Suicide in the USA: a public health emergency
Authors: None The Lancet Public Health
Journal: The Lancet Public Health (2018)

The deaths by suicide of American designer Kate Spade and chef Anthony Bourdain earlier this month have propelled suicide into the headlines. Their deaths, tragic as they are, provide an opportunity to increase awareness and promote societal change about suicide and self-harm. It is a sobering reminder that about 45 000 Americans (aged 10 years or older) died by suicide in 2016. The US suicide mortality rate in 2016 was 15·3 per 100 000, well above the global average (10.6 per 100 000). On June 8, 2018, the US Centers for Disease Control and Prevention published a report entitled Trends in State Suicide Rates—United States, 1999–2016 and Circumstances Contributing to Suicide—27 States, 2015. In this report, Deborah Stone and colleagues estimate state-level trends in suicide rates from 1999 to 2016 using data from the National Vital Statistics System for 50 states and the District of Columbia. In addition, they use 2015 data from the National Violent Death Reporting System, available for 27 states, to examine the circumstances surrounding suicides. The key finding of the report is that suicide rates have been rising in nearly every state, with wide differences in rates and trends between states. Suicide rates varied fourfold, from 6·9 per 100 000 persons in the District of Columbia to 29·2 in Montana. Percentage increases in rates ranged from 5·9% in Delaware to 57·6% in North Dakota. 25 states saw their suicide rate increase by more than 30%. While those who took their lives were prominently male (77%), average annual percentage increases were worryingly higher for women (2·6% vs 1·1% for men). Another important finding of the report is that more than half of people who died by suicide did not have a known diagnosed mental health disorder. And there are differences among those with and without mental health conditions: people without a known mental health disorder were more likely to be male and to die by a firearm. In dissecting the circumstances and possible factors associated with suicide, the report shows that 20% had prior suicide attempts, 23·5% disclosed a suicide intent, 28% had problematic substance use, and 42% had relationship problems. Clearly, a wide range of factors (including relationship, physical health, job, financial, and legal issues) potentially contribute to suicide. These circumstances often fall outside the remit of mental health or psychiatric services and are associated with broader social determinants of health. A comprehensive public health approach is crucial to address the wide range of factors that can contribute to suicide. Areas of uncertainty remain in suicide prevention and further research is needed in response to changing patterns of suicide. Targeted approaches for high-risk individuals exist and can reduce risk. But individual risk prediction is so difficult, and large numbers of people who die by suicide have no contact with services in the first place. It is important to tackle multiple determinants at the same time if we are to make a difference. Involvement from all in society is needed: from government and policy makers, but also from employers, educational and media organisations, and to every single one of us. Better access to high quality mental health services as part of stronger health-care systems, promoting safe environments (eg, by limiting access to lethal means such as guns), creating supportive environments (reducing stigma, but also improving connectedness, reducing loneliness and despair), developing coping and resilience skills, providing financial support to individuals in need (to ease unemployment or housing issues), and reducing socio-economic inequalities and stressors more broadly—all of these interventions are needed. Finally, a suicide cannot be considered as a one life lost. Suicide affects many lives. A review in The Lancet Psychiatry by Alexandra Pitman and colleagues shows that suicide bereavement is associated with negative health and social outcomes; exposure to suicide is associated with “an increased risk of suicide in partners bereaved by suicide, increased risk of required admission to psychiatric care for parents bereaved by the suicide of an offspring, increased risk of suicide in mothers bereaved by an adult child's suicide, and increased risk of depression in offspring bereaved by the suicide of a parent.” A US study also showed an increased risk of suicidal thoughts and attempts in adolescents after the suicide of a peer. While all suicides might not be preventable, the increased in suicide rates seen in the USA over the past 20 years should fuel urgent concern and must now be a trigger for immediate societal action.