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Why Aren’t Promising Treatments for Suicide Being Used?

If you go to any doctor in the country with an infection, you’ll probably be given an antibiotic, which is the standard and accepted treatment for infection. If you see a therapist for depression, however, you might receive any number of treatments, including well-meaning but ineffective ones.

“If a physician rubs olive oil on an infected area and the infection gets worse, that person could be sued for malpractice, as they should. They didn’t use the evidence-based intervention,” said Matthew Nock, a Harvard psychology professor who studies suicide. “The same isn’t necessarily true for psychology.”

A mental illness can be as debilitating and rooted in biology as a physical one. But treatment protocols are far more consistent and regulated for a misfiring thyroid than a misfiring brain. When researchers develop promising new methods to prevent or manage mental conditions, those methods don’t always find their way into therapists’ offices or hospitals. The lack of uniformity concerns Nock and others who study self-harm and suicide; just as with an infection, the consequences of ineffective treatment can be fatal.

Following the recent high-profile deaths by suicide of designer Kate Spade and chef Anthony Bourdain, calls to suicide hotlines have gone up by about 25 percent, according to the National Suicide Prevention Lifeline. Across the U.S., per the latest Centers for Disease Control and Prevention data, the suicide rate has increased 30 percent in the past 15 years, making it the second leading cause of death for Americans between ages 10 and 34. While experts are quick to note that suicide rates do ebb and flow over time, and that the current rate is about the same as it was in 1916, we’re nonetheless in a flow period.

There are no formal guidelines for treating suicidal patients.

Going forward, suicide rates might climb even higher for reasons that have nothing to do with media coverage or bullying: The link between suicide and high temperatures is so strong that some researchers suggest climate change will further compound suicide risk in years to come. A recent study on this phenomenon, as The Atlantic reported, “concludes that humans can do little about this suicide-climate link beyond developing better medical care to address suicide specifically.”

Right now, there are no formal guidelines for treating suicidal patients. Just last month, the American Medical Association announced a vague policy to “increase awareness” of suicide risk factors by educating residents and doctors about them. The American Psychiatric Association’s own recommendations for treating suicidal patients are as nonspecific as “effective mental health care.”

Efforts to understand and prevent suicide are also sorely underfunded: The National Institutes of Health spent about $35 million on suicide prevention in 2017, during which time 45,000 Americans died by suicide. That same year, breast cancer research received $689 million from the NIH, while the disease claimed about 40,000 lives. Even without adequate funding, experts say innovative research initiatives and effective new treatments do exist. The problem is, they’re hardly being used.

Where the promise lies 

One relatively new treatment for suicidal ideation is called dialectical behavior therapy, or DBT. Originally developed to manage borderline personality disorder, the technique has been applied to suicide prevention in the last few years. Through DBT, which combines group and individual therapy, patients learn skills to manage their emotions, navigate relationships and become more mindful of what they’re thinking and what’s happening around them.

There’s also a monitoring component, in which a clinician is on call 24/7. “If it’s a Saturday night and I feel like I want to cut myself,” Nock explained, “I can page my clinician and say, ‘I’m having a tough time, can you walk me through the use of my skills?’” However, if a patient makes that call after they’ve already harmed themselves, the clinician won’t talk to them, so as not to reinforce the behavior. The monitoring component, according to one 2015 study, may be the most effective part of the whole DBT package.

About 60 percent of people who die by suicide do so on the first attempt.

Suicide-focused cognitive behavioral therapy, a distinct but similar method to DBT, has been shown to cut people’s risk of repeat suicide attempts. Technically called CBT- SP (suicide prevention), it focuses on strengthening emotional regulation and impulse control, as well as reframing negative perspectives.   

At this point, suicide experts are reluctant to say one of these two methods is better than the other. The American Foundation for Suicide Prevention funds clinician trainings across the country on both. While CBT training is fairly accessible, DBT training is extensive, and many clinicians don’t do it for that reason.

“You might have been trained in how to do a treatment a certain way; now we come along and say, ‘Here’s this new way to do it,’” said Nock. “Learning this new treatment requires you to stop work for a week, fly to Seattle, get trained and so on. Practically, it’s tough to do.”

Compared to behavior therapy techniques, medications are logistically easier to transport — to literally bottle up and dispense to psychiatrists across the country. That’s not to say pharmacological remedies are useless. For people with bipolar or depressive disorders, lithium has been shown to decrease suicide risk. Ketamine has also been shown to have anti-suicidal effects, sometimes within an hour of being administered, according to one study.

But research is still in the early stages, and these drugs aren’t appropriate for all patients at risk for suicide. Ketamine, for example, could be dangerous for those with a history of psychosis or substance abuse.

 Finding the 5 percent  

Most suicide research focuses on preventing people who’ve already made one suicide attempt from making a second one. Intervening before first attempts is trickier to do. It’s also considered by many suicide experts to be the “holy grail” of suicide-reduction efforts — one that could make an enormous difference in saving lives. About 60 percent of people who die by suicide do so on the first attempt.

Some researchers are fighting to include suicide screenings in routine care. “If you just wait for people to bring it up on their own, we’ll probably miss half the people who need help,” said psychologist Jane Pearson, chair of the Suicide Research Consortium at the National Institute of Mental Health. “If we give them a screen that everybody gets and just ask about it matter of factly, so that patients are always asked about smoking, how much they drink, if they’ve thought about suicide, we’ll double the rate of people who say they have a problem.”

The future of predicting suicide risk might be in machine-learning methods, such as creating algorithms to identify high-risk people and tracking medical records of patients within a healthcare network. This approach, recent research suggests, can help identify the 5 percent of people most at risk for suicide over the next year. That 5 percent accounts for half of all suicide deaths over the next year. “People talk about finding the suicidal person ahead of time as finding a needle in a haystack,” said Nock. “This one haystack has 50 percent of all the needles.

Technology might offer solutions to bridge the research-practice gap as well. The AFSP has developed an online program for patients designed to supplement therapy. Nock and his team have built an app called Tec-Tec, which uses an aversion therapy game to reduce suicidal thoughts.

“It’s not just asking somebody whether they have ever thought about suicide; it’s about understanding their history.”

“Much more scalable interventions are now possible with advancements in technology,” Nock said. “We need to change the way we do interventions that we know are effective — scale them up,” in order to reach more people. “This could be online, via self-administered versions. Or instead of seeing a clinician for an hour a week, you’re self-guided through the principles of cognitive therapy and DBT, and then you talk to a clinician for 10 to 15 minutes a week.”

Pearson says a big challenge in curbing suicide is the variety of trajectories that can lead to it. “You can have a substance abuse problem, depression, sexual abuse. A veteran could become suicidal [following] their exposure to trauma. There are so many different ways that get you there.”

In the meantime, many leaders in the field are pressuring professional organizations like the American Psychological Association to require suicide-prevention training in clinical doctoral programs, and for medical residency programs to mandate it too.

“There’s no requirement for suicide training, so clinicians don’t learn how to work with people who are suicidal,” said Jill Harkavy-Friedman, vice president of research at the AFSP. “Suicide cuts across every domain, and everybody should have a full assessment. It’s not just asking somebody whether they have ever thought about it; it’s about understanding their history. Just like any other health condition — you should keep a steady eye and get help if the need emerges.”

Campaigns for early intervention and mandatory suicide training dovetail with an approach called the Collaborative Care model. The underlying idea is to integrate behavioral healthcare with medical healthcare, so that providers across different specialties talk to one another and coordinate care for patients. Initial studies suggest this model could improve treatment for depression and reduce suicidal thoughts in some patients. 

Lasting help for fleeting thoughts 

If someone is having suicidal thoughts, finding evidence-based treatment can prove daunting. Nock suggests using the NIMH and Association for Behavioral and Cognitive Therapies websites or reaching out to a therapist in your area who practices evidence-based treatments like CBT-SP or DBT and asking them about their approach and training.

“We know from decades of research that suicidal thoughts and behaviors very often are transient in nature,” said Nock.

In a forthcoming study, he and colleagues found that in about half of people who have thoughts of suicide, the thoughts don’t persist. “They have them, they go away,” Nock said. “People go through suicidal periods. If we can keep them alive through that, they go on to live a happy, healthy, high-functioning life, often. If we don’t help them through that period, they never have that opportunity.”

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