When Robin Williams ended his life last month, his suicide sparked a raft of online and print commentary about the dangers of depression and the need to inject more resources into our mental health care system. I strongly agree with these sentiments. After all, as a psychiatrist at the Massachusetts General Hospital, I regularly speak with patients who have been diagnosed with depression or who are actively thinking about ending their lives.
But what if suicide prevention isn’t just about better screening, diagnosis and treatment of depression? What if there were a better way to go about preventing suicides?
It is undeniable that people with mental illnesses such as depression and bipolar disorder are at greater risk for suicidal thinking or suicide attempts. But not everyone with depression commits suicide, and not everyone who has committed suicide suffered from depression. In fact, even though depression is a strong predictor of suicidal thinking, it does not necessarily predict suicide attempts among those who have been thinking about suicide. Instead, among people who are actively thinking about suicide, the mental illnesses that most strongly predict suicide attempts are those characterized by anxiety, agitation and poor impulse control.
These epidemiological facts have been on my mind during this week’s National Suicide Prevention Week activities. Suicide is the 10th leading cause of death in the United States and is now responsible for more deaths than motor vehicle accidents. It is also a global phenomenon: As described in the World Health Organization’s recently published landmark report on suicide prevention, the global toll of suicide exceeds the number of deaths from conflicts and natural disasters.
Middle-aged men appear to be particularly susceptible: Suicide rates in this demographic have increased in the United States by nearly 30 percent over the past decade.
In collaboration with colleagues at the Harvard School of Public Health and University of Laval, I have sought to better understand the social factors driving suicide in this demographic. The scarcity of available data makes this a difficult issue to study. On the one hand, death registries and vital statistics can provide us with an immense amount of information about suicide trends in different demographic groups—but they frequently lack information about social characteristics. And researchers who have the opportunity to collect new, detailed social data often lack the resources to recruit a large enough general population sample, or follow them for a long enough period of time, to generate meaningful conclusions.
We tackled this problem by accessing data from a unique study, the U.S.Health Professionals Follow-up Study. Upon enrollment, these middle-aged men answered a battery of questions about health and nutrition, as well as questions about the extent of their participation in a range of different social relationships. They were then followed biannually with mailed surveys, with deaths ascertained using the National Death Index.
Our findings, published recently in the July 15 issue of the Annals of Internal Medicine, would be unlikely to surprise a sociologist or a social epidemiologist. Over 24 years of follow-up, men were much less likely to commit suicide if they scored highly on measures of social connectedness. Specifically, men who were in the highest category of social connectedness had a more than twofold-reduced risk of suicide. Being married, frequently attending religious services, and having a large social network appeared to be especially protective.
More surprising is the fact that we demonstrated these findings in a cohort of generally healthy men. Study participants were not, as is typical practice in the field, selected on the basis of being previously diagnosed with serious mental illnesses or having recently been psychiatrically hospitalized. These were dentists, physicians, veterinarians and pharmacists—some of whom were being treated for depression (as is likely the case in any population sample), but the vast majority of whom were generally healthy.
The field has come to view suicide almost solely through a psychiatric or psychological lens. Understandably, suicide prevention tends to focus on individuals deemed to be at highest risk.
However, as our research demonstrates, there may also be important social (or economic or political) factors to consider in preventing suicide.
In contrast to the prevailing emphasis on the mental health care system as the locus of suicide prevention, a population health-oriented approach might try to harness these and other related research findings to prevent suicide. The program would recognize that each completed suicide likely represents the final destination for a weary sojourner (and his or her family, friends and wider community) whose previous layovers along an extended route of personal suffering could have provided many opportunities for earlier intervention.
On the Harvard campus, where I work, a population health-oriented suicide prevention program would promote emotional well-being and social cohesion among all students, not just those diagnosed with depression and thought to be at imminent risk for suicide. All frosh could begin engaging in conversations about stress, achievement and suicide through pre-orientation programs, entryway meetings, or Community Conversations. Such curricula might include basic knowledge about key risk factors for suicide, referral pathways for students requiring urgent attention, and skills to implement minor interventions.
Those with particularly close ties to students—including resident tutors in the houses, proctors and host families in the Freshman Dean’s Office, and even graduate students in the teaching fellow program—could receive more detailed awareness education and training in suicide prevention. They themselves would also be encouraged to make appropriate use of mental health services when needed, to change the campus culture around seeking assistance.
Other program elements might involve allocating resources for preventive functions to be performed by mental health professionals outside of the clinical setting, changing policies to monitor suicide risk among students undergoing disciplinary proceedings, and establishing crisis teams to help House Masters and proctors organize systematic responses in the event of student suicides.
Ultimately, the population health approach to suicide prevention would seek to change social norms about stress, both achievement and failure, and health care seeking behavior. On the Harvard campus, these goals are unlikely to be achieved overnight.
http://www.rwjf.org/en/blogs/human-capital-blog/2014/09/changing_the_culture.html
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