[In an intermittent series of articles I plan to review the most recent literature on suicide with an eye toward how the research can inform public and personal action on this matter.]

When it comes to suicide, nobody knows anything. Despite a half-century of research and three scholarly journals devoted to the topic, despite the creation of countless scales purporting to assess suicidal risk, despite the expenditure of millions of dollars on crisis lines, suicide hotlines, and prevention programs, the suicide rate in this country has continued to climb, rising 31% from 2001-2017.[1] Ostensibly, suicide studies (or suicidology as it is formally known) should aim at two goals: the identification of individuals at high risk of ending their lives and the creation of interventions designed to prevent this from happening. The evidence suggests that both projects have been miserable failures.

.Although there exist numerous lists of risk factors for suicide—the American Psychiatric Association, National Institute of Mental Health, Center for Disease Control, and countless other organizations each have their own—no consensus exists among the various lists. Not only is there no agreed upon list of risk factors. Recent research has shown that the traditional risk factors for suicide are in fact risk factors for suicidal ideation, not attempts. A recent meta-study that looked at a dozen of the most common risk factors for suicide concluded that the majority could not be used to distinguish suicide ideators from suicide attempters.[2] Another meta-study of more than 100,000 adults in 21 countries which created a risk index for 12 month suicide attempts determined that most of the factors are associated with suicide attempt “because they are predictive of suicide ideation even though they do not significantly predict the occurrence of suicide attempts among those with suicide ideation.” [3] The few risk factors that can be associated with suicide attempts “are common in clinical populations so that positive predictive value is low and they are of little use clinically.”[4] As another study which looked at risk factors among those who were recently discharged from psychiatric hospitals concluded: “A statistically strong and reliable method to usefully distinguish patients with a high-risk of suicide remains elusive.” [5]

But if we don’t know who is at a high risk of suicide, then the process of intervention becomes, well, complicated. Consider for a moment a parallel case in the area of physical health. We have a fairly good idea of what puts one at risk of having a heart attack, and all the major health organizations agree on what these factors are. Being a male over 45 or a woman over 55, having a family history of heart attacks, smoking tobacco, having high blood pressure or high cholesterol levels and being overweight all qualify as risk factors for having a heart attack. [6] Successful interventions address those risk factors that can be altered—known as dynamic risk factors. In the case of heart attack prevention, this involves things like smoking cessation programs, high blood pressure or cholesterol mediations, and diets. There exists a coherent strategy for lowering the risk of heart attacks occurring, which is why the heart attack rate has been going down.

When it comes to suicide, we are not so fortunate. Instead, in the words of Bob Seger, we are “searching for mysteries without any clues.”

NOTES

  1. NIMH. https://www.nimh.nih.gov/health/statistics/suicide.shtml
  2. May, A., and Klonksy, E., (2016) What Distinguishes Suicide Attempters from Suicide Ldeators? A Meta-Analysis of Potential Factors. Clinical Psychology 23(1)
  3. Borges, G., Nock, M. K.,  Abad, J. M., et al(2010). Twelve month prevalence of and risk factors for suicide attempts in the WHO World Mental Health Surveys. Journal of Clinical Psychiatry, 71(12):1617-28.
  4. Mulder, R., et. al. (2016). The futility of risk prediction in psychiatry. The British Journal of Psychiatry 209, 271-272
  5. Large, M., et al. (2016). Meta-Analysis of Longitudinal Cohort Studies of Suicide Risk Assessment among Psychiatric Patients: Heterogeneity in Results and Lack of Improvement over Time.” PLOS ONE. Jun 10;11(6):e0156322. doi: 10.1371/journal.pone.0156322. eCollection 2016
  6. https://www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106