Preventing Suicide in the United States

Jerome M. Adams, MD, MPH

Vice Admiral, US Public Health Service

US Surgeon General

Suicide is the second leading cause of death among people aged 10-34 and the 10th leading cause of death overall in the United States. In 2018, more than 48 000 people in the United States died of suicide, a 34% increase since 1999. ¹ That same year, 1.4 million US adults attempted suicide. ¹ An estimated 1 in 14 US adults knows someone who has died of suicide in the past 12 months.^2,3 In addition to its emotional toll, suicide has a substantial economic burden in the United States. In 2018, the Centers for Disease Control and Prevention (CDC) estimated that together, suicides and self-harm injuries cost the nation approximately $70 billion per year in direct medical and work loss costs. ⁴ This loss has been further exacerbated by the current coronavirus disease 2019 (COVID-19) pandemic. A 2020 study by the Meadows Mental Health Policy Institute quantified the risk of COVID-19–related unemployment on suicide, estimating that for every 5 percentage-point increase in unemployment in Texas during the COVID-19 recession across a year, an additional 300 Texans could die each year of suicide. ⁵

One in 5 people in the United States has a mental health condition. ⁶ Conditions such as depression, posttraumatic stress disorder, psychosis, and substance use are associated with increased suicide risk. For example, each year, as many as 50% of people with bipolar disorder will attempt suicide, and 11% will die of suicide. ⁷ However, death by suicide is usually a result of a complex interaction of factors. ⁸ Data from CDC show that in 2015, 54% of people in the United States who died of suicide did not have a known mental health condition at the time of their death. ⁸ Most of these deaths were precipitated by economic losses, relationship issues, substance use, physical health problems, or housing stress. ⁸ Even among people with known mental health conditions, relationship problems, other life stressors, substance use, and recent acute crises were prevalent. ⁸ Although mental illness and suicide are often conflated and people with mental illness are certainly at an elevated risk of suicide, there is no single cause of suicide, and suicide risk extends beyond mental health conditions. ⁸ Longitudinal studies show that only a small minority of people diagnosed with a mental illness die by suicide; most die of other causes. ⁹

Veterans are one population that is disproportionately at risk for suicide. Every day, about 20 veterans—including 2 or 3 guardsmen and reservists—take their lives, totaling more than 6000 per year. ¹⁰ After leaving the military, most service members transition to civilian life and lead healthy, productive lives. However, some veterans have substantial mental health conditions, including posttraumatic stress, substance use disorders, depression, and anxiety. ¹¹ In addition to health problems, veterans can face other life stressors that can contribute to suicide risk. In 2017, the US Department of Housing and Urban Development estimated that 40 000 veterans had experienced homelessness and more than 15 300 veterans were living on the street on any given night. ¹² Veterans die of suicide at a rate 1.3 times that of the general population after adjusting for age and sex, and female veterans die of suicide at a rate of 2.2 times that of the general population after adjusting for age. ¹¹ In 2017, the highest suicide rate (44.5 vs 14.0 per 100 000 population in the United States overall) was among veterans aged 18-34, and 38% of suicide deaths among veterans were among older adults aged 55-74. ¹¹

In response to the morbidity and mortality caused by suicide, President Trump signed an Executive Order in 2019 creating the President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS) Task Force, identifying suicide as a national health crisis, especially among the veteran population. ¹³ The PREVENTS Task Force, on which I (Dr. Jerome Adams) serve as a national ambassador (individuals at the national level who have a sustained connection to PREVENTS and its campaigns), aims to amplify and accelerate progress in addressing the suicide epidemic in the United States. ¹³ PREVENTS uses a multipronged public health approach that strives to change the way all people in the United States think about, talk about, and address mental health broadly and suicide in particular. It also focuses on identifying and promoting effective evidence-based preventive programs in communities across the nation while expanding the reach of suicide prevention research.

In addition to PREVENTS, the National Strategy for Suicide Prevention (National Strategy), a joint effort of the Office of the Surgeon General and the National Action Alliance for Suicide Prevention—the nation’s public–private partnership for suicide prevention—is a call to action intended to guide the nation’s suicide prevention efforts. ¹⁴ The National Strategy presents 13 goals and 60 objectives for suicide prevention and describes the role that each of us can play in preventing suicide and reducing its impact on individuals, families, and communities, with the goal of reducing the number of deaths by suicide 10% nationally by 2027. ¹⁴ The US Department of Veterans Affairs has also taken a multifaceted approach to suicide prevention through its National Strategy, which emphasizes population approaches, primary prevention, and a commitment to scientific discovery in suicide prevention. The US Department of Defense has taken similar steps, creating the Defense Suicide Prevention Office to advance holistic, data-driven suicide prevention in our military community. Lastly, CDC has outlined recommendations and strategies for improving suicide prevention efforts. ¹⁵

Given the national priority to prevent suicide, we must accelerate our understanding of the complexities underlying suicide and begin to address the cultural barriers surrounding suicide and mental health conditions. Progress in the following 6 areas, which parallel the focus of the PREVENTS Task Force, will help reduce suicides in the United States:

1. Communications: Develop and implement a coordinated and comprehensive public health messaging campaign that educates, inspires, and calls people in the United States to action to prevent suicide. By advising citizens to recognize their own risk and protective factors, by encouraging those in need to reach for help before the point of crisis, and by calling on everyone to reach out to those who are at risk of suicide, we will increase the likelihood that those in need will seek and receive the care and services they deserve.

2. Research: Promote positive changes to the research ecosystem that accelerate scientific development through innovative policies, shared data, and novel funding mechanisms that support collaborative scientific efforts.

3. Lethal means safety: Reduce accessibility of lethal means to lower the number of suicides. ¹⁶ Common lethal means include medications, firearms, bridges, railroads, and more. Understanding these means and developing mechanisms to enhance safety is crucial to suicide prevention.

4. State, local, and community action: Strengthen suicide prevention through local, state, and national engagement and reach people across the spectrum of risk with evidence-driven programs as part of a comprehensive and coordinated public health approach. ¹⁵

5. Workforce and professional development: Continue to leverage partnerships in the private and public sectors to prioritize mental health and wellness practices in the workplace and through suicide prevention training.

6. Partnerships: Facilitate the development of effective partnerships across government and between government and nongovernmental entities. Examples include faith-based organizations, nonprofit entities, community-based organizations, and veterans services organizations/military service organizations.

Together, we must change the conversation and embrace a cultural shift in the way we view, talk about, and treat mental health conditions and suicide. Lasting and meaningful improvements in suicide prevention must occur through comprehensive and unified public health action at a state and community level. We know that people who are struggling may feel hopeless and desperate. It is time to equip our citizens and our communities with knowledge and tools that will prevent suicide and save lives.