Treatment-Seeking and Suicidality by Suicide Method

A recent study looked at treatment-seeking and suicidality among people who died by firearm suicide compared to those who died by other suicide methods.

Using data from the National Violent Death Reporting System (NVDRS), researchers studied 234,652 people who died by suicide between 2003 and 2018. Comparing those who died by firearms to those who used other methods, the researchers examined history of mental health or substance use treatment, suicidal thoughts or plans, suicide attempts, and disclosure of suicidal thoughts or plans.

Study participants were mostly male (77.8%) and white (87.8%) with a mean age of 46. In this sample, firearms were the most frequently used suicide method (49.9%), followed by hanging, strangulation, or suffocation (26.7%), and poisoning (15.3%). Most participants were not receiving mental health or substance use treatment when they died, had not sought treatment in their lifetime, did not have a lifetime history of suicidal thoughts or plans or suicide attempts, and had not disclosed suicidal thoughts or plans in the month before they died. Those whose highest level of education was a high school diploma made up the largest percentage of deaths across all methods of suicide.

The analysis found that individuals with a history of mental health or substance use treatment or suicide attempts were significantly less likely to die by firearms than other methods. Those who recently disclosed suicidal thoughts or plans had higher odds of dying by firearms but were not more likely to have a previous history of suicidal thoughts or plans. These findings were consistent for both male and female participants ages 18 to 84. Compared to individuals who died by poisoning, those who died by firearms were significantly more likely to have a history of suicidal thoughts or plans and to have recently disclosed suicidal thoughts or plans. Compared to people who died by hanging, those who used firearms were more likely to have recently disclosed suicidal thoughts or plans.

Study participants who died by firearm suicide were less likely to seek mental health treatment or to have attempted suicide compared to those who died by other methods, suggesting many likely died on their first attempt. These individuals may be less likely to be identified through evidence-based suicide interventions that take place in mental health care settings. Those who died by firearms were also more likely to have disclosed suicidal thoughts or plans to someone in the month before their death, but they were not more likely to have a history of suicidal thoughts or plans. These findings highlight the need for more universal prevention strategies to raise awareness of suicide risk factors, warning signs, and prevention strategies in the general population. Among potential upstream interventions, the authors note safe storage of firearms is associated with decreased firearms suicide. To increase their effectiveness, they recommend programs that promote safe storage practices reflect the language and culture of firearms owners.

Limitations of this study include the homogeneity of the sample and the lack of specifics about the mental health services used and the nature and recipients of suicidal disclosure. Individuals who did disclose thoughts or plans represented a small subset of those who used firearms, an indication that disclosure is rare. During the study, the dataset expanded from 6 states in 2003 to 32 states in 2018. The earlier data account for a disproportionate number of deaths in this sample and may not represent more recent socio-demographic trends or changes.

Bond, A. E., Bandel, S. L., Rodriguez, T. R., Anestis, J. C., Anestis, M. D. (2022). Mental health treatment seeking and history of suicidal thoughts among suicide decedents by mechanism, 2003-2018. JAMA Network Open, 5(3): e222101. doi:10.1001/jamanetworkopen.2022.2101

Racial Differences in Suicide Risk among Adults in Criminal-Legal Systems

Research shows that adults in the criminal-legal system have higher rates of suicide and behavioral health disorders than the general population. There are also documented racial differences in experiences of criminal processing and access to behavioral health care. However, few studies have looked at whether this population’s suicide risk varies by race. To fill that gap, researchers conducted a study to identify risk factors for suicide among adults involved in the criminal-legal system and to find out if there were differences in suicide risk based on race.

The sample for this study was 16,849 adults with recent criminal-legal involvement who were enrolled in a statewide behavioral health treatment program, Indiana Recovery Works, between October 2015 and March 2018. Participants only included those who identified as either White or Black. The group was predominantly White and male with an average age of 35. Suicide risk was determined by clinicians using the Adult Needs and Strengths Assessment (ANSA) tool. Researchers carried out analyses to model suicide risk overall and within each of the racial groups and to identify differences between them. 

The initial analyses revealed that one in five individuals had suicide risk, a majority had a primary diagnosis of substance use disorder and a primary mental health diagnosis, and a small percentage had a history of self-harm. Black participants were significantly older, had lower suicide risk and higher criminal behavior risk, and were more likely to have mental health or substance use diagnoses. White participants were more likely to have a co-occurring diagnosis, evidence of self-harm, and prior substance use episodes, and were more likely to be female and have worse scores on the domains of life functioning, strengths, and behavioral health needs. The secondary analyses found no evidence of differences in suicide risk between the groups based on race alone.

It is important to note that the study participants had already been identified as needing behavioral health treatment and therefore may have had higher suicide risk than the general population and others in the criminal-legal system. Without a behavioral health diagnosis or participation in treatment, additional or different risk factors may have been found, particularly since Black and White disparities have been found in both access to treatment and the likelihood of incarceration. All study participants were referred to treatment based on clinical diagnosis, which may have been influenced by implicit clinician bias (i.e., an association outside conscious awareness that lead to a negative evaluation of a person or group on the bias of irrelevant characteristics such as race or gender1).

Nonetheless, these findings suggest that adults with behavioral health disorders and recent experience in the criminal-legal system experience risk factors for suicide similar to those in the general population. The association of substance use and co-occurring behavioral health disorders with suicide risk is particularly important given the current opioid epidemic. As the authors note, these findings highlight the need for more investigation on how criminal-legal involvement may worsen suicide risk.

Lawson, S. G., Lowder, E. M., & Ray, B. (2022). Correlates of suicide risk among Black and White adults with behavioral health disorders in criminal-legal systems. BMC Psychiatry, 22(163). doi: 10.1186/s12888-022-03803-8

  1. Fitzgerald, C., & Hurst, S. (2017.) Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics, 18(1). doi: 10.1186/s12910-017-0179-8

Outreach Programs vs. Usual Care for Self-Harm Prevention

In a recent clinical trial conducted in four U.S. health systems, researchers compared the effectiveness of two low-intensity outreach programs with usual care for preventing self-harm. Participants were 18,882 outpatients who reported recent frequent thoughts of death or self-harm on the nine-item Patient Health Questionnaire (PHQ-9) between March 2015 and September 2018.

Participants were randomly assigned to one of three groups: (1) usual care plus an online care management intervention, (2) usual care plus an online skills training intervention to learn four dialectical behavior therapy (DBT) skills, or (3) usual care only (no offer of additional services). The care management intervention included regular outreach for suicide risk screening and follow-up. The skills training intervention provided video instruction in mindfulness, mindfulness of current emotion, opposite action, and paced breathing, supported by a skills coach.

The two outreach programs lasted up to 12 months, delivered mostly through electronic health record messaging, and were designed to supplement ongoing mental health care. The primary outcome was first observed fatal or non-fatal self-harm within 18 months of randomization. Analyses compared groups according to randomized assessment, regardless of participation in the intervention.

This study tested the effectiveness of the two outreach programs under everyday practice conditions and found that neither program decreased risk of self-harm compared to usual care only. Compared to the group that was offered usual care only, the risk of self-harm was not statistically significantly different in the care management group. Compared to usual care only, the risk of self-harm was statistically significantly higher in the skills training group. The findings from the study do not support implementation of the outreach programs as they were tested.

While the findings of the study indicate that the two tested programs have no benefit over usual care in the participating health systems, the findings should not discourage systematic patient screening and intervention to prevent suicide in health care settings.

Study limitations include restrictive inclusion criteria and low participant engagement in the tested interventions. It should also be noted that all subjects had access to specialty mental health services and the comparative effectiveness of the two interventions tested might differ for patients without such services.

Simon, G. E., Shortreed, S. M., Rossom, R. C., Beck, A., Clarke, G. N., Whiteside, U., Richards, J. E., Penfold, R. B., Boggs, J. M., & Smith, J. (2022). Effect of offering care management or online dialectical behavior therapy skills training vs. usual care on self-harm among adult outpatients with suicidal ideation: A Randomized Clinical Trial. JAMA, 327(7), 630–638.

Ethical Issues in Suicide Prevention Research

A new consensus study summarizes key ethical considerations in suicide prevention research from multiple expert perspectives.

According to the study authors, research to understand and address suicide is critically important but must align with ethical guidelines and include safeguards for both participants and researchers. To identify the most important ethical issues to consider when designing such studies, they surveyed 34 suicide researchers and 32 people with lived experience (i.e., individuals who had attempted or considered suicide, lost a loved one to suicide, or cared for someone during a suicidal crisis). The study design was co-created by researchers with lived experience and used an online questionnaire that was based on previous findings.

The results showed strong agreement between respondents who were researchers and those who had lived experience. Researchers emphasized adherence to national guidelines, while people with lived experience focused on care and support for participants and researchers. In addition to concern about the availability of support and crisis intervention for study participants, respondents raised concern about the vulnerability of those conducting the research and the need to address potential vicarious trauma.

This study was conducted in Australia and although it provides important insights into ethical issues that need to be considered when designing and implementing suicide research, its generalizability to other cultural contexts and countries may be limited. Another limitation, acknowledged by the authors, is that because the design was a single-round consensus study, there was no opportunity for participants to reconsider ratings based on group scores. 

Dempster, G., Ozols, I., Krysinska, K., Reifels, L., Schlichthorst, M., Pirkis, J., & Andriessen, K. (2022). Ethical issues to consider in designing suicide prevention studies: An expert consensus study. Archives of Suicide Research, 1–17. https//

Association of the Song “1-800-273-8255” with Lifeline Calls and Suicides

In April 2017, hip-hop artist Logic released “1-800-273-8255,” a song featuring the phone number and services of the National Suicide Prevention Lifeline (Lifeline), highlighting the benefits of seeking help during a suicidal crisis. Findings from a recent study suggest the song was associated with an increase in calls to the Lifeline and a possible reduction in suicides during the study period.

Researchers conducted time series analyses looking at the number of Lifeline calls after three events: (1) the release of the song on April 28, 2017; (2) Logic’s performance of the song at the MTV Video Music Awards on August 27, 2017; and (3) his performance at the Grammy Awards on January 28, 2018.

To estimate public attention to the events, the researchers obtained Twitter data from data reseller Brandwatch, examining tweets that contained the search terms “Logic” and “1-800-273-8255” from March 1, 2017 to April 30, 2018. They also obtained call data from the Lifeline, as well as daily numbers of suicides from the National Center for Health Statistics, for the period January 31, 2010 to December 31, 2018. Sudden changes in Lifeline calls and suicides associated with each event were compared to trend data obtained from Brandwatch and the National Center for Health Statistics. 

In the 34 days after the three events, there was a statistically significant 6.9% increase in calls to Lifeline over the expected number, and a statistically significant decrease of 245 below the expected number of suicides. Twitter activity related to each event peaked rapidly and reached their maximum within one day. Activity was most pronounced following Logic’s performance at the 2017 MTV Video Music Awards, with an average of 1,324 posts daily over a 28-day period.

Previous research on the association between media messaging and suicide has focused on the negative effects of such publicity, such as increases in reported suicides or suicidal thoughts following media exposure. This is one of the few studies examining the positive impacts of media messaging. The results suggest media coverage focused on hope and recovery from suicide can be an effective prevention strategy.

It is important to note this is an observational study, and although it found a possible association between “1-800-273-8255” and help-seeking, it does not establish causality. Even so, this is a well-designed study that compares changes close in time to the presumed exposure (event) to longer data trends that reflect expected numbers of Lifeline calls and suicide deaths. The results suggest an innovative and potentially impactful approach to suicide prevention that needs to be explored further.

Niederkrotenthaler, T., Tran, U. S., Gould, M., Sinyor, M., Sumner, S., Strauss, M. J., Voracek, M., Till, B., Murphy, S., Gonzalez, F., Spittal, M. J., & Draper, J. (2021). Association of Logic’s hip-hop song “1-800-273-8255” with Lifeline calls and suicides in the United States: Interrupted time series analysis. BMJ, 375, e067726. 

Update July 2022: 988 has been designated as the new three-digit dialing code that will route callers to the National Suicide Prevention Lifeline (now known as the 988 Suicide & Crisis Lifeline), and is now active across the United States. (Please note, the previous 1-800-273-TALK (8255) number will continue to function indefinitely.) Click here to learn more about 988.

Optimizing Suicide Research

A recent article reviews challenges in suicide research and proposes ways to address them.

The authors discuss multiple sources of bias that may limit the usefulness and validity of findings in current suicide research. These include publication bias, in which negative findings are less likely to be published, skewing the body of research in favor of those that do get published. They also note a bias toward publishing studies that demonstrate statistical significance without considering effect sizes (i.e., the strength of findings). This can result in studies of risk factors that are not robust enough to advance research and prevention practices.

In addition to these current challenges, the authors warn against a practice called “p-hacking,” in which researchers develop a hypothesis after running multiple exploratory analyses in search of significant findings, instead of setting out to confirm a hypothesis. While this practice is common in clinical research, it is unclear how widespread it is in suicide-related studies.

Other challenges discussed include low power (i.e., low chance of finding a real statistically significant effect) due to small sample sizes (i.e., small number of people studied). The authors also argue that definitions of constructs such as suicide risk, intent, and attempts vary across studies, which limits the replication of positive results and makes it difficult to interpret the body of research.

To help identify and address these biases and limitations in suicide research, the authors advocate for more “open science,” such as:

  • Providing free and open access to research products such as conference papers, book chapters, and dissertations. Research could be archived in online repositories that allow for a more extensive review of research protocols and analyses by peers prior to publication. A preregistration process like that used by the National Institutes of Health could require that researchers specify their analysis plans upfront, ensuring that exploratory and confirmatory analyses are differentiated from one another. 
  • Describing detailed methodology in research manuscripts, including issues of effect size and power.
  • Encouraging the use of standard data collection instruments to facilitate the aggregation of findings across studies. This could provide sample sizes large enough to power the statistical models needed to test hypotheses.
  • Performing preliminary analyses of data during data collection, which could allow researchers to decide whether to stop or continue their efforts.
  • Replicating studies that form the basis for key suicide prevention theories to ensure that findings are consistent and robust, which could also help with determining which findings are valid.

Carpenter, T. P., & Law, K. C. (2021). Optimizing the scientific study of suicide with open and transparent research practices. Suicide and Life-Threatening Behavior, 51, 36–46.

Online Risk Factors and Youth Suicide

A recent study found an association between online risk factors and suicidal behavior among youth. According to the authors, this was the first longitudinal study to examine risk markers for youth suicide-related behavior beyond screen time, with the study design allowing for temporal associations between risk factors and outcomes.

The matched case-control study included students from 2,600 schools participating in an online safety monitoring program via the Bark online safety tool from July 27, 2019 to May 26, 2020. Researchers identified 227 youth (cases) who made statements online indicating an imminent or recent suicide attempt and/or self-harm, which sent a “severe suicide/self-harm alert” to school administrators. These cases were matched to 1,135 youth (controls) who did not have a “severe suicide/self-harm alert,” were enrolled in the same school, and had a similar volume of observable online activity.

The researchers then evaluated the association between eight potential suicide risk factors with having a “severe suicide/self-harm alert”: cyberbullying, drug-related content, sexual content, violence, hate speech, profanity, depression, and viewing content related to suicide or self-harm (which sent a “low-severity suicide/self-harm alert” to school administrators).

Of the eight potential risk factors examined, the researchers found all except hate speech demonstrated significant differences between case and control youth, with cyberbullying being the most prevalent. They also found an intensifying risk of experiencing a “severe suicide/self-harm alert” based on the number of risk factors that a student displayed.

These findings were limited by a lack of data on hospitalizations or suicides among the youth studied, making it impossible to establish a causal link between online behavior and actual suicide attempts or self-harm. Data were also limited to online behaviors happening inside the school systems. Although cases and controls were diverse and randomly drawn, the analysis did not stratify results by demographic factors. Finally, the study took place during the COVID-19 pandemic, which could have influenced the results, as many students were spending more time online.

Sumner, S. A., Ferguson, B., Bason, B., Dink, J., Yard, E., Hertz, M., Hilkert, B., Holland, K., Mercado-Crespo, M., Tang, S., & Jones, C. M. (2021). Association of online risk factors with subsequent youth suicide-related behaviors in the U.S. Jama Network Open, 4(9): e2125860.

Systematic Review of Suicide Prevention Strategies

Researchers performed a systematic review of studies published around the world between September 2005 and December 2019 to identify evidence-based, scalable suicide prevention strategies. They found the most effective strategies were training primary care physicians to identify and treat depression, educating youth on depression and suicide, reducing access to lethal means among those at risk, and following up after hospital discharge or suicidal crisis.

The review focused on randomized controlled trials (n=97) that reported suicidal thoughts or behavior as an outcome variable and epidemiological studies at the county, city, or practitioner level (n=30). The scalability of approaches was determined based on the complexity and cost of required training. Findings included the following:

Provider Training

  • Primary care physicians and other non-psychiatric practitioners saw 45% of those who died by suicide in the 30 days prior to their death, and 77% in the 12 months prior.
  • Training primary care providers at the state and local levels in screening and treating depression, with available assistance from psychiatrists, lowered suicide rates, nonfatal suicide attempts, and suicidal thoughts.
  • Refresher sessions after the initial training reduced suicide rates progressively for years, while single-day training sessions produced no benefit for suicide deaths over 3 years.
  • Depression screening and treatment referral lowered suicide rates compared to programs in similar geographic areas that did not include screening and referral.

Youth Education

  • Educating youth about mental health and suicide prevention was found to be more effective in preventing suicide compared to education strategies that targeted gatekeepers such as teachers or parents.

System-Level Education

  • Large-scale, system-wide interventions targeting students, mental health professionals, primary care providers, and other gatekeepers have shown promise. However, more research is needed to identify the effectiveness of specific components of interventions that incorporate multiple strategies and audiences.

Treatment Interventions

  • Antidepressants reduced suicidal thoughts in 9 of 12 studies on adults.
  • Studies of antidepressants in children and teens found the risk of harm to be greater compared to control groups not given antidepressants.
  • Additional research is needed on the use of fast acting medications such as ketamine, which has been found to reduce suicidal thoughts, as the effect of these drugs on suicidal behavior is unclear.
  • Psychotherapeutic interventions with groups at high risk, such as individuals with depression and borderline personality disorder, were found effective in reducing suicidal thoughts and reattempts.
  • Follow-up contacts after a suicide attempt were found to reduce reattempts by as much as 45%.

Lethal Means Reduction

  • Reducing access to the most lethal means available was shown to reduce suicide deaths.
  • Gun access reduction and gun safety education programs reduced firearm suicides.

Based on these findings, the authors recommended suicide prevention efforts focus on the following:

  • Training primary care physicians in depression management and evaluating the expansion of such programs to non-psychiatric medical specialists.
  • Targeting education programs to high school youth about mental health and evaluating the extension of this approach to college students.
  • Pre-discharge education, follow-up contacts, and outreach for psychiatric patients discharged from the emergency department or hospitals and for individuals who have previously experienced a suicidal crisis.
  • Means reduction, especially gun safety education.

The authors also suggested other promising strategies include specific psychotherapies, such as cognitive behavioral therapy and dialectical behavior therapy; fast-acting medications, such as ketamine; and online screening, treatment, and continuous monitoring of risk.

The most significant limitation of this review was the heterogeneity of the populations studied and strategies employed, as well as the inconsistent quantity and quality of available data on suicide prevention. In addition, the scalability of interventions was difficult to determine due to the lack of objective criteria for determining the feasibility of scaling up from the local to the national level.

Mann, J. J., Michel, C. A., & Auerbach, R. P. (2021). Improving suicide prevention through evidence-based strategies:  A systematic review. American Journal of Psychiatry, 178(7), 611–624.

Suicide Mortality in the U.S., 1999–2019

A study looked at trends in suicide mortality from 1999 to 2019, using data from the National Vital Statistics System stratified by sex, age group, and suicide method. It found that the total age-adjusted suicide rate increased 35.2% from 10.5 per 100,000 in 1999 to 14.2 in 2018, and then decreased by 2.1% to 13.9 in 2019.

Additional findings include:

  • Suicide rates for females increased from 1999 to 2019 for all age groups except 75 and older. During this period, rates were highest among women ages 45 to 64, followed by women 25 to 44. 
  • Suicide rates for males increased between 1999 and 2019 for all age groups except those 75 and older. However, suicide rates were highest for men ages 75 and older.
  • Rates for both females and males were lowest in the 10 to 14 age group.
  • Suicide rates by sex and age group remained stable or declined from 2018 through 2019
  • Firearm suicide increased from 1.5 in 1999 to 1.4 in 2007, increased to 1.9 in 2016, then remained stable through 2019.
  • Among females, there was a shift away from suicide by poisoning with higher rates for firearms suffocation.
  • Among males, suicide rates by firearms and suffocation also increased.

These findings can help guide suicide prevention strategies and assist in identifying populations at elevated risk. Increased rates of firearm suicide among both sexes indicate a need for more efforts to reduce access to guns among those at risk.

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Hedegaard, H., Curtin, S. C., & Warner, M. (2021). Suicide Mortality in the United States, 1999–2019. NCHS Data Brief, no 398. Hyattsville, MD: National Center for Health Statistics. doi: