Epidemiology Needs to Inform Suicide Prevention Strategies

Dr. Brent’s Master Clinician Review: Saving Holden Caulfield: Suicide Prevention in Children and Adolescents is a timely synthesis of evidence-based approaches to suicide reduction, including prevention strategies and programs, increased access to mental health care, changes in systems of care delivery, and means restriction.1Brent D.A. Master clinician review: Saving Holden Caulfield: suicide prevention in children and adolescents.J Am Acad Child Adolesc Psychiatry. 2019; 58: 25-35Abstract Full Text Full Text PDF Scopus (13) Google Scholar Although this review appears in what is predominantly a journal for clinicians working in their offices or on hospital units, it is notable that most of the approaches he describes operate at primary or secondary prevention levels. That is, they use population-level strategies to prevent the development of suicide risk (primary prevention), or devise programs to detect and treat individuals before they become dangerously symptomatic (secondary prevention). Office-based psychiatrists treating individuals with emergent psychopathology are exercising tertiary prevention. While doing their best to help suicidal patients under their care, psychiatrists may come to realize that treating one patient at a time is not sufficient to meet the needs of the communities in which they live. This can create cognitive dissonance. To address this dissonance, the approaches that Dr. Brent describes are urgently required. A recent report on a cohort of youth making first suicide attempts coming to medical attention (index attempts) provides epidemiological data that underscore the need for primary and secondary preventive efforts in populations.2McKean A.J. Pabbati C.P. Geske J.R. Bostwick J.M. Rethinking lethality in youth suicide attempts: first suicide attempt outcomes in youth ages 10 to 24.J Am Acad Child Adolesc Psychiatry. 2018; 57: 786-791Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar In a cohort of 813 youths aged 10 to 24 years, almost three-quarters (71.4%) of suicide deaths occurred on an index attempt. In addition, over 40% of those making index attempts had no prior psychiatric diagnoses, mental health visits, or psychotropic medication trials. Albeit important, interventions that begin with an office visit would not have helped these youths; rather, these individuals would have had to been identified as being at risk prior to their index attempt. These findings support primary and secondary prevention—detecting early warning signs of suicidal behavior and addressing its antecedents, so that potential attempters can be identified and offered care prior to that first attempt. Dr. Brent cites programs that address child abuse and maltreatment and its effects on development of psychopathology, as well as initiatives that offer training to empower schools, families, and communities to look for warning signs in at-risk youth. Efforts such as these could minimize youth suicide attempts through identifying warning signs of imminent suicidal behavior in susceptible individuals and encouraging mental health interventions before first attempts occurs. Furthermore, the study underscores the preeminence of firearms in completed youth suicides: 85% of index attempt completions were from gunshot. These harrowing data add to the argument that means restriction is essential in reducing the suicide rate in American youth; but in a nation committed to second amendment rights, access to guns is ubiquitous. As Dr. Brent points out, surveys suggest that families are more open to conversations about gun storage safety than removal.3Garbutt J.M. Bobenhouse N. Dodd S. Sterkel R. Strunk R.C. What are parents willing to discuss with their pediatrician about firearm safety? A parental survey.J Pediatr. 2016; 179: 166-171Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Empowering primary care providers (PCPs) to talk with families about how to store firearms safely is clearly important. But not all families have a PCP, and when they do, the PCP may already have too much to do in the limited time available in an outpatient visit to also address firearm safety. Thus PCPs cannot be the only ones charged with this task. Non-medical community members must own and tackle the problem, with community and government initiatives that educate the public in schools, libraries, and churches, leverage the expertise of law enforcement, engage retailers, and hold gun manufacturers accountable. Gun safety truly takes a village. In sum, making progress in reducing youth suicide will necessitate a population-level vision that harnesses all members of the community and not just physicians to work toward minimizing drivers of suicide attempts before they occur. The good news, as Dr. Brent rightly points out, is that the tools already exist to reduce youth suicide. The challenge is in implementing them. To make a lasting difference, we must look beyond our offices and beseech our communities to join us in finding ways to address the scourge of youth suicide. Master Clinician Review: Saving Holden Caulfield: Suicide Prevention in Children and AdolescentsJournal of the American Academy of Child & Adolescent PsychiatryVol. 58Issue 1PreviewThe rate of adolescent suicide and suicidal behavior has risen dramatically in the past decade. The title of this article comes from the classic coming-of-age novel by J.D. Salinger, The Catcher in the Rye. Its protagonist, Holden Caulfield, is a precocious adolescent who, in the face of his inability to cope with his own self-destructives urges, imagines himself saving “little kids playing some game in this big field of rye.” He is standing on the edge of a cliff trying to catch “thousands of little kids” before they fall to their demise. Full-Text PDF Rethinking Lethality in Youth Suicide Attempts: First Suicide Attempt Outcomes in Youth Ages 10 to 24Journal of the American Academy of Child & Adolescent PsychiatryVol. 57Issue 10PreviewAlthough suicide is the second most frequent cause of death in American youth, suicide research has heretofore been confined to convenience samples that represent neither psychiatric nor general populations and that fail to include individuals dying at their first attempts. These limitations were addressed by assembling a youth cohort followed from the first medically recorded attempt (index attempt [IA]). It was hypothesized this approach would more accurately represent the prevalence of completed suicide after an attempt and underscore lethality based on method. Full-Text PDF In ReplyJournal of the American Academy of Child & Adolescent PsychiatryVol. 58Issue 9PreviewI want to thank McKean and Bostwick1 for the thoughtful comments on my review of some effective approaches to the prevention of adolescent suicide. I am in complete agreement that much of what is required to reverse the unrelenting increase in adolescent suicide lies in the realm of population health and universal or indicated prevention. However, I did not mean to imply that individual clinicians are helpless to do anything about adolescent suicide. Full-Text PDF