90 Percent

In September I attended the International Association for Suicide Prevention 2013 World Congress in Oslo, Norway. More than 800 delegates were in attendance. Several of the speakers addressed an issue that I’ve been thinking about a lot lately: the often quoted statistic that more than 90 percent of suicides are associated with mental illness or a substance use disorder. Several speakers from low- and middle-income countries pointed out that the 90 percent figure is based on psychological autopsy studies− most of which were done in high-income Western countries. They suggested that the proportion of suicides associated with mental illness or substance use disorders in the developing nations may be lower than in the West. They also suggested that in low- and middle-income countries, other risk factors may play more important roles than mental illness does.

Dr. Michael Phillips, Executive Director of the World Health Organization Collaborating Center for Research and Training in Suicide Prevention in Shanghai, China, pointed out that 84 percent of suicides in the world take place in low- and middle-income countries. Many of the low-income countries lack anything resembling a mental health infrastructure. Yet there have been a number of remarkable suicide prevention successes in these countries. Several Asian countries have dramatically reduced the suicide rate through the safe storage of pesticides. These efforts have met with success regardless of the strength of the association between mental illness and suicide – and regardless of the availability of mental health services in these countries. These public health approaches made a difference and that is what matters.

Listening to my colleagues who work in low- and middle- income countries reinforced my determination to think about what the “90 percent” figure really means and why it is so often cited in our literature. What is the value of constantly restating this figure?  Coincidentally, there recently was a discussion about the “90 percent” figure on the American Association of Suicidology listserv. I’m not going to summarize that discussion here. Nor am I going to take sides. That is not my purpose in this piece. Let me be clear: there is little disagreement that mental illness is a risk factor for suicidal behavior. We certainly need to learn more about the relationship between mental illness and suicidal behaviors. I welcome any research and dialogue that will help clarify this association. But from a prevention standpoint, we should not let the “90 percent” figure limit our pursuit of solutions or prevention opportunities.

No one with experience in suicide prevention would seek to restrict our efforts to promote access to treatment and discard the other methods that have been shown effective in preventing suicide – methods such as restricting access to lethal means for those at risk, strengthening social connectedness, and teaching problem-solving skills that help people cope with life transitions and stress. We need to be careful not to let a discussion about the association between mental illness and suicide – be that 40 percent, 60 percent, or 90 percent – lead the public, researchers, practitioners and policymakers to think that treatment is the only solution to the problem of suicide. We know that is simply not the case. It is not a question of either prevention or treatment. We know that both are vital. We must continue to champion a comprehensive and multidimensional approach to preventing suicide.