Hotlines Aren’t Enough to Help People at Risk of Suicide

Cara Angelotta, suicide prevention, health policy


Contrary to popular belief, the risk of suicide does not increase around the holidays. But, according to the Centers for Disease Control and Prevention, annual suicide rates in the U.S. have risen nearly 30 percent since 1999.

Much of the media coverage following the high-profile suicides of Kate Spade and Anthony Bourdain has followed recommended best practices to reduce risk of suicide contagion or “copycat” suicides by including warning signs a person may be at risk of suicide due to depression and contact information for the national hotline for suicide prevention. This overly simplistic approach implies that we can prevent all suicides by reaching out to loved ones in emotional distress and advertising the existence of mental health treatment.

As a psychiatrist who treats individuals hospitalized for acute suicide risk, I am concerned that much of the media coverage has belied the complexity of suicide. While we do not yet fully understand why suicide rates are rising, we do know that suicide is a complex public health problem that will require a multifaceted approach to reduce deaths. Increased awareness of depression as a treatable medical illness is an important but insufficient response to the suicide epidemic.

Risk factors for suicide extend beyond depression and suicidal ideation, which is the psychiatric term for contemplating suicide. Substance abuse (in particular alcohol and prescription drugs like opioids and benzodiazepines), prior suicide attempts, a history of psychiatric hospitalization, psychotic illnesses, personality disorders, and a family history of suicide are among the many psychiatric factors that are associated with an increased risk of completed suicide.

Social stressors, like financial distress and relationship problems, and medical problems, like traumatic brain injuries and physical pain, also increase suicide risk. Given the varied profile of individuals who die by suicide, a one size fits all approach of increased awareness of depression treatment will not be effective in reducing the rising rates of suicide.

Given that most people with suicide risk factors will not attempt suicide and many more people contemplate suicide than complete suicide, accurate prediction of individual suicide risk is challenging at best. The results of a recent study in the American Journal of Psychiatry suggest that electronic medical records may be utilized to help clinicians flag those at highest risk of future suicidal behavior.

Advertising suicide hotlines is a good start to reducing the risk of suicide for some vulnerable people, but psychiatric treatment alone is unlikely to solve the suicide epidemic. According to a World Psychiatry report, although the use of mental health treatments in the U.S. has increased since the early 1990s, largely driven by increases in antidepressant medication use, there is no evidence for any corresponding reduction in mental illness among U.S. adults in this same period. In a study of U.S. suicide deaths, nearly 25 percent of individuals received a mental health diagnosis in the four-week period prior to suicide.

While treatment, in its current state, is not a panacea for all individuals at risk of suicide, there must be high quality, evidence-based mental health treatment readily available for those that call suicide hotlines. There is a nationwide shortage of psychiatrists. Psychiatric treatment is often difficult to access with insurance and even harder to access without insurance or the means to pay directly for care. Mental health treatment also varies substantially in quality.

In addition to access to high-quality treatment, public health measures to reduce access to lethal means of suicide are important. According to the CDC, a firearm was used in nearly half of completed suicides in the United States between 1999 and 2016 for which data were available to analyze. Reducing access to guns has reduced suicide rates in other countries. Within the United States, state laws that limit access to handguns, like gun locks, universal background checks, and waiting periods for gun purchases, have been associated with reduced suicide rates.

Kindness, reaching out, and reduced stigma are necessary responses to suicide. Individuals have a role in suicide prevention, but society must make sweeping changes to solve this growing problem. The best means to reduce suicide on a population level will also involve commonsense public health approaches, expanded access to a full spectrum of high quality care provided by well-trained professionals, and increased funding of research to improve suicide risk prevention and mental health treatment.

Cara Angelotta MD is a forensic psychiatrist, Assistant Professor of Psychiatry at Northwestern University Feinberg School of Medicine and a Public Voices Fellow with The OpEd Project.

4 replies »

  1. I agree that Hotlines aren’t enough to help people at risk of suicide. Suicides are increasing day by day. There are many reasons behind their suicide. Everyone has some or the other issues in life, but that does not mean that one should end up their lives like this. One should find reasons to live life. We get our life to live once, so why end it up like this. If one found themselves in problems like this then they should consult some Professional like at Voyance Pure From Martine Voyance at http://www.martine-voyance.com/qui-suis-je for their help, Or can consult to someone that they find can help them come out of their Problems.

  2. Maternal mortality incidence has worsened by 239% in the last 30 years,
    .Mass shootings incidence has worsened by 234% in the last 30 years,
    ..National health spending per citizen has worsened by 270% in the last 30 years,
    …Our nation’s longevity has now decreased 4 years in a row, and
    ….Social mobility declined by 67% during 1940-60 and by another 17% during 1970-85

    Social mobility represents the likelihood that a child will subsequently have a higher income as an adult than their parents.

    In addition, homelessness, childhood obesity, substance abuse, adolescent homicide, mid-life depression/disability continue to worsen, by a lot. Is there any reason to believe that our nation’s current strategy for healthcare reform will solve our nation’s worsening suicide rates as well as all the other outcomes listed above??? Right, absolutely not? While Congress and the National Academy of Sciences continue to fidget amid the Paradigm Paralysis of the healthcare industry, we need another goal as a basis for meaningful healthcare reform.

    With the application of infection control and anesthesia, healthcare in the last 150 years has become conceived as preferably managed within a semi-autonomous industry of society. In fact, it begins and flourishes within the confines of a community, its neighborhoods, and each citizen’s family. A community by community focus on its level of SOCIAL CAPITAL will be required. A similar effort by the Cooperative Extension Service for agriculture has promoted our nation’s role as the world-wide leader for efficient and effective production of food (originated by Congress in “1914” ). Adapted to promoting a community by community, uniquely local collaborative commitment, our nation’s level of Social Capital must be enhanced for the HEALTH of each citizen.

    To begin this national commitment, it begins with three definitions: COMMUNITY, SOCIAL CAPITAL and CARING RELATIONSHIPS. (as follows)

    COMMUNITY may be defined as a Cluster of persons identifiable by certain uniform attributes, typically as citizens living within a geographically defined municipality, who share a valued awareness about their interconnected identity that is borne out of “mutually experienced events” and each person’s memory of the ecological and cultural traditions associated with these “mutually experienced events.”

    SOCIAL CAPITAL may be defined as a community’s Trust, Cooperation and Reciprocity that its citizens spontaneously express for resolving the Social Dilemmas they encounter daily within their community’s Municipal Life WHEN Caring Relationships are persistently nurtured within the social networks of the community’s citizens, especially the enduring Caring Relationships occurring within the Micro-Neighborhood Network of each citizen’s Family.

    CARING RELATIONSHIP may be defined as a variably asymmetric, social interaction between two persons that begins with a Beneficent goal to enhance each other’s Autonomy and flourishes from a shared obligation to communicate “in harmony” with Warmth, Non-critical Acceptance, Honesty and Empathy.

    The perception of emptiness from a family member’s death related to depression or substance use is not abated by any knowable remediation. I join Dr. Palmer.

    To connect Social Capital and HEALTH, I offer the following citation by Giordano and Lindstrom http://dx.doi.org/10.1136/jech-2015-205822

  3. I’ve had two experiences with this in close family. Our efforts failed. Tears. What we learned: 1. Depression is deadly and there is nothing in health care that requires more expertise or skill. It is as significant as any of the big killers such as cancer or heart disease. 2. These folks, when they are determined to leave, will use extreme cleverness and ingenuity and will devise unbelievable plans to succeed. Eg write bogus counterfeit prescriptions. 3. The brain can have a need for different chemistry and genetics (people are lucky to find a good drug), but it may also require synapses to be altered by skilled psychotherapy, often taking a long time and much dough. In other words change the anatomy of the wiring and the circuit board. You can feel this by imagining how the brain can change after being in a war. You thus may have to treat in two ways and one of these might take a long time and be very costly.

    I don’t think society can do all this now. It is too daunting. We can’t afford to do this correctly and we do not know enough.

    I think the best alternative now is to keep looking at the genome wide association studies in depressed people and keep developing new drugs. And, we have to insist that all psychologists see depression as a red flag warning that is a marker for a lethal disease….just as significant as chest pain or bleeding from the rectum or severe abdominal pain. Maybe require all providers of depressed patients to get at least one consultation…? I hate to see more rules but the health care sector needs to feel an amplification boost from society in its treatment of this illness.