pathways to prevention - science...science sciencemag.org psychiatric hospitalization—a shift...

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Can a three-digit phone number

avert suicides on a grand scale? Last

week, the Federal Communications

Commission recommended desig-

nating 988 as a nationwide suicide

prevention hotline number. Cur-

rently, the National Suicide Pre-

vention Lifeline can be reached around

the clock through the more cumbersome

1-800-273-TALK (8255).

Many paths in life can bring someone to

the brink of suicide, and a shorter phone

number might seem to be a naïvely simple

solution. But researchers have repeatedly

found that simple works: Callers routinely

credit the existing hotline, which is on

track to take 2.5 million calls this year,

with keeping them safe. “It’s one of the

most basic human realities,” says Lifeline

Director John Draper, a counseling psycho-

logist with Vibrant Emotional Health, the

New York City nonprofit that administers

the hotline. “Helping people feel under-

stood and cared about saves lives.”

government agencies and nonprofits now

spend tens of millions more. Suicide has

shed some of its stigma and is increasingly

viewed as a public health issue.

Researchers, meanwhile, are document-

ing the power of simple prevention ap-

proaches and refining them. At the most

personal level, they’re learning how calls

with a crisis counselor, such as those who

staff the Lifeline, can be made more ef-

fective. Hundreds of hospital systems are

implementing a strategy that, in its first

real-world test, cut suicides among at-

risk patients by three-quarters. And entire

countries have reduced suicide rates by

banning commonly used lethal methods.

But even as scientists find tactics that

can save lives, they’ve struggled to make

headway against the high U.S. suicide rate.

One hurdle is the diffi-

culty of expanding ac-

cess to interventions;

another is a lack of

community or politi-

Some straightforward approaches show promise.One question is how they can reach more people

PATHWAYS TO

PREVENTION

Research on hotlines

underscores how a

crisis counselor can

help save lives.PHO

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23 AUGUST 2019 • VOL 365 ISSUE 6455 745

By Greg Miller

More than 47,000 people died by sui-

cide in the United States in 2017. Although

the global suicide rate has dropped, in the

United States it has increased 33% since

1999. Beating back that number is chal-

lenging. Although suicide is the 10th lead-

ing cause of death in the United States,

it’s still rare enough that designing large

studies to probe interventions is difficult—

and the high stakes bring ethical worries.

“For a long time, the field was just kind of

demoralized,” says Jane Pearson, a clini-

cal psychologist and researcher who helps

strategize suicide prevention research for

the National Institute of Mental Health

(NIMH) in Bethesda, Maryland.

But Pearson and others see glimmers

of optimism. NIMH spent $51 million on

suicide prevention research in 2018, twice

as much as in 2015 though still well below

research funding for other conditions that

cause similar numbers of deaths. Other

For help, call 1-800-273-8255 for the National Suicide Prevention Lifeline, or visit

https://www.speakingofsuicide.com/resources.

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NEWS | FEATURES | UNRAVELING SUICIDE

sciencemag.org SCIENCE

cal will. “We do have effective treatments,”

Pearson says. “They’re probably not as

available as they should be, and that’s what

we want to change.”

WHEN MADELYN GOULD, a psychiatric epide-

miologist at Columbia University, began to

study suicide hotlines nearly 20 years ago,

her colleagues thought it was a strange

thing to do. Crisis hotlines had been around

since the 1950s, but nobody really knew

whether they worked. Some ivory tower

experts doubted that call center volunteers,

few of whom were psychiatrists or psycho-

logists, could defuse a crisis. “I was skepti-

cal, too,” Gould says. But she forged ahead.

A randomized trial—putting half the

callers on hold, for example—was clearly

unethical. Instead, Gould and colleagues

evaluated 1085 calls over 17 months. The

researchers trained crisis center staff to ask

specific questions to assess callers’ suicidal-

ity at the beginning and end of the call and

to score their responses. Counselors also

asked callers whether they would consent

to a follow-up call from the researchers a

week or two later. Not only did callers’ sui-

cidality subside during the calls, but their

feelings of hopelessness and psychological

pain had continued to diminish when the

researchers called them back, Gould and

colleagues reported in 2007 in the journal

Suicide and Life-Threatening Behavior.

In another study in the same issue, a team

led by Brian Mishara, a psychologist at the

University of Quebec in Montreal, Canada,

evaluated 1431 crisis calls in real time. (A re-

corded message announced that calls might

be monitored.) The researchers found it was

critical for counselors to quickly establish a

rapport with callers by treating them with

respect and empathy. “If they didn’t do that

in the first 3 minutes, they were less likely

to have a positive effect,” Mishara says. The

most effective counselors then worked with

callers to explore alternatives to suicide,

asking how they’d dealt with past crises or

who in their lives could help.

Gould’s and Mishara’s research also ex-

posed room for improvement. Alarmingly,

Mishara found that counselors asked only

about half the callers whether they were sui-

cidal. It’s a hard question to broach, Mishara

says, even though no evidence suggests that

doing so heightens risk. Mishara’s findings

spurred call centers to revamp their proto-

cols, and the roughly 170 centers that make

up the Lifeline network now assess suicide

risk on every call, Draper says. (In 2005, the

federal Substance Abuse and Mental Health

Services Administration in Rockville, Mary-

land, established the Lifeline network to co-

ordinate crisis centers; the agency supplied

$6.1 million in funding last year.)

Gould’s research uncovered another key

preventive: following up. After her 2007

study showed that 43% of callers reported

suicidal thoughts weeks after their call, the

Lifeline began to encourage call centers

to reach out again, phoning people who

had expressed suicidal thoughts. De-

spite limited resources, about 80% of

call centers now do so, typically within a

day or two, Draper says. A February 2018

study by Gould and colleagues shows the

power of a follow-up call. Among 550 peo-

ple who reported suicidal thoughts in their

initial contact, nearly 80% said the subse-

quent call played a role in saving their life,

the team reported in Suicide and Life-

Threatening Behavior.

sion. “There was a nurse at the table who

said that if we really designed perfect care,

then no one would die by suicide,” says

Brian Ahmedani, who directs Henry Ford’s

Center for Health Policy and Health Ser-

vices Research in Detroit. “Zero suicide”

became the aspirational goal.

The program launched in 2001. Now

called Zero Suicide, it has evolved to in-

corporate new research findings and

screening tools, but the core elements are

unchanged. Behavioral health patients are

assessed for suicide risk at every visit and

assigned to one of four risk categories. For

each, the program gives a timetable and

a menu of treatment options. A person

at acute risk gets an in-depth psychiatric

evaluation and begins treatment that same

day, as an inpatient if necessary. Someone

at moderate risk is evaluated within 1 week

and likely referred for outpatient therapy.

“The idea is to provide structure and stan-

dardization of care, rather than making an

educated guess at each visit as to what cli-

nicians should do,” Ahmedani says.

Providers help each at-risk patient de-

velop a safety plan. They ask, for example,

about firearms and stashes of medication

inside the home and then urge the patient

to hand those over to a friend or family

member. Staff send postcards and call to

check in during transitions in care, espe-

cially when a patient returns home after a PHO

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746 23 AUGUST 2019 • VOL 365 ISSUE 6455

Nearly 2 decades after she started to

study caller-counselor conversations,

Gould is no longer a skeptic. “It works,”

she says. At the same time, it’s not always

enough. “You’re not going to solve a life-

time of problems on a phone call,” Gould

says. A next step is harnessing that call to

chart a path to long-term care.

ONE VISION of what such care might look

like was born at Henry Ford Health Sys-

tem, a sprawling mix of hospitals and out-

patient clinics in southern Michigan. Al-

most 20 years ago, a group of Henry Ford

practitioners gathered to consider how to

better support their patients with depres-



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psychiatric hospitalization—a shift linked

to elevated suicide risk. Henry Ford evalu-

ates providers by how well they adhere to

the Zero Suicide protocol, not on whether

every patient survives.

Apart from one 18-month stretch, Zero

Suicide hasn’t literally lived up to its name.

But its impact has been remarkable. Before

the program began, suicide among Henry

Ford’s behavioral health patients averaged

roughly 100 per 100,000, comparable to

rates in similar patient populations else-

where. In the program’s first 9 years, the

rate averaged 22 per 100,000, the team

reported in JAMA Psychiatry in 2015. The

group is preparing more recent numbers

for publication.

Zero Suicide is now expanding into pri-

mary care—because although not everyone

who attempts suicide seeks mental health

treatment, 83% do see a doctor in the year

before dying, Ahmedani and others re-

ported in 2014. To capitalize on those visits,

Henry Ford now aims to give all of its mil-

lion patients a suicide evaluation at least

once a year with their general practitioner.

Zero Suicide’s success—and the rela-

tively modest investment it requires,

mostly for training staff and updating elec-

tronic health records—has helped it catch

on. At least 500 U.S. health care systems

are implementing it, as are some hospi-

tals in the United Kingdom, Australia,

try’s suicide rate had dropped from 57 to

17 per 100,000. “Sri Lanka’s pesticide regu-

lations appear to have contributed to one

of the greatest decreases in suicide rate

ever seen,” Eddleston and two colleagues

wrote in a 2017 editorial in The Lancet

Global Health. That dip, Eddleston’s re-

search suggests, came at no cost to the

country’s agricultural output.

Recent research suggests pesticide bans

have also lowered suicide rates in Bangla-

desh and South Korea. In South Korea,

which has one of the world’s highest sui-

cide rates, politicians and the public sup-

ported the ban, says Eddleston’s colleague

Won-Jin Lee of Korea University College

of Medicine in Seoul. But in the United

States, a ban on the most common sui-

cide method—guns, which accounted for

half the suicide deaths in 2017—is a politi-

cal nonstarter.

Some states and organizations are trying

more modest steps. In July, Hawaii became

the 17th state to pass a “red flag” law, which

allows family members, police, physicians,

or mental health providers (depending on

the state) to petition a court to temporar-

ily remove firearms from people believed

to be at imminent risk of harming them-

selves or others. The American Medical

Association encourages doctors to screen

and counsel patients on firearm safety,

which can include temporarily transfer-

ring guns during a crisis. And in 2016,

AFSP began to develop brochures and

other educational materials for gun own-

ers and retailers, in collaboration with the

National Shooting Sports Foundation, a

gun industry trade association. Reminding

retailers that they can refuse to sell a fire-

arm to someone who appears to be in crisis

is one major goal, Harkavy-Friedman says.

Whether those efforts are paying off is not

yet known.

As the field matures, scientists will test

a host of tactics—and implementing those

that show promise will be up to health care

systems, policymakers, and the public. For

those that do save lives, such as hotlines, a

big question is how to deploy them more

broadly. Handling the surge of calls that

could result if the three-digit number goes

live will likely tax the resources of call cen-

ters, many of which already operate on a

shoestring budget. Strategies such as Zero

Suicide and means reduction call for new

ways of thinking.

Most important, no single approach can

do it all. “When you’re thinking about sui-

cide prevention,” Pearson says, “you’ve got

to think at many levels all at once.” j

Greg Miller is a science journalist in

Portland, Oregon.

“Sri Lanka’s pesticide regulations appear to

have contributed to one of the greatest decreases in suicide

rate ever seen.”Michael Eddleston and colleagues,

in The Lancet Global Health

23 AUGUST 2019 • VOL 365 ISSUE 6455 747

and beyond, says Julie Goldstein Grumet,

a clinical psychologist and director of

the Zero Suicide Institute in Washington,

D.C., a nonprofit independent of Henry

Ford that helps health care systems adopt

the program. (Guidelines are available at

http://zerosuicide.sprc.org/.)

As Zero Suicide spreads beyond Michi-

gan, a key question for Ahmedani is how

well it works elsewhere. Earlier this year,

he won a $1.1 million grant from NIMH to

evaluate Zero Suicide initiatives at six U.S.

health care systems covering more than

9 million people. Goldstein Grumet is op-

timistic. The program “just makes sense,

and that’s what’s inspiring people to try it,”

she says.

MICHAEL EDDLESTON REALIZED that another

prevention effort made sense after he ar-

rived in Sri Lanka as a medical student

in the mid-1990s. He had a research fel-

lowship to study snakebites, but “we only

saw six bites in 2 months,” Eddleston says.

What he did see, in the clinic where he

worked, was a startling number of patients

dying after intentionally swallowing pesti-

cides. It was a common means of suicide

in rural Asia, where farmers have ready ac-

cess to agricultural chemicals.

The experience altered the trajectory of

Eddleston’s career. Now the director of the

Centre for Pesticide Suicide Prevention at

the University of Edinburgh, he focuses on

what’s called means reduction—restricting

access to lethal methods. It’s one of the

most promising prevention approaches

and one that can be unleashed across entire

countries. In England and Wales, a switch

in the 1960s to domestic gas that contains

less carbon monoxide tracked with a drop

in the suicide rate. So did tighter restric-

tions on sedative prescriptions in Australia

in the late 1960s and early 1970s.

Those early observations are backed by

a growing body of research that counters

the popular misconception that people

who attempt suicide once will keep try-

ing, through whatever means necessary.

The reality is that those in the grip of a

suicidal crisis often can see only one

way out—and if that route is barred,

they’re unlikely to turn to another, says

Jill Harkavy-Friedman, a clinical psycho-

logist and vice president of research at the

American Foundation for Suicide Preven-

tion (AFSP) in New York City.

Sri Lanka is a vivid illustration. Laws

passed there over 27 years, starting in the

mid-1980s, banned many of the most le-

thal pesticides. Before the bans, Sri Lanka

had one of the world’s highest suicide

rates, and pesticides accounted for two-

thirds of those deaths. By 2015, the coun-



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Pathways to preventionGreg Miller

DOI: 10.1126/science.365.6455.745 (6455), 745-747.365Science

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