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Pathways to prevention

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Science  23 Aug 2019:
Vol. 365, Issue 6455, pp. 745-747
DOI: 10.1126/science.365.6455.745

Some straightforward approaches show promise. One question is how they can reach more people.


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Research on hotlines underscores how a crisis counselor can help save lives.

PHOTO: AARON ONTIVEROZ/THE DENVER POST VIA GETTY IMAGES

Can a three-digit phone number avert suicides on a grand scale? Last week, the Federal Communications Commission recommended designating 988 as a nationwide suicide prevention hotline number. Currently, the National Suicide Prevention Lifeline can be reached around the clock through the more cumbersome 1-800-273-TALK (8255).

Many paths in life can bring someone to the brink of suicide, and a shorter phone number might seem to be a naïvely simple solution. But researchers have repeatedly found that simple works: Callers routinely credit the existing hotline, which is on track to take 2.5 million calls this year, with keeping them safe. “It's one of the most basic human realities,” says Lifeline Director John Draper, a counseling psychologist with Vibrant Emotional Health, the New York City nonprofit that administers the hotline. “Helping people feel understood and cared about saves lives.”

More than 47,000 people died by suicide in the United States in 2017. Although the global suicide rate has dropped, in the United States it has increased 33% since 1999. Beating back that number is challenging. Although suicide is the 10th leading cause of death in the United States, it's still rare enough that designing large studies to probe interventions is difficult—and the high stakes bring ethical worries. “For a long time, the field was just kind of demoralized,” says Jane Pearson, a clinical psychologist and researcher who helps strategize suicide prevention research for the National Institute of Mental Health (NIMH) in Bethesda, Maryland.

But Pearson and others see glimmers of optimism. NIMH spent $51 million on suicide prevention research in 2018, twice as much as in 2015 though still well below research funding for other conditions that cause similar numbers of deaths. Other government agencies and nonprofits now spend tens of millions more. Suicide has shed some of its stigma and is increasingly viewed as a public health issue.

Researchers, meanwhile, are documenting the power of simple prevention approaches and refining them. At the most personal level, they're learning how calls with a crisis counselor, such as those who staff the Lifeline, can be made more effective. Hundreds of hospital systems are implementing a strategy that, in its first real-world test, cut suicides among atrisk patients by three-quarters. And entire countries have reduced suicide rates by banning commonly used lethal methods.

But even as scientists find tactics that can save lives, they've struggled to make headway against the high U.S. suicide rate. One hurdle is the difficulty of expanding access to interventions; another is a lack of community or political will. “We do have effective treatments,” Pearson says. “They're probably not as available as they should be, and that's what we want to change.”

WHEN MADELYN GOULD, a psychiatric epidemiologist at Columbia University, began to study suicide hotlines nearly 20 years ago, her colleagues thought it was a strange thing to do. Crisis hotlines had been around since the 1950s, but nobody really knew whether they worked. Some ivory tower experts doubted that call center volunteers, few of whom were psychiatrists or psychologists, could defuse a crisis. “I was skeptical, too,” Gould says. But she forged ahead.

A randomized trial—putting half the callers on hold, for example—was clearly unethical. Instead, Gould and colleagues evaluated 1085 calls over 17 months. The researchers trained crisis center staff to ask specific questions to assess callers' suicidality at the beginning and end of the call and to score their responses. Counselors also asked callers whether they would consent to a follow-up call from the researchers a week or two later. Not only did callers' suicidality subside during the calls, but their feelings of hopelessness and psychological pain had continued to diminish when the researchers called them back, Gould and colleagues reported in 2007 in the journal Suicide and Life-Threatening Behavior.

In another study in the same issue, a team led by Brian Mishara, a psychologist at the University of Quebec in Montreal, Canada, evaluated 1431 crisis calls in real time. (A recorded message announced that calls might be monitored.) The researchers found it was critical for counselors to quickly establish a rapport with callers by treating them with respect and empathy. “If they didn't do that in the first 3 minutes, they were less likely to have a positive effect,” Mishara says. The most effective counselors then worked with callers to explore alternatives to suicide, asking how they'd dealt with past crises or who in their lives could help.

Gould's and Mishara's research also exposed room for improvement. Alarmingly, Mishara found that counselors asked only about half the callers whether they were suicidal. It's a hard question to broach, Mishara says, even though no evidence suggests that doing so heightens risk. Mishara's findings spurred call centers to revamp their protocols, and the roughly 170 centers that make up the Lifeline network now assess suicide risk on every call, Draper says. (In 2005, the federal Substance Abuse and Mental Health Services Administration in Rockville, Maryland, established the Lifeline network to coordinate crisis centers; the agency supplied $6.1 million in funding last year.)

Gould's research uncovered another key preventive: following up. After her 2007 study showed that 43% of callers reported suicidal thoughts weeks after their call, the Lifeline began to encourage call centers to reach out again, phoning people who had expressed suicidal thoughts. Despite limited resources, about 80% of call centers now do so, typically within a day or two, Draper says. A February 2018 study by Gould and colleagues shows the power of a follow-up call. Among 550 people who reported suicidal thoughts in their initial contact, nearly 80% said the subsequent call played a role in saving their life, the team reported in Suicide and Life-Threatening Behavior.


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“Sri Lanka's pesticide regulations appear to have contributed to one of the greatest decreases in suicide rate ever seen.”

Michael Eddleston and colleagues, in The Lancet Global Health

PHOTO: ROGER HUTCHINGS/ALAMY STOCK PHOTO

Nearly 2 decades after she started to study caller-counselor conversations, Gould is no longer a skeptic. “It works,” she says. At the same time, it's not always enough. “You're not going to solve a lifetime of problems on a phone call,” Gould says. A next step is harnessing that call to chart a path to long-term care.

ONE VISION of what such care might look like was born at Henry Ford Health System, a sprawling mix of hospitals and outpatient clinics in southern Michigan. Almost 20 years ago, a group of Henry Ford practitioners gathered to consider how to better support their patients with depression. “There was a nurse at the table who said that if we really designed perfect care, then no one would die by suicide,” says Brian Ahmedani, who directs Henry Ford's Center for Health Policy and Health Services Research in Detroit. “Zero suicide” became the aspirational goal.

The program launched in 2001. Now called Zero Suicide, it has evolved to incorporate new research findings and screening tools, but the core elements are unchanged. Behavioral health patients are assessed for suicide risk at every visit and assigned to one of four risk categories. For each, the program gives a timetable and a menu of treatment options. A person at acute risk gets an in-depth psychiatric evaluation and begins treatment that same day, as an inpatient if necessary. Someone at moderate risk is evaluated within 1 week and likely referred for outpatient therapy. “The idea is to provide structure and standardization of care, rather than making an educated guess at each visit as to what clinicians should do,” Ahmedani says.

Providers help each at-risk patient develop a safety plan. They ask, for example, about firearms and stashes of medication inside the home and then urge the patient to hand those over to a friend or family member. Staff send postcards and call to check in during transitions in care, especially when a patient returns home after a psychiatric hospitalization—a shift linked to elevated suicide risk. Henry Ford evaluates providers by how well they adhere to the Zero Suicide protocol, not on whether every patient survives.

Apart from one 18-month stretch, Zero Suicide hasn't literally lived up to its name. But its impact has been remarkable. Before the program began, suicide among Henry Ford's behavioral health patients averaged roughly 100 per 100,000, comparable to rates in similar patient populations elsewhere. In the program's first 9 years, the rate averaged 22 per 100,000, the team reported in JAMA Psychiatry in 2015. The group is preparing more recent numbers for publication.

Zero Suicide is now expanding into primary care—because although not everyone who attempts suicide seeks mental health treatment, 83% do see a doctor in the year before dying, Ahmedani and others reported in 2014. To capitalize on those visits, Henry Ford now aims to give all of its million patients a suicide evaluation at least once a year with their general practitioner.

Zero Suicide's success—and the relatively modest investment it requires, mostly for training staff and updating electronic health records—has helped it catch on. At least 500 U.S. health care systems are implementing it, as are some hospitals in the United Kingdom, Australia, and beyond, says Julie Goldstein Grumet, a clinical psychologist and director of the Zero Suicide Institute in Washington, D.C., a nonprofit independent of Henry Ford that helps health care systems adopt the program. (Guidelines are available at http://zerosuicide.sprc.org/.)

As Zero Suicide spreads beyond Michigan, a key question for Ahmedani is how well it works elsewhere. Earlier this year, he won a $1.1 million grant from NIMH to evaluate Zero Suicide initiatives at six U.S. health care systems covering more than 9 million people. Goldstein Grumet is optimistic. The program “just makes sense, and that's what's inspiring people to try it,” she says.

MICHAEL EDDLESTON REALIZED that another prevention effort made sense after he arrived in Sri Lanka as a medical student in the mid-1990s. He had a research fellowship to study snakebites, but “we only saw six bites in 2 months,” Eddleston says. What he did see, in the clinic where he worked, was a startling number of patients dying after intentionally swallowing pesticides. It was a common means of suicide in rural Asia, where farmers have ready access to agricultural chemicals.

The experience altered the trajectory of Eddleston's career. Now the director of the Centre for Pesticide Suicide Prevention at the University of Edinburgh, he focuses on what's called means reduction—restricting access to lethal methods. It's one of the most promising prevention approaches and one that can be unleashed across entire countries. In England and Wales, a switch in the 1960s to domestic gas that contains less carbon monoxide tracked with a drop in the suicide rate. So did tighter restrictions on sedative prescriptions in Australia in the late 1960s and early 1970s.

Those early observations are backed by a growing body of research that counters the popular misconception that people who attempt suicide once will keep trying, through whatever means necessary. The reality is that those in the grip of a suicidal crisis often can see only one way out—and if that route is barred, they're unlikely to turn to another, says Jill Harkavy-Friedman, a clinical psychologist and vice president of research at the American Foundation for Suicide Prevention (AFSP) in New York City.

Sri Lanka is a vivid illustration. Laws passed there over 27 years, starting in the mid-1980s, banned many of the most lethal pesticides. Before the bans, Sri Lanka had one of the world's highest suicide rates, and pesticides accounted for two-thirds of those deaths. By 2015, the country's suicide rate had dropped from 57 to 17 per 100,000. “Sri Lanka's pesticide regulations appear to have contributed to one of the greatest decreases in suicide rate ever seen,” Eddleston and two colleagues wrote in a 2017 editorial in The Lancet Global Health. That dip, Eddleston's research suggests, came at no cost to the country's agricultural output.

Recent research suggests pesticide bans have also lowered suicide rates in Bangladesh and South Korea. In South Korea, which has one of the world's highest suicide rates, politicians and the public supported the ban, says Eddleston's colleague Won-Jin Lee of Korea University College of Medicine in Seoul. But in the United States, a ban on the most common suicide method—guns, which accounted for half the suicide deaths in 2017—is a political nonstarter.

Some states and organizations are trying more modest steps. In July, Hawaii became the 17th state to pass a “red flag” law, which allows family members, police, physicians, or mental health providers (depending on the state) to petition a court to temporarily remove firearms from people believed to be at imminent risk of harming themselves or others. The American Medical Association encourages doctors to screen and counsel patients on firearm safety, which can include temporarily transferring guns during a crisis. And in 2016, AFSP began to develop brochures and other educational materials for gun owners and retailers, in collaboration with the National Shooting Sports Foundation, a gun industry trade association. Reminding retailers that they can refuse to sell a firearm to someone who appears to be in crisis is one major goal, Harkavy-Friedman says. Whether those efforts are paying off is not yet known.

As the field matures, scientists will test a host of tactics—and implementing those that show promise will be up to health care systems, policymakers, and the public. For those that do save lives, such as hotlines, a big question is how to deploy them more broadly. Handling the surge of calls that could result if the three-digit number goes live will likely tax the resources of call centers, many of which already operate on a shoestring budget. Strategies such as Zero Suicide and means reduction call for new ways of thinking.

Most important, no single approach can do it all. “When you're thinking about suicide prevention,” Pearson says, “you've got to think at many levels all at once.”

For help, call 1-800-273-8255 for the National Suicide Prevention Lifeline, or visit https://www.speakingofsuicide.com/resources.

  • * Greg Miller is a science journalist in Portland, Oregon.

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