An illustration of a floating candle. One person is trying to keep the flame lit while the other is trying to snuff it out.

Illuminating Insights

Knowing who's at risk for suicide—and the methods they're likely to use—aids prevention.

By Maryalice Yakutchik • Illustration by Matt Manley

After learning that suicide recently had surpassed motor vehicle crashes to become the leading cause of injury deaths in the U.S., Holly Wilcox, PhD, set out in search of specifics.

She knew the kinds of questions she wanted answered. Are males or females largely responsible? Is there an increase among certain ethnicities or age groups? What methods did they use?

Identifying both the who and the how behind the 38,364 suicide deaths reported by the CDC in 2010 is vital to prevention efforts, says Wilcox, a School of Medicine assistant professor with a joint appointment in Mental Health at the Bloomberg School.

Working with a team led by injury prevention icon Susan Baker, MPH ’68, Wilcox teased apart various threads of the data to learn the specifics behind the 16 percent increase in suicides during the previous decade. Among the trends revealed in the November 22 American Journal of Preventive Medicine:

  • Suicide by hanging rose by 52 percent—the greatest increase of any method. Rates rose by 19 percent for suicide by poisoning but remained flat for suicide by firearm, the predominant method for all ages.
  • The rate of suicide among people ages 45 to 49 increased by 39 percent, the most of any age group.
  • Rates for suicide among females increased faster than for males.
  • Rates for whites, Asians and Native Americans rose by 20, 12 and 10 percent, respectively, while rates for blacks decreased by 6 percent.

“Just knowing that the rate of suicide has increased doesn’t tell us a whole lot,” says Baker, a Health Policy and Management professor and the founding director of the Johns Hopkins Center for Injury Research and Policy. “We need to understand the detailed epidemiology for insight into the causes, and to know where to focus prevention efforts.”

Baker explains that effective prevention strategies reduce access to the means that individuals use for suicide—availability of handguns, for instance. Innovations such as fingerprint recognition systems on firearms can be used to save many depressed teens, she adds.

“Focusing on the means and methods of suicide is a logical and successful approach,” concurs William Eaton, PhD, the Sylvia and Harold Halpert Professor and Chair in Mental Health. “Why? Because, although lots of people don’t believe it, suicide is so often impulsive.”

Eaton relates an anecdote about a young man who survived jumping off the Golden Gate Bridge. The instant after jumping, 
he realized it was the worst decision he had ever made. After his miraculous survival, he went on to lead a long, productive life. The point: Restricting the means for suicide saves lives. Successful interventions include barriers installed 
on bridges, reduced emissions standards 
for cars and modernized gas ovens that 
cut out when there is no flame.

Public health can save more lives, says Wilcox, by emphasizing early intervention. The goal is to alter the trajectory of risk well before individuals pose any danger to themselves.

Currently, there’s no gold standard method for identifying those at future risk of suicide, says Wilcox. However, a proactive screening tool for suicide risk called the Columbia Suicide Severity Rating Scale is being used in several military and clinical settings, including here at Johns Hopkins. The task of screening is complicated because of the multitude of risk factors, few of which are exclusive to suicide. For instance, although the overwhelming majority of people who take their own lives have depressive disorders, only a fraction of people with depression ever attempt suicide.

“It’s difficult to predict which individuals will die by suicide,” Wilcox says, adding that this argues for deploying a coordinated range of screening and intervention strategies. “The recognition and treatment of mental illnesses like depression help to enhance resilience, needed at all ages to cope with the unavoidable stresses of life.”

Universal prevention programs can affect suicide risk factors, according to Wilcox. With Sheppard Kellam, MD, she investigated the fates of young adults who had participated two decades ago in a behavior management method called the Good Behavior Game. (Described by others as a “behavioral vaccine,” the game targets aggression and disruption by treating the classroom as a community. It was implemented in 1985 in 41 first-grade classrooms in Baltimore City schools.)

Wilcox’s research, published in 2008
 in the journal Drug and Alcohol Dependence, found that students who had played the game were 50 percent less likely to report suicide ideation in young adulthood and 
30 percent less likely to report a suicide attempt.

“It taught kids to self-regulate and that their behavior had consequences that affected others,” she explains.

Given that finding, the Good Behavior Game was cited as a promising program in the newly revised National Suicide Prevention Strategy.

The recent rise in suicide rates emphasizes the need for all to be vigilant and proactive at a personal level as well, Wilcox says. If you think someone might be suicidal, it’s important to ask him directly, she advises. “And if someone is suicidal, she should not be left alone and should be connected with mental health resources such as a crisis line or an emergency psychiatric assessment,” she says.

The key is to get the person through the crisis. Wilcox says: “If they have the chance to take a deep breath and think about it, there is hope.

“However, the ultimate goal is to prevent not only the crisis moments from happening but also all the stuff—the mood disorders and the alcohol and drug abuse, for instance—that lead to these moments.”