UPDATED WITH ADDITIONAL COMMENTS June 8, 2018 // Suicide rates continue to rise dramatically for adults in the United States, according to a report by the US Centers for Disease Control and Prevention (CDC) released today.

Between 1999 and 2016, the time of the latest estimates, half of the states saw at least a 30% increase in suicide rates. And all states except Nevada increased by at least 6%. Overall, there were almost 45,000 total deaths by suicide in 2016 alone.

"And, unfortunately, our data show that the problem is getting worse," Anne Schuchat, MD, principal deputy director of the CDC, said at a press briefing.

Suicide rates from 1999 to 2016 increased in all age groups younger that 75 years, with the greatest increase shown in "middle-aged adults" aged 45 to 64 years.

In addition, among individuals with no known mental health conditions who died by suicide, 84% were men and 16% were women. Firearms were the number one cause of death, followed by hanging and then poisoning ― including through the use of opioids.

These new statistics were published online June 8 in the Morbidity and Mortality Weekly Report (MMWR).

"Suicide is a leading cause of death for Americans ― and it's a tragedy for families and communities across the country. Health and behavioral healthcare providers have an important role to play in suicide prevention so that nobody falls through the cracks," said Schuchat.

"Suicide is something we've learned is preventable, and there are several evidence-based strategies that can help. That's our key message here," she told Medscape Medical News.

President of the American Psychiatric Association (APA) Altha Stewart, MD, agreed, noting in a statement from the organization that suicide "is a critical issue" for all clinicians.

"The CDC's report highlights the need for access to mental healthcare," added Stewart. "Anyone contemplating suicide should know that help is available and that there is no shame in seeking care for your mental health."

Early Warning Signs

Earlier in the day, former President of the APA Jeffrey Lieberman, MD, chair of psychiatry at Columbia University's College of Physicians and Surgeons, New York City, talked with CBS This Morning about warning signs of suicide in light of the apparent suicide by designer Kate Spade earlier this week.

"It's hard to believe [in Spade's case] that there were not some indications that she was at risk," said Lieberman.

"Suicide does not just happen out of the blue. About 90% of the people who commit suicide have a preexisting psychiatric condition," he added.

However, the new MMWR report states that 54% of individuals who died by suicide in 27 states in 2015 had not received a clinical diagnosis of a mental illness at time of death.

"Many factors contribute to suicide among those with and without known mental health conditions," write the researchers. They cite relationship, health, housing, job, and legal problems; substance abuse; and experiencing a crisis in the past or in the upcoming 2 weeks, among other factors.

The report also notes, though, that it's "possible that mental health conditions or other circumstances could have been present and not diagnosed, known, or reported."

"Our research suggests that suicide is more than a mental health issue. We know we need improved access to treatment for mental health conditions and better recognition and diagnostics, because there are still stigmas and reasons why people don't present for care," said Schuchat. "But we believe that a comprehensive approach is what is needed to make sure we can prevent suicides and identify concerns earlier.

"I think it's possible that we have some underrecognition of mental health conditions in our data, both because conditions haven't been formally diagnosed and because those left behind might not have been aware of the diagnosis," she added.

"But I think a very important point is that if we only look at the mental health issue, we won't make the proper steps we need. We feel that communities, families, faith-based institutions can really play a role, as can state and local health departments and the healthcare profession."

When asked, Schuchat told Medscape Medical News that she isn't saying that mental illness isn't a risk factor for suicide, only that other things also play a role.

"Among those with mental health conditions, preceding factors such as relationship stressors and imminent crisis were common," she said. "And we think those preceding factors can be a reminder for us to reach out when we know somebody is going to be going through something. Those are the times to really support each other and help those who aren't coping well to get the help they need."

Continuing Problem

Asked for comment, Maria A. Oquendo, MD, PhD, professor and chair of psychiatry at the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia, who is also a past president of the APA, noted that the data in the new report aren't surprising.

"I hate to tell you this but, unfortunately, it's a continuation of what's been going on now for several years," Oquendo told Medscape Medical News.

"Since 1999, the suicide rates have been going up. The reasons are likely to be very complex and multifaceted, but it's a very disturbing situation, especially the CDC's finding on firearms. And the situation with opioids isn't helping either," she said.

Oquendo noted that the 90% rate quoted earlier by Lieberman is well known and that a mood disorder is the most common mental health condition in those who die by suicide, "but the other psychiatric conditions are also associated with suicide rates."

She reported that the 90% rate was based on diagnoses "gleaned from psychological autopsy studies," as well as a review of medical records and talks with treating physicians and family members. "And there are pretty robust data that, yes, they did have a preexisting psychiatric condition," said Oquendo.

"A lot of people, including physicians, often don't realize that some of this is quite familial. There is a very strong heritability, likely due mostly to genetic factors, although there are other factors, too," she added.

State vs State

For the CDC report, researchers analyzed data from the National Vital Statistics Systems to identify trends for suicide in all 50 states and Washington, DC. They also assessed data from the CDC's National Violent Death reporting system, which includes information for 27 states in the year 2015.

The investigators found that in 2016, there were 15.6 per 100,000 suicides in the United States among individuals at least 10 years of age or older.

Although the suicide rate was higher for men, both sexes and all racial and ethnic groups saw increased suicide rates between 1999 and 2016.

The age group with the highest suicide rate increase comprised those who were aged 45 to 64 years (1999, 13.2/100,000 persons; 2016, 19.2/100,000 persons). There were also a total of 232,108 suicides among the age group during this period.

"This is an important age group in terms of the national statitistics, and we're seeing that middle-aged adults have higher rates of drug overdose and the 'depths of despair' that are emerging," said Schuchat.

"Increases in suicide tend to correlate with economic downturns, and some of those downturns may have left some people in this age group really hard hit. But there were probably many factors that fed into this finding," she added.

From 2014 to 2016, Montana had the highest overall suicide rate (29.2/100,000 persons per year); Washington, DC, had a rate of only 6.9/100,000 persons per year.

During the entire study period, the smallest increase in suicide rate was in Delaware, and the highest rate was in North Dakota. Although Nevada was the only state to show a decrease in suicide rate (by 1%), the rate itself remained relatively high.

Nevada "actually has the ninth highest rate in the country. We believe that, like the rest of the states, they have an ongoing challenge with suicide prevention," said Schuchat.

"Comprehensive" Interventions Needed

Schuchat noted that it's important for states and communities to develop comprehensive approaches for suicide prevention. She cited the US Air Force Suicide Prevention Program as one example of a successful strategy.

"This program, which include 11 policy and education initiatives designed to increase social support, social skills, and help seeking, shifted the culture of the Air Force away from viewing suicide as an individual-oriented concern to a larger, service-wide problem that impacts the whole community," she said.

"After the program began, the Air Force saw a 33% reduction in suicide, as well as reductions in other related problems," Schuchat reported.

"By increasing awareness of the range of circumstances contributing to suicide risk and acting to address them during a comprehensive approach, we could reach our national goal of reducing the annual suicide rate by 20% by 2025."

However, she noted that there is a lot that needs to be done before that goal is achieved, including "supporting initiatives from local, territorial, state, tribal, and other partners."

In addition, the CDC has created a "technical package" of suicide prevention strategies, including some for stopping risks for suicide before they even start, as well as for helping individuals who have had a prior suicide attempt.

Importance of Talking

During a question-and-answer session during the press briefing, Schuchat was asked about suicide rates specifically among opioid users. She said that in the report, "physical health problems were present in about one fifth of the individuals, those were circumstances considered to be leading up to the suicide. [The report] didn't differentiate pain from other conditions in a person's actions, however."

Asked what healthcare providers, in particular, should look for in terms of warning signs for suicide, Schuchat said that there should be an awareness of "transitions," such as civilian patients moving between healthcare systems or military personnel moving to out-of-military care.

"We think that high-quality, ongoing care focused on patient safety and suicide prevention is important for health systems to build into their approaches, as is training providers in adopting proven treatments for patients at risk," she added.

"It's not a big part of a primary care physician's training, but there are things to look for to make sure the patient gets the care they need."

To that end, Oquendo noted that behaviors that might "tip off" a clinician that something is wrong include a patient's giving away belongings or having difficulties with sleep.

"People who are struggling with suicidal ideation often feel very isolated and feel like there's nobody they can talk to about it. So it's usually a relief if someone starts making conversation with them," she said.

"This is why screening can be so helpful in reducing suicidal behavior. Clinicians just asking about it, regardless if there are risk factors, often uncovers people who are at risk," she said.

On the other hand, clinicians "have a tremendous amount of pressure on their time," Oquendo noted. "So it's a tricky situation. But helping clinicians find support or interventions when they discover that someone is suicidal is really important."

Saul Levin, MD, CEO, and medical director of the APA, said in the organization's statement that the CDC's report "reinforces the need to fund and enforce laws ensuring access to mental health services.

"Congress has recently passed laws aimed at expanding the psychiatric workforce in the United States and requiring that insurance companies provide equal coverage for mental health as well as physic health, such as diabetes and heart disease, but implementation and enforcement of these laws are needed," said Levin.

"Early identification of mental illness is essential, and we are ready to work with Congress and other stakeholders to ensure that Americans can receive treatment when needed," he added.

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