented research directly focused on suicide," he says. "We now have several types of interventions that have been shown to be effective at reducing suicidal behaviors."
Among those effective interventions is one tested by Miller and colleagues. The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study tested a suicide intervention in eight hospital emergency departments nationwide. Emergency department staff used a brief screening to assess suicide risk among patients. Those who were flagged as at increased risk received a secondary screening, a self-report safety plan, and the Coping Long Term with Active Suicide Program (CLASP), a values-based suicide prevention program delivered by telephone over the following year. Patients who received the intervention had 30% fewer suicide attempts during that year than patients who received standard emergency department care (JAMA Psychiatry, Vol. 74, No. 6, 2017).
The safety planning intervention used in the ED-SAFE study was a paper-and-pencil version delivered by nurses. Face-to-face safety planning has also been shown to be effective as a suicide intervention. One such face-to-face intervention, developed by psychologists Barbara Stanley, PhD, at Columbia University, and Gregory Brown, PhD, at the University of Pennsylvania, and colleagues, is the Safety Planning Intervention (SPI). The SPI involves several steps, including teaching people at risk of suicide to identify personalized warning signs for an impending suicide crisis, determine coping strategies and pinpoint individuals who can support them in a crisis. Stanley and colleagues tested the SPI in nine emergency departments and found that it reduced suicidal behavior and increased treatment engagement in patients at risk of suicide (JAMA Psychiatry, Vol. 75, No. 9, 2018).
Psychologists have played a leading role in developing other evidence-based frameworks to address suicidal thoughts and behaviors, including dialectical behavior therapy (DBT; Linehan, M.M., et al., JAMA Psychiatry, Vol. 72, No. 5, 2015) and the collaborative assessment and management of suicidality (CAMS; Jobes, D.A., Suicide and Life-Threatening Behavior, Vol. 42, No. 6, 2012). Several versions of cognitive-behavioral therapy (CBT) have also been shown to reduce suicide attempts. Asarnow and colleagues showed that the Safe Alternatives for Teens and Youths (SAFETY) intervention, a family-based treatment informed by CBT and DBT, reduced suicide attempts in high-risk adolescents (Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 56, No. 6, 2017).
M. David Rudd, PhD, ABPP, and colleagues demonstrated that even a brief CBT intervention can reduce repeat suicide attempts in military personnel by about 60% (American Journal of Psychiatry, Vol. 172, No. 5, 2015). Still, suicide rates among military personnel and veterans have increased over the last decade. One reason, suggests Rudd, is that evidence-based interventions haven’t become established very quickly in the majority of clinical settings. "The clinical and scientific fields have undeniably moved forward in the last two decades. There’s probably been more movement in the last 15 years than in the previous 50," he says. But evidence-based treatments such as his brief CBT intervention still aren’t widely used in clinical settings, he says. "We need more implementation scientists to get involved as well as policy experts."
Influencing policy and funding
Though progress in that regard is slower than most psychologists would like, many of those in the field say they’re optimistic that prevention and intervention efforts are gaining momentum. In 2010, the National Action Alliance for Suicide Prevention launched as a public-private partnership to advance and update the National Strategy for Suicide Prevention, which details goals and objectives for reducing deaths by suicide.
That alliance includes some 250 partners, including major federal agencies such as NIMH, the Substance Abuse and Mental Health Services Administration (SAMHSA), the Department of Defense and the Department of Veterans Affairs. The creation of this partnership and the development of a national strategy have been major steps forward in the effort to reduce deaths by suicide, says Jane L. Pearson, PhD, a psychologist and special adviser to the director on suicide research at NIMH.
One important recent development was the expansion of the CDC’s National Violent Death Reporting System, which collects data on deaths by suicide and other violent deaths in the United States. Incredibly, that system wasn’t fully funded to collect data from all 50 states until 2018. Without those numbers, it has been hard to paint a complete picture of U.S. suicides, says Pearson. By gathering data on the characteristics and experiences of everyone who dies by suicide, researchers can better understand who is at risk—and find more effective ways to help them, she says.
Having a psychologist such as Pearson involved in NIMH’s efforts has been a boon to suicide research, says Asarnow. Meanwhile, psychologists at SAMHSA have been leading the way on suicide prevention services, she adds. That agency oversees the National Suicide Prevention Lifeline, which last year answered more than 2.2 million calls.
SAMHSA also administers the Garrett Lee Smith State/Tribal Youth Suicide Prevention and Early Intervention Grant Program, which provides funding to states and tribes for implementing youth suicide prevention and early intervention strategies in settings such as schools, juvenile justice systems and foster care programs. Richard McKeon, PhD, MPH, a psychologist and chief of the suicide prevention branch at SAMHSA, has worked with the Garrett Lee Smith program since 2005. During that time, he says, research has shown that the program makes a difference. Evaluation studies have found that counties that received those grants had lower rates of youth suicide attempts and deaths by suicide than matched counties that did not receive funding (Garraza, L.G., et al., JAMA Psychiatry, Vol. 72, No. 11, 2015).
McKeon says he and his colleagues keep a close eye on the latest science as they determine how best to provide support. When data showed that the impact of the Garrett Lee Smith–funded programs faded over time, for example, SAMHSA increased the amount of funding and extended the length of the grants, hoping that sustained support would make the benefits last. "We closely monitor the research to try to incorporate as much as we can into all of our suicide prevention activities," McKeon says.
Outside of government, psychologists such as Harkavy-Friedman at AFSP are advocating for greater research investment and policies that could reduce deaths by suicide. AFSP lobbied for the expanded National Violent Death Reporting System, for instance. And in her role overseeing the organization’s research grant program, Harkavy-Friedman helps support scientists whose work has the potential to inform prevention efforts. "We’re always advocating for increased funding for research, but we also want to show that research is having an impact," she says.
Reaching across the divide
From research labs to hospital corridors, from funding agencies to political rallies, psychologists are deeply embedded in efforts to reduce deaths by suicide. Though their roles and backgrounds differ, many of those experts echo the same two major takeaways when describing the current state of their field: First, suicide research has recently made significant strides.
But second, there’s still a lot of work to be done.
"We’ve found some things that work, and we’re starting to get more clues about how to prevent suicide. But we need more researchers looking at this," Pearson says.
And the best way to accomplish that? Just start, says psychologist Janis Whitlock, PhD, a research scientist and associate director for teaching and training at the Bronfenbrenner Center for Translational Research at Cornell University. Whitlock’s own research focuses on self-injury, which is a risk factor for suicide. And in her teaching role, she trains other scientists to translate their research into practice. "Exposure is the best teacher. If you’re interested in working across fields of psychology, the best thing you can do is invite in people who are sitting in a different place," she says.
Whitlock recommends that when psychologists are reaching out to form those collaborations, they should start with a lot of questions—and be open to hearing the answers. "When researchers want to start working across fields, the biggest mistake is that they assume people think like them. They go in with their road map and start charting things out in a linear way. But the best way to cultivate relationships is to ask questions, listen and integrate everybody’s perspective," she says. "You have to learn to take different perspectives: how to wear the policymaker hat or the practitioner hat. That’s not intuitive for most researchers."
Though it might not come naturally, it’s well worth the effort, says Mitch Prinstein, PhD, ABPP, a distinguished professor of psychology and neuroscience at the University of North Carolina at Chapel Hill who studies adolescent depression and self-injury. "The field of psychology is unique in our ability to move science from the lab to providers’ offices, and even into legislative efforts," he says. "Psychology can make an enormous difference by working together across science, practice and policy. Together, our work can truly save lives."
