HARVARD GAZETTE ARCHIVES

Ronald Kessler and his colleagues believe that new drugs and psychotherapies are not reaching suicidal people quickly enough and are not effective enough. Those who are thinking about suicide typically get treatment after, not before, they try to take their lives, he says. (Staff photo Jon Chase/Harvard News Office)

Why there is no decrease is worth looking into simply because suicide attempts are good predictors of who will succeed in taking their lives. And suicides are one of the leading causes of death worldwide.

"If we can find out why such behaviors as suicidal thoughts, plans, gestures, and events have not declined, we will be in a better position to further decrease the number of completed suicides," notes Ronald Kessler, professor of health care policy at the Harvard Medical School.

According to death certificate surveys, in the United States about 30,000 people a year kill themselves. For each completed suicide, there are 50 attempts, or about 1,500,000 people threatening or trying to end their lives. (Women attempt suicide more often than men, but more men than women succeed at it.)

The suicide rate among men and women ages 18 to 54 years fell a modest 6 percent since 1990. In 1990-92, the rate was approximately 15 out of every 100,000 adults. It was down to about 14 out of 100,000 in 2000-02. At the same time, 3,000 out of every 100,000 people reported that they had thoughts of killing themselves, and 500 of every 100,000 actually attempt to do so. These numbers come from two National Comorbidity Surveys covering the periods 1990-92 and 2001-03.

"We actually expected to see increases in both completed and attempted suicides because of things like the 9/11 terrorist attacks, the war in Iraq, health-care costs, a sluggish economy, etc.," Kessler says. "But seeing a decrease in suicide deaths and a flattening of attempts and thoughts of suicide were pleasant surprises. The lack of a rise in suicidal behavior can be considered good rather than bad because it tells us that the rate of emotional distress in the U.S. has stabilized."

Treatment is lacking

But why is the news not better? Why didn't attempts at suicide drop as much as actual self-killings? "The short answer is that we don't know," Kessler admits.

In an article published in the May 25 Journal of the American Medical Association, he and his colleagues discuss possible reasons. One is that suicide-related behaviors would have gone up instead of staying the same without the treatments that have successfully lowered completed suicides. Another possibility is that, as in the case of arthritis, new treatments are up dramatically, but the pain does not go away. The drugs and talk therapy make you feel better but many people still think life has dealt them a lonely and emotionally painful hand.

Kessler does not think either is the right answer. "The best information we have leads us to conclude that the majority of patients currently in treatment for mental disorders receive care that fails to meet even minimal standards. Another complication may be that the benefit of drugs and psychotherapy for some patients is offset by the adverse effects of antidepressant drugs in others."

Also, the researchers believe, things are the way they are because increased treatment did not reach suicidal people quickly enough, or when it was delivered in time, it was ineffective. "Attempters typically get treatment only after they try to commit suicide," Kessler points out. "Or the increase in treatment either before or after a suicidal act is not good enough."

Many people who try to take their lives don't really want to succeed. They are merely crying out to the world for help. But such gestures can be damaging. A botched attempt can leave a person seriously damaged, even permanently disabled.

What's to do

What can be done to reduce suicidal behavior? "First, let's do practical things that are obvious," Kessler answers. "Then follow up with research to gain additional insight into what else can be done."

As a start, Kessler and his colleagues want to see improvements in the quality of care, and in letting suicidal people know help is out there for them. He characterizes available treatments as a "hodge podge." If you see a primary care doctor, he or she may prescribe an antidepressant, without being fully aware of what dosage or which medication is best for you. A psychologist or social worker may treat you with talk. A psychiatrist may mix pills and talk. But across these treatments enormous variation exists in the intensity of talk and the dosage of the medication.

"There are guidelines out there, of course," Kessler comments. "They make recommendations about the number of hours of talk therapy, about dosages of antidepressants, and about following up to be sure what helps one patient does not make things worse for another.

"As things are now, only about half of those with emotional problems are getting any treatment at all," he continues. "Many people suffer in isolation. Even if there is help, they don't know about it or how to get it.

"Advocate groups who provide this information are growing, and celebrities with emotional problems are bringing them out of the closet," Kessler continues. "But we are still a long way from providing the quality of care that's needed and making informed consumers out of people who question whether it's worth living. That may help explain why thoughts and attempts at suicide have not decreased in response to the improved treatments that have reduced actual suicides."