• Can we prevent suicides?

    There were 41,149 suicides in 2013, about 2.5 times the number of homicides. Suicide is the second leading cause of death among persons aged 15-34 years, and the risk may be increasing. Since 9/11 we have made a trillion dollar effort to prevent deaths from terrorism, a subtype of homicide. This expenditure is orders of magnitude more than we spend trying to prevent suicide. This disparity seems hard to justify.

    However, it isn’t worth spending anything on suicide prevention if it doesn’t work. My sense is that many people believe that there is nothing we can do. But there is encouraging research suggesting that we can reduce the number of suicides.

    In the American Journal of Public Health Christine Walrath and her colleagues report encouraging results about the Garrett Lee Smith (GLS) Memorial Suicide Prevention program, a US government initiative targeting youth suicide.

    OBJECTIVES: We examined whether a reduction in youth suicide mortality occurred between 2007 and 2010 that could reasonably be attributed to [GLS] program efforts.

    METHODS: We compared youth mortality rates across time between counties that implemented GLS-funded gatekeeper training sessions (the most frequently implemented suicide prevention strategy among grantees) and a set of matched counties in which no GLS-funded training occurred. A rich set of background characteristics, including preintervention mortality rates, was accounted for with a combination of propensity score-based techniques…

    RESULTS: Counties implementing GLS training had significantly lower suicide rates among the population aged 10 to 24 years the year after GLS training than similar counties that did not implement GLS training (1.33 fewer deaths per 100 000; P = .02). Simultaneously, we found no significant difference in terms of adult suicide mortality rates or nonsuicide youth mortality the year after the implementation.

    How many lives did GLS save?

    these results suggest that approximately 427 deaths were avoided between 2007 and 2010 after GLS program implementation.

    In JAMA Psychiatry, the same authors reported that the GLS counties also had a lower rate of suicide attempts.

    DESIGN, SETTING, AND PARTICIPANTS We conducted an observational study of community-based suicide prevention programs for youths across 46 states and 12 tribal communities. The study compared 466 counties implementing the GLS program between 2006 and 2009 with 1161 counties that shared key preintervention characteristics but were not exposed to the GLS program. The unweighted rounded numbers of respondents used in this analysis were 84 000 in the control group and 57 000 in the intervention group…

    RESULTS Counties implementing GLS program activities had significantly lower suicide attempt rates among youths 16 to 23 years of age in the year following implementation of the GLS program than did similar counties that did not implement GLS program activities (4.9 fewer attempts per 1000 youths [95%CI, 1.8-8.0 fewer attempts per 1000 youths]; P = .003). More than 79 000 suicide attempts may have been averted during the period studied following implementation of the GLS program. There was no significant difference in suicide attempt rates among individuals older than 23 years during that same period.

    Moreover,

    we also found that the positive effects of the GLS program on suicide attempt rates were not sustained 1 year after implementation of the program activities.

    That is, if you stop doing the program, the preventive effect goes away, as you would expect if the GLS program is the actual cause of the reduction in suicide attempts.

    Unfortunately, these results were not based on a randomized design, and the authors explain what this means.

    causal claims outside the context of the ideal randomized experiment are intrinsically more tentative. In particular, despite the use of an extensive set of covariates, as well as the analysis of control outcomes, there could be unaccounted differences between intervention and control counties that are influencing the results. For example, it is plausible that the location and timing of implementation may have been influenced by the level of readiness of the local child-servingagencies and administrative entities to participate in the GLS program. In such scenarios, the estimated effect may overstate the potential effect of implementation.

    The GLS program is currently up for Congressional reauthorization. Should we do it?

    Yes. The program appears to cost about $45 million dollars a year. Let’s assume that the estimated number of lives saved reported above is roughly accurate. If GLS saves 100 young lives per year at the current scale of implementation, that would be a cost of $450,000 per life saved. This is well below the values of saving a life used in standard cost-effectiveness analyses, which are in millions of dollars, and it neglects the enormous value of preventing about 20,000 suicide attempts a year. So GLS is likely cost-effective, even if the effectiveness of the program is actually substantially smaller than the estimates reported above.

    So we can do something to prevent youth suicide and we should. One hundred lives a year seems tiny compared to the tens of thousands of annual suicides. Perhaps that is why people believe that suicide prevention is futile. But that is the wrong way to think about the problem. Lives are worth saving, whether they are saved in large increments or small ones.

    Having said that, I regret that the first implementation of the GLS program did not use a stronger empirical design. Counties applying for GLS funding could have been randomized to an immediate implementation versus waiting list control condition. If this had been done, we would have more reliable estimates of the numbers of lives saved by the program, and less doubt about whether this is worth doing.

    @Bill_Gardner

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