Suicides Decrease in 2020, However the Full Picture is Still Not Clear

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Suicides Decrease in 2020, However the Full Picture is Still Not Clear

Washington, D.C. (April 2, 2020) – Preliminary data in a report in The Journal of the American Medical Association (JAMA) shows that while there was a 17.7% increase in overall deaths in the US in 2020, there were 2677 fewer suicides (44,834) than those reported in 2019 (47,511). Due to the number of COVID-19 related deaths, suicide dropped to the 11th leading cause of death. It should be noted that this is an estimated total and not final national data as officially reported by the Centers for Disease Control and Prevention. These data follow reports in 2018 of an increase in suicide rates and 2019 with a smaller decrease in rates after nearly a decade of annual increases in the number of suicide deaths. Previous reports have shown increases in suicide deaths among all demographic groups as well, further illuminating the critical need to fund comprehensive suicide prevention initiatives in the US. After consulting with subject matter experts, the American Association of Suicidology would like to offer the following information.

What we know: 

• This is a very promising estimate. We hope that this is signaling a trend in lowered suicide deaths in the country and an indication that the efforts of suicide prevention initiatives are effective in lowering suicide rates at population scale.
• Some municipalities and locations are reporting higher numbers of suicides in 2020, which indicates that some vulnerable populations exist based on location, access to services, demographic subgroup, or other factors.

What we don’t know: 

• We don’t know for certain that specific suicide prevention efforts are lowering rates at a national level.
• We do not know if these numbers are, as we’ve seen in the past, a result of lowered suicide rates during a time of national crises.
• We do not know if some suicides are being masked by COVID deaths in 2020, meaning some of those 2677+ people who would have died by suicide, instead died by COVID or had COVID at the time of their suicide and were characterized as such by coroners/medical examiners.
• Overdose deaths also increased in 2020, and it is often hard to distinguish some overdoses from suicides, again possibly masking the true number.
• We often focus only on the total number of suicide deaths, however we have very poor mechanisms for capturing the true number of suicide attempts in this country. So while a lowered rate of suicides is a good signal, it doesn’t necessarily indicate a lowered level of despair in the country. In fact, many recent reports have shown higher levels of mental health issues, including anxiety, depression and suicide thoughts in certain demographics.
• We should be cautious in celebrating this decrease too early as the data points from 2019 and 2020 do not necessarily indicate a trend. We may see a delayed increase in suicides in 2021 or 2022 similar to what we witnessed following the financial collapse in 2008. 

Christopher W. Drapeau, PhD, HSPP, Licensed Psychologist and Adjunct Faculty Member in the Department of Health Policy and Management, IU Richard M. Fairbanks School of Public Health provided further explanation: 

“It is tempting to conclude that the decreases in suicide for 2019 and the provisional decreases for 2020 reflect our hard work as a field to reduce suicide but surface-level thinking about changes in mortality data can be deceptive. It has long been argued that medicolegal professionals (i.e., medical examiners and coroners) tend to set a higher evidentiary threshold for certifying suicide as a manner of death compared to other manners of death (i.e., natural, accidental, homicide, and undetermined). If this argument holds for most medicolegal professionals across the United States, then it could be argued further that an increase in suicide should be viewed as a more accurate approximation of reality than a decrease given the level of rigor that a confirmed suicide must meet to be certified as such.” 

“Additional reasons why it is wise to remain cautious in the wake of recent declines in suicide are due to evidence suggesting that: 

• suicides are misclassified as other manners of death and significant increases have been observed for unintentional/accidental deaths from 2015 to 2020 (which may be a landing place for misclassified suicides)
• suicides are undercounted in areas of the United States that rely on elected coroners for death investigations
• suicides are undercounted for specific demographic groups (i.e., Black Americans, Hispanic Americans, Women) and certain mechanisms of injury (e.g., poisoning/overdoses, drowning, singular motor vehicle fatalities, etc.) 
• surveys of Americans show that reports of suicide ideation and other risk factors for suicide have been elevated to a significant degree during the pandemic and evidence showing why deaths by suicide have decreased while risk factors have increased is lacking”

“If the above reasons could be ruled out as explanations for the reported decreases in suicide for 2019 and 2020, then that would provide greater confidence in the conclusion that these decreases are true decreases and that we are doing things across the country that may be moving us in the right direction as a field. The Suicidology listserv discussions over the past few days also show that there are other alternative explanations to test before final conclusions are drawn about the 2019 and 2020 suicide mortality data.” 

“It also may be helpful to consider that the morality data, first and foremost, represent the opinion of medicolegal professionals whenever we seek to draw conclusions about changes in mortality data over time.  When noticing changes in the mortality data in general (not just suicide), it seems important to first consider whether the practices of medicolegal professionals have changed and if deaths of ambiguous intent have become more prevalent compared to past years. One question in particular that could be explored more thoroughly in the field of suicidology is: How does medicolegal professional understanding of suicide research and/or assumptions about who does and does not die by suicide influence death certifications? (especially when it comes to classifying manner of death across racial and ethnic groups, when deaths are attributed to poisoning, and/or when circumstantial evidence is minimal).”    

“Finally, an argument could be made that we focus too much on mortality data as a barometer of our efforts and that there may be value in focusing more on “risk” data (e.g., suicide ideation) and examining how truly upstream efforts impact the year-to-year surveillance data on suicide-related thoughts and behaviors.  Thinking big picture, is the purpose of our work to stop suicides from happening (which may compel us to pay more attention to suicide mortality data) or to empower people to the point where suicide becomes irrelevant to them?  And if the purpose of suicide prevention is the latter, does mortality data allow us to measure that well?”  

There is only speculation as to why suicide rates have fallen in the US. It remains important for the media, suicide prevention, and mental health organizations to communicate to the public that any single explanation for why individuals attempt or die by suicide is insufficient. In fact, it could be detrimental to imply that we can explain its causes without direct scientific evidence to support such claims. Conversely, this means that no single approach to solving the problem of suicide is sufficient, but rather a multidisciplinary, multi-sector strategy is necessary.

Systems for gathering data about suicide deaths, attempts, and ongoing suicidal experiences are significantly underdeveloped and undersupported. The US must establish better epidemiology around suicide, as well as develop innovative methods for collecting data at scale so our best researchers can help us understand what is happening. This specifically includes funding for suicide prevention at the scale of the problem, nationally, regionally, and locally. If we continue to fund suicide prevention research in a piecemeal way, we will never understand its causes or effectively support its prevention at scale. Recent increases in funding for the CDC and NIH are an excellent start but do not reflect the size and scope of the public health crisis. 

“We have evidence showing the positive impact of crisis lines, training of healthcare professionals, and maintained contact with people experiencing thoughts of suicide have on decreasing suicide rates, but we need to start increasing our attention and focus on, access to lethal means. ” said Colleen Creighton, CEO of AAS. “By putting space and time between someone experiencing thoughts of suicide and their method, namely firearms, we greatly increase their chances of survival. We see very promising research surrounding firearms safety legislation and its potential to reduce suicide rates at population levels.” 

In the US, there is no national requirement for crisis response training among healthcare professionals despite suicide being the 10th leading cause of death. No national standard suicide risk assessment or standardized requirement for suicide care yet exists in the private healthcare system. It is left to individual health systems to make suicide-safer care a priority. Few regulatory bodies are currently invested in the research that would make such standards of care mandatory for every patient or client. Given the scope of the public health crisis of suicide, training and regulatory bodies have much room to improve the systems of care and ensure providers are ready to help someone at risk of suicide.

For the Media: Responsible reporting on suicide, including stories of hope and resilience, can prevent more suicides. Please visit the Suicide Reporting Recommendations for more information.

About AAS: The American Association of Suicidology is the world’s largest membership-based suicide prevention organization. Founded in 1968 by Edwin S. Shneidman, PhD, AAS promotes the research of suicide and its prevention, public awareness programs, public education and training for professionals and volunteers. The membership of AAS includes mental health and public health professionals, researchers, suicide prevention and crisis intervention centers, school districts, crisis center volunteers, survivors of suicide loss, attempt survivors, and a variety of laypersons who have in interest in suicide prevention. You can learn more about AAS at www.suicidology.org.

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