Since graduate school in the 1980s, I have been dedicated to the field of suicide prevention. I have worked as a clinician, theoretician, and active clinical researcher in the assessment and treatment of suicide risk. Over 40 years of working in this field, I have endeavored to navigate the choppy sea of working to decrease suicide-related suffering.

Needless to say, I was recently sobered by the new provisional 2022 data coming from the Centers for Disease Control and Prevention, with the United States having the highest number of suicides in our nation’s history—49,449 deaths (final CDC data for 2022 will be reported early in 2024). Like other colleagues in suicidology, I am discouraged by these provisional data but not deterred. Despite these discouraging data, I nevertheless would contend that the field of suicidology has realized a meaningful tipping point in general public awareness, media focus, funding for research and prevention, markedly better science, and ever-wider use of suicide-focused clinical practices that are supported by rigorous randomized controlled trials (RCTs). While these developments in the field are encouraging, I have nevertheless become preoccupied with a sense that we are missing a big-picture issue that needs much more focus and attention.

Serious thoughts of suicide
Purely from a population perspective, the biggest challenge we face in the field of suicide prevention is the massive number of people in the world who suffer from suicidal ideation, which I argue in an editorial with my colleague Dr. Thomas Joiner. According to a Substance Abuse and Mental Health Services Administration annual survey (SAMHSA, 2022), 15,600,000 American adults and teens in 2021 (the most recent year) reported having “serious thoughts of suicide” in the 30 days prior to being queried by the SAMHSA survey. This finding utterly dwarfs those who report making a suicide attempt and this population is well over 300 times greater than the number of those Americans who died by suicide in 2021. Identifying and meaningfully helping those with serious thoughts of suicide “upstream” could perhaps lead to fewer suicide attempts and suicides “downstream.” Moreover, while completed suicides actually dipped in 2019 and 2020—only to increase again in 2021 and apparently 2022—serious thoughts of suicide among American adults and teenagers only steadily continued to increase since these data have been surveyed.

There are significant clinical implications to this big-picture problem. For example, there is a meta-analysis of widely used Safety Planning-Type interventions (a plan of what a patient should do if they become suicidal) that showed that they do appear to decrease suicide attempts, but do not reliably decrease suicidal ideation (Nuij and colleagues, 2021). A handful of suicide-specific clinical treatments such as dialectical behavior therapy, cognitive therapy for suicide prevention, and brief cognitive behavioral therapy reliably decrease suicide attempts in replicated RCTs, but do not necessarily impact suicidal ideation (Jobes, 2023). However, other interventions such as collaborative assessment and management and attachment-based family therapy do reliably reduce suicidal ideation but not necessarily suicidal behaviors (although there is mixed and some preliminary support for collaborative assessment and management reducing suicide attempts and self-harm in a couple of studies).

There is no one-size-fits-all approach
The point is that we have an apparent bifurcation of differential impacts of suicide-focused treatments—some reduce suicidal behavior while others reduce suicidal ideation. Based on this consideration, we cannot take a one-size-fits-all approach to clinical suicidology (Jobes and Chalker, 2019). Indeed, with 15.6M Americans struggling with serious thoughts of suicide and an apparent record peak of suicide deaths in 2022, we need everything that clinical science can bring to bear on this major public and mental health issue. The good news: We believe our clinical trial research data has now evolved to a point where clinicians can broadly benefit from common factors of effective care that cut across proven treatment—for both suicidal behavior and ideation—so that we may now be poised to better decrease suicide-related suffering in all its forms (Rudd and colleagues, 2022). In the daunting yet compelling field of clinical suicide prevention, we need everything we can bring to bear to change suicidal behaviors and suicidal ideation.