The Bloomberg School’s Department of Mental Health is the first and the only department-level unit devoted to mental health in a school of public health. Dr. Holly Wilcox is an associate professor in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health who specializes in suicide research and prevention. Suicide has been a focus in the news this year, with several high-profile suicides and a report, issued in June by the Centers for Disease Control and Prevention (CDC), that found that the U.S. suicide rate has increased by 25 percent since 1999.
In this Q&A, Dr. Wilcox discusses the challenges of preventing suicide, identifies programs that have shown success and calls for more funding, given suicide rates are climbing and suicide is a leading cause of death among young people, both in the U.S. and globally. She also underscores the role that access to a means to self-harm – mainly guns in the U.S., and pesticide internationally – plays in suicide.
In the U.S. in the past six months we’ve seen data from the CDC that show that the U.S. suicide rate has increased more than 25 percent since 1999. What are the underlying causes for this increase?
Although we don’t know for sure why rates of suicide have increased since 1999, the economic conditions and possible cohort effects have been implicated among other factors. According to a few recent studies, those with a birth year of 1950 or later and entering labor market around 1970 or later without a college degree have had especially steep increases in suicide and drug- and alcohol-related mortality.
Do these data include accidental suicides?
The extent of accidental suicides in the United States is unclear. Coroners and medical examiners make a determination on manner of death based on available evidence. Unless there is a suicide note left by the decedent, suicide intent is a challenge to firmly establish. Accidental death by drug overdose and death by suicide can have overlapping features and are challenging to accurately classify.
What does you work involve in terms of research, interventions, etc.?
I have a new project focused on conducting data linkage and informatics approaches to utilize existing data resources to improve suicide risk identification and prevention. I am collaborating on this project with colleagues Dr. Hadi Kharrazi, assistant professor in the Bloomberg School’s Department of Health Policy and Management, and Dr. Paul Nestadt, assistant professor in the Department of Psychiatry of the Johns Hopkins School of Medicine, and our regional health information exchange, Chesapeake Regional Information System for our Patients.
In addition, I am currently involved in several “universal” (directed at everyone not just those at risk) prevention projects in schools, primary care, emergency departments and college campus settings. Because there are substantial barriers to mental health treatment due to stigma, such as access to services, I have been focused on testing the impact of and disseminating practical skill-building approaches implemented early in development in community settings that serve young people.
What are the opportunities for prevention when it comes to suicide?
Many suicide attempts are impulsive. States with the lowest suicide rates have stricter gun laws. Two-thirds of gun-related deaths in America are suicides, according to the Centers for Disease Control and Prevention. Legislation in the United Kingdom on analgesic pack size of paracetamol has also been shown to prevent suicides. Evidence-based, comprehensive systems-level approaches have also shown impact in reducing suicide deaths. The U.S. Air Force Suicide Prevention Program, the implementation of mental health service recommendations as was done in England and Wales, and the White Mountain Apache Suicide Surveillance System have each demonstrated notable impact on suicide deaths. They also need attention to quality of implementation. There are several policies and programs that simultaneously reduce/prevent addiction and multiple domains of violence including suicide. Our team at the Bloomberg School has shown that school-based universal programs such as the Good Behavior Game, a classroom management program that rewards children for displaying appropriate on-task behaviors during instructional time, which can be implemented as early as first grade, reduce the incidence of suicidal ideation and attempts and many other outcomes over a decade later.
What about globally – World Mental Health Day is Oct. 10 – what are the numbers telling us and what is being done to prevent suicide around the world?
Close to 800,000 people die by suicide every year, yet many more attempt suicide. Suicide is the second leading cause of death among 15-29 year olds globally. Although 79 percent of suicides occurred in low- and middle-income countries in 2016, many evidence-based approaches are being introduced in these countries with the goal of reducing suicides. Pesticide self-poisoning is an important global means of suicide with approximately 168,000 suicide deaths per year by pesticides. Restricting easy access to pesticides and removal of more toxic pesticides have reduced suicide rates. Responsible media reporting – such as avoiding language which sensationalizes or normalizes suicide or presents it as a solution to a problem, avoiding pictures and explicit description of the method used and providing information about where to seek help – is recommended for the reduction of suicidal behaviors. This applies to both the U.S. and globally.
Access to a means to commit suicide seems to be a theme.
Easy, immediate access to firearms increases suicide risk threefold. Most suicide attempts happen with little planning.
Is there anything to be optimistic about?
Several treatment approaches such as Cognitive Behavioral Therapy, Dialectical Behavior Therapy, Multisystemic Therapy and Attachment-Based Family Therapy have shown to reduce the rates of suicidal behaviors. Antidepressants have also shown to reduce suicidal behaviors. Early prevention programs targeting key risk factors for suicide such as anxiety, depression and aggressive behavior have shown to prevent the incidence of suicidal ideation and attempt. It would be ideal to implement “evidence-based” programs on a broader scale.
What is needed as far as funding?
Other leading causes of death such as HIV/AIDS, heart disease and prostate cancer have seen drops in mortality when federal research funding increased. Because suicide is the second leading cause of death in young people and rates are increasing greater investment is needed to reduce the rate of suicide in the U.S. Such funding could go to research and expand programs that have shown to be effective in preventing suicide attempts and deaths.