CHPR: Please tell us what led to your interest in researching suicide prevention strategies. 

Dr. Mann: I got into the field by collecting brain samples from people who died by suicide, thinking this was a way to study the biology of depression. I wasn’t very long into this approach when I realized that only about half the people suffered from a major depressive episode and the rest suffered from a whole variety of different psychiatric disorders. I gradually evolved into looking at genetic, social, and environmental risk factors for suicide as well as suicide prevention approaches. In 2005, I became involved with the American Foundation for Suicide Prevention and became interested in what worked for suicide prevention. That led to writing a paper that appeared in JAMA on suicide prevention (Mann JJ et al, JAMA 2005;294(16):2064–2074). 

CHPR: I understand it’s the most highly cited paper in this field, and you followed it up with another paper where you review evidence-based strategies to improve suicide prevention (Mann JJ et al, Am J Psychiatry 2021;178(7):611–624). What were the most effective interventions?

Dr. Mann: At the top of the list is educating PCPs on how to diagnose and treat major depression. Most patients who die by suicide have seen a PCP within the past 12 months—twice as many as have seen a psychiatrist (Luoma JB et al, Am J Psychiatry 2002;159(6):909–916). To paraphrase the great hockey player Wayne Gretzky, “Skate to where the puck is going, not where it is.” So, primary care is where the patients are going. We need to educate those doctors. Training PCPs, with supplemental support from psychiatrists, reduces suicide rates (Szanto K et al, Arch Gen Psychiatry 2007;64(8):914–920).

CHPR: Have you encountered any challenges to implementing this training? 

Dr. Mann: Unfortunately, we do not have a system for deploying this kind of educational programming throughout the country. One of the frustrating things about the US health care system is that it’s very difficult for the federal government or for the administration of the Department of Health and Human Services to do anything top-down. But there have been programs targeted at doctors across all specialties to teach them better practices for use of opioids that could be extended to depression diagnosis and treatment. 

CHPR: Besides educating PCPs, what other approaches help reduce suicide attempts?

Dr. Mann: Educational programs aimed at schoolkids are also effective in reducing suicidal behavior. Studies have compared the effectiveness of preventive interventions directed at teachers, social workers, school psychologists, parents, and kids, and the most effective approach is to educate the kids (Wasserman D et al, Lancet 2015;385(9977):1536–1544).

CHPR: Please elaborate.

Dr. Mann: So, studies have looked at about a thousand counties throughout the US that got the educational programs for kids and about a thousand demographically, sociologically matched counties that did not. Sure enough, the suicide rate among adolescents was significantly lower in the counties that got the education programs, and if the education was extended for a year or two, or longer, you got even better results (Godoy Garraza L et al, J Child Psychol Psychiatry 2019;60(10):1142–1147). But then if you gave them no further education for two years, all the gains were lost. 

CHPR: It’s encouraging to know that educating youth can have a big impact on reducing youth suicide, at least if the educational programs are ongoing. What topics do these classes cover? 

Dr. Mann: The content isn’t specifically about suicidal behavior; it’s also about destigmatization by providing information about psychiatric disorders, like anxiety disorders, mood disorders, eating disorders, substance use disorders, maybe social anxiety—these are the things that really are troublesome for kids—and telling them they are treatable conditions. This kind of educational programming can’t be too complicated; it must allow time for kids to speak and ask questions, and it can’t take too much time because schools don’t offer much time for this type of education.

CHPR: Do you have any tips for how we can incorporate this education when we work with kids in adolescent psych units? 

Dr. Mann: A similar approach—of providing education, telling kids their conditions are treatable—is likely to help kids when they present to psychiatric services at any level. And of course, they should be screened for suicide risk. If such risk is detected, then it should be addressed, but that treatment should be accompanied by safety training and then regular follow-up contact.

CHPR: Another intervention you mention in your paper is means restriction. Please say more about this.

Dr. Mann: Means restriction determines the most commonly used methods for suicide and the methods with the lowest chance of survival, then prioritizes making access to those two types of methods as difficult as possible. In the US, the most popular and most lethal method of suicide involves use of a firearm. Half of all suicides in the US involve firearms (Anglemyer A et al, Ann Intern Med 2014;160(2):101–1010). We throw our hands up because means restriction almost certainly means restricting firearms, but the country is flooded with firearms so that’s a very big challenge. Regulating firearm availability works in every country that’s tried it properly, although even in the US we have put a slight dent in firearm deaths in some states where there are stricter measures. What we can all agree upon is that storing guns more safely will save a lot of lives. I make sure to educate patients about this point (Editor’s note: The American Academy of Pediatrics has a helpful video series on counseling patients and families about gun safety; see https://www.aap.org/en/patient-care/gun-safety-and-injury-prevention). 

CHPR: Is there anything else we should know about means restriction?

Dr. Mann: Yes—bridges are important. The Golden Gate Bridge in San Francisco has had more suicides than any other bridge in the country, nearly 2,000 suicides since it was erected. There was great resistance to building a barrier on the pedestrian walkway for aesthetic and engineering reasons that reflected a failure to appreciate how many lives such a barrier could save. Fortunately, an anti-suicide net was finally installed in January 2024. 

CHPR: Might that be from a belief that a person bent on suicide would go to another bridge or try another means?

Dr. Mann: People claim this, but the data show it isn’t true. If you have a river with two bridges and people jump off one and you put barriers on that one, they don’t automatically go to the bridge a quarter of a mile down the same river and start jumping off that. Method substitution is a greatly exaggerated problem. Many people will abandon their suicide attempt if the method of their choice proves to be unavailable, rather than switching to another method.

CHPR: That’s interesting. And a third strategy you mention in your paper is very relevant to us here in hospital settings: predischarge education and follow-up outreach. 

Dr. Mann: Right—we found a nearly 50% benefit in terms of reduction of suicidal behavior with these outreach programs (Comtois KA et al, JAMA Psychiatry 2019;76(5):474–483). You start them when the person presents in a suicidal crisis, either in the ED or an inpatient unit. We know the biggest risk period for suicide is the first month after discharge, and then it declines over the course of the first year after discharge. Now, a person who survives a suicide attempt has an 80% chance of never dying by suicide. But of those 20% who do die by suicide, 80% of them are going to die within that first year. So, you want to put your big push on prevention in the first year because if they get through the first year alive, the chances of dying by suicide are much lower after that.

CHPR: What does the outreach consist of?

Dr. Mann: The outreach can be as little as sending postcards or making phone calls. Call patients one week, two weeks, three weeks, four weeks after discharge and just ask “How’re you doing?” And then call them in six months and again in 12 months. Or send emails or texts, something like “How are you? Hoping everything is okay. Contact us if you need us.” Any staff member can do this outreach.

CHPR: Besides outreach, you mention predischarge education is important. Please say more about this. 

Dr. Mann: While the patient is in the ED or the hospital, it’s a good chance to give them and the family some education. You review warning signs for suicide, talk about treatment options, and discuss safety planning steps, like locking up guns. An interesting thing happened during the COVID-19 pandemic: The suicide rate dropped (Curtin SC et al, NVSS-Vital Statistics Rapid Release 2021;16:1–13). That was surprising, but it could well have been from the public educational efforts telling people to get help. Everybody was saying “It’s okay if you have a mental health problem.” The message was everywhere—churches, synagogues, employment, all over the TV, electronic media everywhere. And there was a big uptick in help-seeking.

CHPR: That goes to show the importance of public messaging and education. I’d like to ask you about my experience with two patients who died by suicide. In both cases, in my last appointment with them, they seemed relaxed and stable. Both patients had struggled with anxiety and depression, and they seemed to be doing better than they had in years, and then they ended their lives. Have you encountered cases like these? 

Dr. Mann: Most patients welcome the opportunity to be forthcoming. They want help. But every now and then you’re going to have patients who decide the moment has come and they’re going to kill themselves and they feel they’re finally going to have relief, and yes, they actually look better. If you ask them, they answer “no” to suicidal ideation. They don’t want to be deflected from their goal. All we can do is ask about suicidal thoughts regularly, treat their depression, and try to get them as well as ­possible. 

CHPR: I remember a study that found antidepressants can help reduce suicidal feelings even among patients who are otherwise not improving and remain depressed (Dunlop BW et al, Psychol Med 2019;49(11):1869–1878; CHPR Jul/Aug/Sep 2022). So, it’s encouraging that some antidepressants—escitalopram and duloxetine were used in this particular study—may have antisuicide effects. 

Dr. Mann: Right.

CHPR: And moving on to another challenging problem: Sometimes patients on our inpatient unit will tell us they’re thinking of suicide when they are actually malingering. Do you have any recommendations for how to work with these individuals?

Dr. Mann: It’s a very difficult problem. We’ve seen a similar problem in the research sphere. People make a living as professional research subjects. We see people who are healthy volunteers in one study who then appear in another study for depression or suicidal behavior or social phobia or some other thing. They even go in double-blind clinical controlled trials, but they don’t take the meds. But to answer your question about malingering, you look for certain things. They might say they feel suicidal, but they’re eating and sleeping well, seem to have plenty of energy, and chat with other patients in an animated and cheerful manner. It’s tricky, and there’s no easy answer.

CHPR: Before we end, please say something about safety planning cards. 

Dr. Mann: Sure. Suicidal crises are often quite fleeting, and that’s why a safety planning approach is so useful. Safety cards are a great tool. You work with the patient to identify steps they can take when they are in crisis, and they write them down on a card. They can list coping strategies that might help them, like going for a walk or listening to music. They can write down addresses and hours of operation for places they can go that might distract them, like a park or coffee shop. They can include phone numbers of friends, professionals, and hotlines they can reach out to. You educate them to pull out their safety card and focus on following the steps on the card. As they work their way through that list, the power of the suicidal ideation may diminish. That may save their lives (Editor’s note: See a sample safety planning card at www.thecarlatreport.com/safetycard).

CHPR: Thank you for your time, Dr. Mann.