The New Suicide Prevention

When Robin Williams ended his life last month, his suicide sparked a raft of online and print commentary about the dangers of depression and the need to inject more resources into our mental health care system. I strongly agree with these sentiments. After all, as a psychiatrist at the Massachusetts General Hospital, I regularly speak with patients who have been diagnosed with depression or who are actively thinking about ending their lives.

But what if suicide prevention isn’t just about better screening, diagnosis, and treatment of depression? What if there were a better way to go about preventing suicides?

It is undeniable that people with mental illnesses such as depression and bipolar disorder are at greater risk for suicidal thinking or suicide attempts. But not everyone with depression commits suicide, and not everyone who has committed suicide suffered from depression. In fact, even though depression is a strong predictor of suicidal thinking, it does not necessarily predict suicide attempts among those who have been thinking about suicide.

These epidemiological facts have been on my mind with World Suicide Prevention Day occurring just this week. Suicide is the third leading cause of death in the U.S. among young adults. It is also a global phenomenon: As described in the World Health Organization’s recently published landmark report on suicide prevention, suicide accounts for nearly 1 in 10 deaths among young adults worldwide. So it is very likely that many of the students reading this essay have had their lives touched in some way by suicide, either through the suicide of a family member or friend, or even a friend of a friend.

While I spend my clinical time providing mental health treatment services as a psychiatrist, I spend my research time trying to better understand the social factors driving suicide. In collaboration with colleagues at the Harvard School of Public Health, I recently published a study in the Annals of Internal Medicine showing that social connectedness is an important protective factor against suicide among middle-aged men. Although not directly generalizable to other age groups, our findings are consistent with smaller studies conducted among adolescents and young adults. The fact that we demonstrated our findings in a large cohort of generally healthy persons—rather than in a sample of study participants characterized by mental instability and high suicide risk—is particularly notable.

The field has come to view suicide almost solely through a psychiatric or psychological lens. Yet, as our research demonstrates, there may also be important social (or economic or political) factors to consider.

Clearly, then, suicide prevention is not just about improved screening, diagnosis and treatment of depression.

In contrast to the current focus on the mental health care system, a public health-oriented program might try to harness these and other related research findings to prevent suicide. The program would recognize that each completed suicide likely represents the final destination for a weary sojourner (and his or her family, friends, and wider community) whose previous layovers along an extended route of personal suffering could have provided many opportunities for earlier intervention.

While changes to the mental health care system—in terms of financing, access, and quality—would certainly deserve consideration, in the college campus context a public health-oriented suicide prevention program would promote emotional well-being and social cohesion among all students, not just those diagnosed with depression and thought to be at imminent risk for suicide. Here are just a few examples of hypothetical program elements.

All frosh could begin engaging in conversations about stress, achievement, and suicide through pre-orientation programs, extended orientation workshops, entryway meetings, or Community Conversations. Such curricula might include—hopefully not in a heavy-handed fashion—basic knowledge about key risk factors for suicide, referral pathways for students requiring urgent attention, and skills to implement minor interventions.

Programs during the school term would provide additional opportunities for reinforcement, such as through the Residential Education, Reflecting on Your Life, and thesis advising programs.

Those with particularly close ties to students—including resident tutors in the house advising system, proctors and host families in the Freshman Dean’s Office, and even graduate students in the Teaching Fellow program—could receive more detailed awareness education and training in suicide prevention. They themselves would also be encouraged to make appropriate use of mental health services when needed, to change the campus culture around seeking assistance.

Other program elements might involve allocating resources for preventive functions to be performed by mental health professionals outside of the clinical setting, changing policies to monitor suicide risk among students undergoing disciplinary proceedings, and establishing crisis teams to help House Masters and Freshman Proctors organize systematic responses in the event of student suicides, or creating surveillance databases.

Numerous institutions on campus—ranging from Harvard University Health Services and the Bureau of Study Counsel, to Room 13 and Eating Concerns Hotline and Outreach—have made substantial progress towards helping us shift from viewing suicide solely as a psychiatric or psychological problem and instead viewing it as a community-wide problem.

Ultimately, the public health approach to suicide prevention would seek to change social norms about stress, both achievement and failure, and health care seeking behavior. On the Harvard campus, these goals are unlikely to be achieved overnight.

Alexander C. Tsai ’98 is a psychiatrist on staff at Massachusetts General Hospital and an Assistant Professor of Psychiatry at Harvard Medical School.