Decades of national suicide prevention measures have not reduced the number of deaths

If you or someone you know may be going through a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialling or texting '988'.

When Pooja Mehta’s younger brother Raj committed suicide in March 2020 at the age of 19, she was completely taken aback.

Raj's last text message was to his college lab partner and was about assigning homework questions.

“You don't say you're going to answer questions 1 through 15 if you plan to be dead an hour later,” said Mehta, 29, a mental health and suicide prevention activist in Arlington, Va. She had completed training in mental health first aid – a nationwide program that teaches how to recognize, understand and respond to signs of mental illness – but she said her brother had shown no signs of trouble.

Mehta said some people blamed her for Raj's death because the two were involved in COVID-19 pandemic while Raj was taking online classes. Others said her education should have helped her realize he was struggling.

But, says Mehta, “we act like we know everything there is to know about suicide prevention. We've done a really good job of developing solutions to part of the problem, but we really don't know enough.”

Raj's death came amid decades of unsuccessful attempts to Suicide rates nationwide.

Over the past two decades, federal agencies have launched three national suicide prevention strategies, one of which was announced in April.

The first strategy, announced in 2001, focused on tackling suicide risk factors and relied on a few common interventions.

The next strategy involved developing and implementing standardized protocols to identify and treat people at risk of suicide, as well as providing follow-up care and the support needed to continue treatment.

The latest strategy builds on previous ones and includes a federal action plan that envisages the implementation of 200 measures over the next three years, including prioritizing population disproportionately affected by suicide, such as black youth and Native American and Alaska Native peoples.

Despite these evolving strategies, suicide rates increased most years between 2001 and 2021, according to the Centers for Disease Control and Prevention. Preliminary data for 2022, the most recent figures available, show that deaths by suicide increased another 3% from the previous year. CDC officials expect the final number of suicides in 2022 to be higher.

Over the past two decades, suicide rates in rural states such as Alaska, Montana, North Dakota and Wyoming have been about twice as high as in urban areas, according to the CDC.

Despite these persistently disappointing figures, mental health experts say national strategies are not the problem. Instead, they argue, the measures are simply not being funded, adopted and used – for many reasons. This slow implementation has been exacerbated by the pandemic, which has had wide-ranging, negative impacts on mental health.

Many national experts and government officials agree that these strategies are simply not being widely adopted, but they also point out that even basic recording of deaths by suicide is not everywhere.

Surveillance data is often used to improve the quality of health care and has been shown to be helpful in treating cancer and heart disease, but it has not been used in research into behavioral health problems such as suicide, says Michael Schoenbaum, senior adviser for mental health services, epidemiology and economics at the National Institute of Mental Health.

“We simply think about treating behavioral health problems differently than we think about physical health problems,” Schoenbaum said.

Without accurate statistics, researchers cannot find out who dies most often by suicide, which prevention strategies work, and where money for prevention is most urgently needed.

Many states and territories do not allow medical records to be linked to death certificates, Schoenbaum said, but NIMH is working with a handful of other organizations to document that data for the first time in a public report and database that should be released by the end of the year.

The strategies are also hampered by fluctuating federal and state funding and by the fact that some suicide prevention efforts do not work in some states and localities due to difficult geographic locations, says Jane Pearson, special adviser to the NIMH director for suicide research.

Wyoming, whose several hundred thousand residents live scattered across a vast, rugged landscape, regularly ranks among the states with the highest suicide rates.

State authorities have been working for many years to get the state's suicide problem under control, says Kim Deti, a spokeswoman for the Wyoming Department of Health.

But deploying services such as mobile crisis units – a key element of the recent national strategy – is difficult in a large, sparsely populated state.

“The work doesn’t stop, but some strategies that make sense in some geographic areas of the country may not make sense for a state with our circumstances,” she said.

The lack of implementation is not just a problem for state and local governments. Although there is evidence that screening patients for suicidal thoughts during doctor visits can prevent disasters, health professionals are not required to do so.

Many doctors shy away from suicide recognition because they lack the time and training and because they don't feel comfortable talking about suicide, says Janet Lee, an adolescent medicine specialist and associate professor of pediatrics at Temple University's Lewis Katz School of Medicine.

“I find it really scary and kind of amazing to think that someone can't ask when it's a matter of life and death,” she said.

The use of other measures was also inconsistent. Crisis intervention services are a core part of national strategies, but many states have not established standardized systems.

Crisis systems such as mobile crisis units are not only fragmented, but can also vary from state to state and county to county. Some mobile crisis units use telehealth, others operate 24 hours a day, some 9 a.m. to 5 p.m., and still others use local police forces instead of mental health professionals to respond.

As well young 988 Suicide & Crisis Lifeline faces similar, serious problems.

Only 23% of Americans know the 988 number, and there is a significant knowledge gap regarding the situations in which to call 988, according to a recent survey conducted by the National Alliance on Mental Illness and Ipsos.

Most states, territories and tribes also have not yet permanently financed 988which was introduced nationwide in July 2022 and has received about $1.5 billion in federal funding, according to the Substance Abuse and Mental Health Services Administration.

Anita Everett, director of the Center for Mental Health Services within SAMHSA, said her agency is conducting an awareness campaign to promote the system.

Some states, including Colorado, are taking other steps. There, officials have created financial incentives for implementing suicide prevention and other patient safety measures through the state's Hospital Quality Incentive Payment Program. The program pays hospitals about $150 million annually for good performance. Last year, 66 hospitals improved their care for patients with suicidality, said Lena Heilmann, director of the Office of Suicide Prevention at the Colorado Department of Public Health and Environment.

Experts hope that other states will follow Colorado's example.

And despite the slow pace of development, Mehta sees bright spots in the latest strategy and action plan.

Although it is too late to save Raj, “it gives me hope when we address the social causes of mental illness and suicide and invest in spaces where people can get help long before a crisis occurs,” Mehta said.

Reporting by Cheryl Platzman Weinstock is supported by a grant from the National Institute for Health Care Management Foundation.

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