One of my biggest frustrations in working with the field of suicide prevention is the regular dust-ups between researchers and advocates about the percentages of people who complete suicide that have a diagnosable mental health condition. That conversation then goes to whether interpersonal crises are a more important factor than mental health.
The latest analysis of this issue is Fowler, K. A., Kaplan, M. S., Stone, D. M., Zhou, H., Stevens, M. R., & Simon, T. R. (2022). Suicide Among Males Across the Lifespan: An Analysis of Differences by Known Mental Health Status. American Journal of Preventive Medicine.
The article itself does not really break new ground. It finds that 60% of male suicide decedents from 2016-2018 did not have a known mental health condition as reported by the Centers for Disease Control and Prevention’s National Violent Death Reporting System (NVDRS) variable “diagnosed mental health problem.” It then delves into the recent/impending crises that these people faced.
As others have before, the authors state it is really hard to determine whether someone had the standard symptoms that would justify a mental health diagnosis after their suicide if they have not previously accessed mental health care. The authors also describe how it was more likely that suicidal decedents would not have a diagnosed mental health condition if they were minorities, had lower education levels, and lived in rural areas. The authors rightfully point out that the lack of mental health diagnoses in these populations may mostly signal “potential disparities in identifying suicide risk in these populations and in accessing/delivering mental health care/supportive services.”
This doesn’t even go into the legitimate weaknesses in the mental illness diagnostic system’s categories of symptoms and whether those categories are the best way of determining whether someone needs mental health care. That’s a precision mental health research challenge that hopefully will eventually solve this debate once and for all.
But until then, my biggest frustration with this article is that the suicide prevention research community does have a better way of thinking about suicide data like this that has both marks of mental health conditions and interpersonal crisis – the diathesis-stress model.
Wilcox (2019, p. 212) offers an in-depth explanation:
In this model, diathesis describes the development of risk, defined by conditions that create an enduring vulnerability to be suicidal. Stress refers to triggering environmental (and contextual) factors that promote acute risk and the breakdown of protective factors among those already vulnerable. The development of suicidal behavior is the result of an interaction between stressors and a susceptibility to suicidal behavior (diathesis). A typical stressor includes the acute worsening of a psychiatric condition, but often an acute psychosocial crisis seems to be the most proximate stressor or ‘the straw that broke the camel’s back’ leading to suicidal behavior.
Pessimism and aggression/impulsivity are components of the diathesis for suicidal behavior. Sex, religion, familial/genetic factors, childhood experiences, and various other factors influence the diathesis stress model. The model posits that suicide is the result of an interaction between state dependent (environmental) stressors a trait-like diathesis or susceptibility to suicide behavior, independent of psychiatric disorder. Stressors, such as life events and psychiatric disorders, are important risk factors for suicide, but the diathesis concept explains why only a few of these individuals exposed to these stressors will take their own life. Early-life adversity and epigenetic mechanisms seem to be related to causal mechanism for diathesis.
Beyond that, there is even a systematic review of research-proven suicide prevention practices by Mann (2021) that has a graphic (below) that factors in these combined criteria and then lays out pathways to pursue research-proven interventions and for areas to target for more research.
The people at risk of suicide and their families need suicide prevention researchers and advocates to get past this hackneyed question of whether mental health diagnoses or interpersonal crises matter more, to focus on a model that includes multiple factors and relatively clear directions for research-proven interventions.
Citations:
Fowler, K. A., Kaplan, M. S., Stone, D. M., Zhou, H., Stevens, M. R., & Simon, T. R. (2022). Suicide Among Males Across the Lifespan: An Analysis of Differences by Known Mental Health Status. American Journal of Preventive Medicine.
Mann, J. J., Michel, C. A., & Auerbach, R. P. (2021). Improving suicide prevention through evidence-based strategies: a systematic review. American Journal of Psychiatry, 178(7), 611-624.
Wilcox, H. C., Clarke, D., Grzenda, A., Smith, S. G., & Eaton, W. W. (2019). Suicide as a public health burden. In W. W. Eaton & M. D. Fallin (Eds.), Public mental health (pp. 207–222). New York, NY: Oxford University Press. doi: 10.1093/oso/9780190916602.001.0001
