The Casual Sadism of Suicide Prevention
Most efforts are aimed at kicking the can down the road, not reducing suicidal feelings
There was another article about suicide prevention in The NY Times today, on the remarkably long journey to get a suicide barrier constructed on the Golden Gate Bridge, which has been a temple to killing one’s self for decades. Back in 2019, the NYT opinion section—with a psychiatrist writing— referred to “the empty promise of suicide prevention.” I often dunk on the Times, but this was accurate:
If suicide is preventable, why are so many people dying from it? Suicide is the 10th leading cause of death in the United States, and suicide rates just keep rising.
This was a “no brainer”— death by suicide has long been an outcome determined by the lethality of the means at hand. Men die by suicide more often than women1 in the US, largely because males tend to reach for easily accessible and fatal firearms. In rural China, women lead the way to death by suicide, with organophosphate pesticides result available and highly lethal.2
The focus on prevention of death—as the only positive story in mental health-related mortality reduction—is about reduced access to lethal means. As a public health and less-death enthusiast, I find this trend heartening. However, it leaves something crucial to be desired—relief from suffering because we acted to relieve suffering.
That having been said, recent updates to policies like the Joint Commission update on sentinel events to include death by suicide up to 7 days after discharge from an acute care setting ignores a crucial aspect. The interventions we deploy—in almost all acute care settings— to reduce the suffering of people who are suicidal do not, for the most part, work. I’m sorry to be a huge downer, but there is close to zero evidence that psychiatric interventions, as deployed currently, have anything but a deleterious effect on death by suicide, and virtually none of them have been studied in suicidal individuals. ECT is one exception, but it is underutilized, as is IV ketamine.
What makes this situation even more absurd is that we have evidence-based treatments, right now, that relieve acute suicidality. One of them, Janssen’s Esketamine product (Spravato, by trade name) has an FDA Label for the treatment of “Major Depression with Suicidal Ideation,”3 which had its trial replicated in the process of the FDA approval.4
Yes, we have an FDA-approved therapeutic with a specific label on its use in suicidal ideation in depression, and yet, it is NOT administered in acute care settings (e.g. psychiatric hospitals) because there exists no viable payment model, at the time of its FDA approval. So instead of using treatments that would relieve suffering, we content ourselves with $217,000,000 bridge remodeling projects, or, more commonly, not.
Further, thanks in part to the relentless advocacy of this very newsletter, the SAINT neuromodulation system is eligible for payment under the Medicare NTAP program, and before it even had FDA approval, there was published data on its use in suicidal depression.5
We know inpatient hospitalization has no evidence supporting its use in mitigating suicide risk, as I have painstakingly detailed before.
Interventions like the above are part of a new wave that can treat suicidal depression. I have also argued addressing sleep, more sleep, and nightmares can provide robust risk reduction, as can folic acid supplementation. We don’t do them, though. Not in the places, in the US, where people go to get help with their suicidal depression—acute care hospitals.
Say it with me now: We have treatments that work, finally.
Let’s Use Them!
Richardson, C., Robb, K. A., & O'Connor, R. C. (2021). A systematic review of suicidal behavior in men: A narrative synthesis of risk factors. Social Science & Medicine, 276, 113831.
Wang, B., Han, L., Wen, J., Zhang, J., & Zhu, B. (2020). Self-poisoning with pesticides in Jiangsu Province, China: a cross-sectional study on 24,602 subjects. BMC Psychiatry, 20(1), 1-11.
Fu, D. J., Ionescu, D. F., Li, X., Lane, R., Lim, P., Sanacora, G., ... & Canuso, C. M. (2020). Esketamine nasal spray for rapid reduction of major depressive disorder symptoms in patients who have active suicidal ideation with intent: double-blind, randomized study (ASPIRE I). The Journal of clinical psychiatry, 81(3), 6605.
Ionescu, D. F., Fu, D. J., Qiu, X., Lane, R., Lim, P., Kasper, S., ... & Canuso, C. M. (2021). Esketamine nasal spray for rapid reduction of depressive symptoms in patients with major depressive disorder who have active suicide ideation with intent: results of a phase 3, double-blind, randomized study (ASPIRE II). International Journal of Neuropsychopharmacology, 24(1), 22-31.
Williams, N. (2019). 67. Stanford Accelerated Intelligent Neuromodulation Therapy for Suicidal Ideation (SAINT-SI). Biological Psychiatry, 85(10), S28.
All of these articles suicide prevention strategies are off base unless they include the name Igor Galynker, head of suicide prevention at Mt. Siani, who has shown conclusively that we're asking the wrong questions. As another commenter below said, suicidal ideation is very weakly correlated with actual suicide. Many people think about suicide all the time but never act on it. On the other hand, many people who have never thought about it find themselves suddenly in a radically hopeless situation and kill themselves. To prevent suicides, the screening questions all medical professionals should be required to ask are:
1. Are you in control of your own thoughts?
2. Do you have any hope for your future?
If we asked those questions instead of "Are you thinking about committing suicide?" we could save many lives.
My daughter has dedicated her life to the prevention of suicide. She told me these things. Suicidal ideation is not intrinsically tied to either depression or mental illness. Factors such as hopelessness, desperation, isolation, and feelings of being a burden to those around them, are major factors in the decision to end one's life. In the county where she is based, only 40% of all suicide deaths can be attributed to diagnosable mental illness. Further, acute-care facilities are providing those medications known to be helpful in the treatment of suicidal ideation. She is involved after that to provide not only the medication but to surround that individual in the care these individuals need.