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Mental Health by the Numbers:
Prevalence of Mental Illness
Approximately 1 in 5 adults in the U.S.—43.7 million, or 18.6%—experiences mental illness in a given year.1
Approximately 1 in 25 adults in the U.S.—13.6 million, or 4.1%—experiences a serious mental illness in a given year that substantially interferes with or limits one or more major life activities.2
Approximately 1 in 5 youth aged 13–18 (21.4%) experiences a severe mental disorder in a given year. For children aged 8–15, the estimate is 13%.3
1.1% of adults in the U.S. live with schizophrenia.4
2.6% of adults in the U.S. live with bipolar disorder.5
6.9% of adults in the U.S.—16 million—had at least one major depressive episode in the past year.6
18.1% of adults in the U.S. experienced an anxiety disorder such as posttraumatic stress disorder, obsessive-compulsive disorder and specific phobias.7
Among the 20.7 million adults in the U.S. who experienced a substance use disorder, 40.7%—8.4 million adults—had a co-occurring mental illness.8
Social Stats
An estimated 26% of homeless adults staying in shelters live with serious mental illness and an estimated 46% live with severe mental illness and/or substance use disorders.9
Approximately 20% of state prisoners and 21% of local jail prisoners have “a recent history” of a mental health condition.10
70% of youth in juvenile justice systems have at least one mental health condition and at least 20% live with a serious mental illness.11
Only 41% of adults in the U.S. with a mental health condition received mental health services in the past year. Among adults with a serious mental illness, 62.9% received mental health services in the past year.8
Just over half (50.6%) of children aged 8-15 received mental health services in the previous year.12
African Americans and Hispanic Americans used mental health services at about one-half the rate of Caucasian
Americans in the past year and Asian Americans at about one-third the rate.13
Half of all chronic mental illness begins by age 14; three-quarters by age 24. Despite effective treatment, there are long delays—sometimes decades—between the first appearance of symptoms and when people get help.14
Consequences of Lack of Treatment
Serious mental illness costs America $193.2 billion in lost earnings per year.15
Mood disorders, including major depression, dysthymic disorder and bipolar disorder, are the third most common cause of hospitalization in the U.S. for both youth and adults aged 18–44.16
Individuals living with serious mental illness face an increased risk of having chronic medical conditions.17
Adults in the U.S. living with serious mental illness die on average 25 years earlier than others, largely due to treatable medical conditions.18
Over one-third (37%) of students with a mental health condition age 14­–21 and older who are served by special education drop out—the highest dropout rate of any disability group.19
Suicide is the 10th leading cause of death in the U.S.,20
the 3rd leading cause of death for people aged 10–2421 and the 2nd leading cause of death for people aged 15–24.22
More than 90% of children who die by suicide have a mental health condition.23
Each day an estimated 18-22 veterans die by suicide.24

Bipolar disorder is a clinically challenging condition. In addition to the multiple mood states that patients can experience, the illness is frequently associated with multiple comorbid medical and psychiatric conditions. Bipolar disorder can best be understood as a family of related disorders that share core features of mood or affective variation, impulsivity, propensity toward substance abuse, and predisposition to other psychiatric conditions.1 Most patients who have bipolar disorder have a coexisting anxiety disorder.2 These include generalized anxiety disorder (GAD), social phobia, panic disorder, and PTSD.2Anxiety disorders, by themselves or in combination with a mood disorder, are associated with an increased risk of suicide and psychosocial dysfunction.
The prevalence of comorbid bipolar and anxiety disorders (with the exception of simple phobias) is high in youths. For example, it is at least twice as high as comorbid anxiety and disruptive behavior disorders. GAD and separation anxiety are the anxiety disorders most commonly associated with bipolar disorder. In children with type I bipolar disorder, comorbid anxiety predicted greater dysfunction, manifested by earlier onset of bipolar disorder and more frequent psychiatric hospitalizations.
A comorbid anxiety disorder in bipolar patients greatly complicates the presentation, the interpretation of symptoms, and the treatment of bipolar disorder, and it negatively alters the prognosis.

Anxiety disorders comorbid with bipolar disorder
Panic disorder. In the Epidemiologic Catchment Area (ECA) study of the early 1990s, 21% of patients with bipolar disorder had comorbid panic disorder. This is a 26-fold higher incidence than in the general population.3 Panic disorder and bipolar disorder may share a special relationship with each other. A study of bipolar probands and their siblings found that panic disorder travels with bipolar disorder exclusively and rarely occurs independently of bipolar disorder.4 This unique relationship may be mediated by a genetic predisposition that resides in chromosome 18.5

Obsessive-compulsive disorder (OCD). In both the ECA study and the more recent National Comorbidity Survey, the incidence of OCD was 10-fold greater in bipolar patients than the general population.2,6 The risk of OCD is greater in family members of bipolar probands, which suggests a familial or genetic association. However, episodic obsessive-compulsive symptoms may simply be a variant of how bipolar disorder is expressed and not a true comorbidity. Either way, the relationship between bipolar disorder and OCD frequently has its origins in childhood and yields a greater burden of anxiety symptoms.

Posttraumatic stress disorder. PTSD may have a special relationship with bipolar disorder because both mania and depression may be perceived as traumatic or because events in the course of the illness may increase the risk of severe traumatic events.7 Consequently, PTSD may be over 6 times more likely to occur in bipolar patients than in the general population.2 The co-occurrence of PTSD with bipolar disorder lowers quality of life, increases rapid cycling and suicide attempts, and reduces the likelihood of remaining well.8

Social anxiety. Despite frequent grandiose or expansive behavior during mania, most patients with bipolar disorder actually suffer from social phobia—a potential contributor to dysfunction in bipolar patients.2

Comorbidity and outcomes
The combined burden of bipolar and anxiety disorders nearly always has a deleterious effect on outcomes.9 Comorbid illness is associated with marked increases in symptom burden that includes greater risk of psychosis, earlier age at onset of psychiatric symptoms, worse treatment response and more treatment resistance, impaired quality of life, increased suicidal ideation and actions, and increased substance abuse.9 Whether the poor prognosis is due to an interaction between the two conditions or to the additive burden is unknown.

Accurate diagnosis of comorbid anxiety disorder and bipolar disorder is important. The cost of care increases when a bipolar patient is treated exclusively for anxiety because of a misdiagnosis. Once a dual diagnosis has been made, effective treatment may be challenging.

Treatment of anxiety disorders

Antidepressants. Serotonergic antidepressants have shown efficacy as acute and prophylactic treatment for all anxiety disorders and are considered first-line agents.10 This is generally true whether the serotonergic effect is alone, is associated with noradrenergic reuptake inhibition, or is obtained by reuptake or monoamine oxidase inhibition.11 Non-serotonergic antidepressants (specifically bupropion) do not appear to be particularly effective.
In bipolar patients, antidepressants have the potential to induce mania, destabilize the course of illness by increasing bouts of mania and depression, and induce a chronic depressive state.11 The risk of these complications is higher if the bipolar patient receives antidepressants during periods of euthymia or over long periods.11 Use of antidepressants specifically for anxiety in bipolar patients would be expected to be associated with more complications. This may account for the observation that pharmacological treatments of comorbidities, such as anxiety disorders, in bipolar patients are generally underused, whereas psychosocial services are used more frequently by patients with coexisting anxiety disorders.12

Antipsychotics. Second-line pharmacotherapy for anxiety becomes first line in bipolar patients with anxiety disorder. Specifically, studies of atypical antipsychotics such as quetiapine have shown that these agents reduce anxiety in social anxiety disorder and GAD.13 Although the patients recruited for these studies did not have a mood disorder, quetiapine monotherapy (300 to 600 mg/d) significantly reduced anxiety and depressive symptoms in patients with bipolar disorder.14 Quetiapine may be of questionable benefit in patients with PTSD. While open-label, uncontrolled studies support use of this agent for PTSD, there were more early discontinuations with quetiapine than with prazosin and, thus, long-term benefit was lost.15,16

At doses below 4 mg/d, risperidone does not appear to be helpful for the treatment of anxiety symptoms in patients with bipolar disorder.17 Augmentation of mood stabilizer treatment with risperidone was also ineffective.18

The olanzapine/fluoxetine combination is approved for the treatment of bipolar depression. It may be useful in the treatment of comorbid anxiety as well. However, olanzapine alone has minimal effect.19

Anticonvulsants. There are no randomized controlled trials that examine the use of anticonvulsants for the anxiety component in bipolar patients. However, anticonvulsants appear to have a small effect in reducing anxiety. In a small open-label study, more than 40% of patients with GAD (without mood disturbance) saw at least a 50% improvement in symptoms with valproate.20 Similarly, modest benefit was seen in a group of patients with PTSD who received divalproex in an open-label study.21 Unfortunately, when the effect size is small in open-label studies, it suggests that results of blinded studies are likely to be negative.

Alternative agents. Gabapentin has been shown to be effective for social phobia in a randomized placebo-controlled trial.22 This effect on anxiety is probably what underlies the early reports of gabapentin efficacy in bipolar disorder. The related anticonvulsant, pregabalin, is also useful in social phobia and GAD at higher doses (approximately 600 mg/d).23 These agents have not been studied in bipolar patients with anxiety but are probably safe to use in this patient population.

Benzodiazepines are clearly effective in many different types of anxiety disorders. However, their use is problematic, and these agents must be prescribed cautiously.

Nonpharmacological approaches. Psychotherapy may be the treatment of choice for patients with anxiety disorders in general. For example, CBT is as effective as medications in the acute management of panic disorder. Unlike medications, the effect lasts long after treatment has ended.24 However, there are no randomized controlled trials for psychotherapy in bipolar patients who have comorbid anxiety. Nonetheless, therapies such as CBT and relaxation training may be useful in bipolar patients.25

Summary
Anxiety disorders are commonly comorbid with bipolar disorder and are responsible for much of the morbidity associated with this condition. Treatment of anxiety can be a challenge, since the mainstay of treatment—serotonergic antidepressants—may adversely affect the course of bipolar disorder. Although other agents are available, there is a dearth of information on the outcomes of anxiety treatment for bipolar patients.
Clinicians generally must apply the results of studies performed in patients who have anxiety disorders without mood disturbance to their bipolar patients. This is a reasonable practice, although it is far from ideal. The field needs more high-quality research studies to define the best practice options in treating patients with comorbid anxiety and bipolar disorders.

Quite reasonably, patients with bipolar disorder want treatment that provides sustained relief from their illness without incurring serious side-effects. Functionally, this translates to the resumption of purpose and enjoyment. But of the numerous drugs available for the management of bipolar disorder, only lithium seems to truly stabilise mood.1 Its status as an effective prophylactic agent was convincingly reinstated by the findings of the randomised, open-label BALANCE trial,2 which corroborated empirical knowledge. The BALANCE investigators showed that lithium alone, or lithium plus valproate, are more likely to prevent relapse than valproate monotherapy, and prophylaxis with lithium monotherapy might be on a par with lithium plus valproate.

Hence, despite fluctuating popularity, lithium remains a first-line option for the treatment and prophylaxis of bipolar disorder in therapeutic guidelines.3 However, use of lithium in practice is limited by concerns about safety and adverse effects with long-term use.

Extending previous research that examined the short-term tolerability of lithium,4 in The LancetBrian Shine and colleagues5 have drawn on a large set of data to determine the long-term effects of lithium on renal and endocrine function. Data from 4678 patients were included in the study, of whom 2795 had their serum lithium measured more than once. Shine and colleagues’ findings show that lithium was associated with increased risk of stage three chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1·73m2; hazard ratio 1·93, 95% CI 1·76–2·12), hypothyroidism (thyrotropin activity >5·5 mU/L; 2·31, 2·05–2·60), and hypercalcaemia (1·43, 1·21–1·69).

These findings send a key message to clinicians to monitor lithium therapy closely from the outset. Both thyroid hormone secretion and renal function can decline with long-term lithium use and can, in some cases, lead to hypothyroidism and stage three chronic kidney disease. Interestingly, these complications are more likely to occur in women than in men, and are detected early in the course of lithium treatment. In addition, long-term lithium therapy can also cause hypercalcaemia (ie, total plasma calcium concentration ≥2·6 mmol/L).

All adverse effects are more likely to occur when plasma lithium concentration is high. Therefore, patients receiving lithium therapy should have thyroid function, renal clearance, and blood calcium concentrations assessed carefully at the beginning of therapy and monitored closely thereafter. Shine and colleagues5 provide clear evidence of the potential risks associated with long-term lithium treatment. But because bipolar disorder typically emerges at a young age6 and requires lifelong treatment, these findings prompt the question: how can these hazards be navigated?

The answer is twofold. First, avoid sustained periods during which plasma lithium concentrations are high to diminish the risk of serious adverse effects. Second, all the parameters that need regular assessment, such as thyroid and renal function tests and plasma lithium and calcium concentrations, can be measured reliably and easily. However, the treatment of type I bipolar disorder, the subtype best suited to lithium therapy,7 is often complicated by comorbid anxiety and substance misuse. Furthermore, lithium’s therapeutic effect occurs at concentrations that can be toxic if maintained in the long term.8 These concerns reinforce a widely held view that lithium therapy is problematic. But all drugs are associated with side-effects, and long-term management often involves a risk–benefit analysis at some point in the treatment course; lithium is no exception.

Maintenance of lithium concentrations at the lower end of the therapeutic range (ie, 0·6 mmol/L) can reduce the adverse outcomes associated with lithium treatment. For plasma lithium concentrations to be high enough to be efficacious, but low enough to avoid toxicity, is a delicate balance. The simple pharmacokinetics of lithium in plasma offer some assistance, but the pharmacokinetics of lithium within the brain are more complex because the blood–brain barrier insulates the brain from rapid changes in plasma lithium concentration and facilitates its accumulation in neural tissues, which can be neurotoxic.9

The movement of lithium between plasma, cerebrospinal fluid, and brain tissue is not fully understood, and future research will need to examine the effects of different doses and duration of lithium treatment on concentrations within these various compartments. For example, a low concentration of lithium in the plasma (0·2–0·4 mmol/L) has little effect on renal and thyroid function,10 and is achievable with alternate-day dosing.9

Lithium is without doubt the best treatment for many patients with bipolar disorder because it confers long-term mood stability and prophylaxis (figure). Lithium also reduces the risk of suicide11and is possibly neuroprotective.12 The dilemma of lithium therapy arises because, if poorly managed, lithium can compromise renal function, sometimes irreversibly, and severely disrupt endocrine homoeostasis—ultimately limiting its usefulness. Therefore, lithium therapy remains a challenge that will benefit from a better understanding of its therapeutic properties.

Figure

The Lithium Membrain by Anne Naylor
Lithium coursing through veins in the brain (blue) provides mood stability by acting as a membrane that prevents the effects of the various faces of the illness (circles) on the brain (neural networks).

Anne Naylor 2014
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I have received research funding from AstraZeneca, Eli Lilly, Organon, Pfizer, Servier, and Wyeth; am a speaker for AstraZeneca, Eli Lilly, Janssen-Cilag, Lundbeck, Pfizer, Ranbaxy, Servier, and Wyeth; and a consultant for AstraZeneca, Eli Lilly, Janssen-Cilag, Lundbeck, and Servier.

Emil Kraepelin’s demarcation between dementia praecox and manic depressive illness defined affective disorder as a remitting and recurring disease. He considered that only long-term outcome was useful in assessing accuracy of diagnosis and treatment response in patients.1 The more recent interest in the outcome of single mood episodes probably indicates motives to register and market drugs rather than assisting clinical practice. This interest has resulted in many 4–8 week randomised trials but few well designed long-term studies in patients with depression.

There is now increasing evidence that Kraepelin was right. Mood disorders are generally recurring, and the relevant measure of clinical success is long-term functioning rather than the outcome of a single mood episode.2 In secondary and tertiary care, less than a third of patients recover and remain well in the 18 months after an episode of depression,3whereas in general practice and community studies, the proportion of patients with recurrence is between 35% and 65%.4 Treatment needs to focus on maintenance and prevention of relapse as well as on the acute mood episode.

The most established treatment for prevention of relapse and recurrence is maintenance antidepressant medication. Studies have consistently reported a reduction in the odds of relapse of about 50–70%.5, 6 However, many patients might not wish to remain on medication or cannot tolerate the side-effects. Alternative non-medication strategies would obviously be desirable.

Mindfulness-based cognitive therapy (MBCT) was developed as an explicit intervention to reduce relapse and recurrence in depression. MBCT teaches people who have had depression that negative feelings and thoughts will recur and that, rather than worrying or ruminating about these experiences, it is possible to become aware of and disengage from them, thereby preventing a downward spiral into depression.7 Although cognitive behavioural therapy and interpersonal therapy also have evidence of efficacy in the prevention of relapse in depressed patients8 neither were developed specifically for this purpose.

Willem Kuyken and colleagues’ study,9 published in The Lancet, of mindfulness-based cognitive therapy in the prevention of depressive relapse or recurrence is therefore timely. It is a pragmatic long-term study done in general practice, where most depression is treated. The randomised trial compared MBCT with maintenance antidepressants in a large sample of patients with recurrent depression in the UK. 212 patients were randomly assigned to MBCT and 212 to maintenance antidepressant treatment, and the time to relapse or recurrence of depression did not differ between treatment groups over 24 months (hazard ratio 0·89, 95% CI 0·67–1·18). The authors’ interpretation of the findings is carefully worded: there is no support for MBCT being superior to maintenance antidepressants in preventing depressive relapse.

Despite this apparent negative result, the findings have substantial clinical significance.
Kuyken and colleagues’ findings, if benchmarked against the studies of maintenance antidepressant therapy, provide evidence that MBCT might offer a similar ongoing protective effect as that of maintenance antidepressants. MBCT therefore provides an alternative effective treatment for patients who cannot tolerate or do not wish to have maintenance antidepressant therapy. Because it is a group treatment that reduces costs and the number of trained staff needed, it might be feasible to offer MBCT as a choice to patients in general practice. Pooling all trial data comparing MBCT and maintenance antidepressant treatment (which is limited to three studies), as Kuyken and colleagues did,9 resulted in a risk reduction of 24% for MBCT compared with maintenance antidepressants (risk ratio 0·76 95% CI 0·59–0·98). Perhaps all patients with recurrent depression should be offered MBCT.

JLP/Jose L Pelaez/Corbis
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We therefore have a promising new treatment that is reasonably cost effective and applicable to the large group of patients with recurrent depression. The next obvious question is whether there are specific effects of MBCT that confer this decreased risk of relapse or whether any structured group psychotherapy would produce similar results. Ongoing studies of mechanism of action are promised by the authors. If the research in long-term treatment of personality disorders is any guide, they are likely to find that general factors such as a manualised approach, active supportive therapists, a focus on patients’ sense of agency and management of life situations are most important,10 rather than specific factors related to mindfulness theory.

Depression remains a disabling condition with high prevalence and a large clinical burden. Despite the increased use of drugs, the long-term outcome of mood disorders has not improved in the modern era.11 Having an alternative non-medication strategy to reduce relapse is an important means to help patients with depression.

Limitation of access to lethal methods used for suicide—so-called means restriction—is an important population strategy for suicide prevention. Many empirical studies have shown that such means restriction is effective. Although some individuals might seek other methods, many do not; when they do, the means chosen are less lethal and are associated with fewer deaths than when more dangerous ones are available. We examine how the spread of information about suicide methods through formal and informal media potentially affects the choices that people make when attempting to kill themselves. We also discuss the challenges associated with implementation of means restriction and whether numbers of deaths by suicide are reduced.

This is the third in a Series of three papers about suicide
Jump to SectionIntroductionTheory of means restrictionSuicide rate, method availability, and lethalityMeans substitution after restrictionThe role of the mediaExamples of means restrictionThe social dilemmaLimitationsConclusionSearch strategy and selection criteriaSupplementary Material

Introduction

For more than a century, writers and researchers have considered suicide from two opposite perspectives, invoking broad cultural and societal factors as causes or focusing on uniquely individual characteristics and experiences to explain why people kill themselves. Public health approaches to suicide prevention, however, have to integrate these viewpoints and to develop strategies that will benefit most lives in an effective and measurable way.

Suicide is a well recognised public health challenge. WHO estimates that the global suicide rate is about 16 per 100 000 individuals per year, which is a 45% increase in the past 45 years.1 Depending on the nation cited by WHO, suicide is one of the top three leading causes of death in people aged 10–24 years or 15–44 years, and often is an especially large burden late in life, when suicide rates are highest in many countries.2 Therefore, suicide causes the loss of many potential years of life and has substantial economic and emotional costs, disrupting families, communities, and society, broadly ramifying sadness and loss.3
Many countries have initiated suicide prevention programmes,4, 5 which use public health strategies that focus on individuals in known high-risk groups and promote population-oriented strategies to broadly reduce risk, in keeping with Rose’s theorem (many people at low risk might give rise to more cases than would a small number at high risk).6 Suicide is not a disease caused by well defined pathological mechanisms, and the occurrence of suicidal behaviour is usually an outcome of complex interactions of socio-environmental, behavioural, and psychiatric factors.6 Identified risk factors, such as severe depression or other mental illnesses, do not have sufficient specificity (ie, high rates of false positives) to guide effective preventive actions.7
One important population strategy to reduce suicides has been modification of the environment to decrease general access to suicide means. This approach (so-called means restriction) is reported to be one of the intervention measures with strongest empirical support.8, 9 Several factors apparently underpin the effectiveness of this approach. Many suicidal people cannot be accessed with interventions or restrictions at the time of their greatest risk; indeed, they often seek to avoid detection. The probability of individuals attempting suicide decreases when they are precluded from implementing a preferred method10—ie, suicide attempts are often method-specific. Moreover, if a highly lethal method is not available and some individuals do not defer their attempt, they frequently use less lethal, more common ones (eg, drug overdose). From the perspectives of public health and injury prevention, the choice of a method that is less lethal than are others can be advantageous if the attempt proves to be non-fatal.
The case fatality of suicide methods varies greatly (appendix).11, 12, 13, 14 The potentially fatal moments of suicidal crises are often brief. Strongly felt ambivalence is common, with competing wishes to die and to live.9 The sudden, unplanned (or briefly planned) nature of many suicides implies that individuals tend to use the method most readily accessible to them. When a lethal method is unavailable at the moment of potential action, suicide attempts might be delayed so that (in some cases at least) suicidal impulses will pass without fatal effects.15 Even when individuals have planned, poor access to the most lethal means can be a substantial impediment.
Although means restriction is considered a generic preventive intervention, few investigators have assessed the relative strength of supporting evidence for different methods. Moreover, the potential effect of decreased access to various methods on overall suicide rates in different countries or regions has not been established. We review the empirical evidence for means restriction from the past decade (figure) and assess its effectiveness and its relation to the dissemination of information about different methods of suicide through various media outlets. We put special emphasis on the difficulties encountered when attempts to measure potential substitution effects are made. Additionally, we draw attention to the potential of socially enacted means restriction (ie, not absolute restriction) as a public health intervention for commonly available products.

Figure

Selection process of studies cited

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Jump to SectionIntroductionTheory of means restrictionSuicide rate, method availability, and lethalityMeans substitution after restrictionThe role of the mediaExamples of means restrictionThe social dilemmaLimitationsConclusionSearch strategy and selection criteriaSupplementary Material

Theory of means restriction

Suicide is a rare event and high-risk factors are common (eg, depression, other mental disorders). A recurring challenge in suicide prevention is how to accurately identify vulnerable individuals in populations at risk. A prevention strategy that targets the population as a whole, such as means restriction, has many advantages, especially when implemented through so-called distal measures—eg, removal of carbon monoxide from domestic gas or withdrawal of highly lethal pesticides from the market.
Means restriction entails a community or societal action that (ideally) does not depend on an individual’s intention or volition. Applied to the population as a whole, it typically affects people whose suicide risk is otherwise undetected and who do not seek therapeutic assistance to prevent their crisis or for life-saving interventions when necessary. Removal or restriction of access to a lethal method changes the context of a potential suicide by precluding potentially fatal actions or forcing the use of a less lethal method. Because means restriction is broadly applied, detection of its individual-level effect is often impossible; it is best measured by aggregate findings of method-specific community rates of suicide and related self-harm injuries.
As a public health measure, means restriction has a long history; removal of the pump handle in Broad Street, London, UK, by John Snow was an early example and a historic landmark in public health practice.16 Similar approaches have been widely applied in criminology, with the label of opportunity-reduction theory (or so-called situational crime prevention).17 Instead of a focus on individual criminals, an opportunity-reduction approach introduces discreet managerial and environmental changes to reduce the opportunities for crime. Suicide can be affected or forestalled by alteration of environments or access.17 To be successful, this type of strategy depends on committed societal leadership and sustained political will. This approach fits with the notion of context changes to make individuals’ default decisions healthy. The principle of this type of intervention is that individuals would have to expend substantial effort not to benefit.18
Although means restriction can be broadly applied, related approaches exist for individuals. Clinicians can work with high-risk patients and their kin to remove potentially lethal methods from the immediate environment. By contrast with universal approaches, this strategy necessitates care providers’ vigilance and cooperative participation by people close to the suicidal individual. Such safety planning is not means specific, but is tailored to individuals and situations.
Jump to SectionIntroductionTheory of means restrictionSuicide rate, method availability, and lethalityMeans substitution after restrictionThe role of the mediaExamples of means restrictionThe social dilemmaLimitationsConclusionSearch strategy and selection criteriaSupplementary Material

Suicide rate, method availability, and lethality

International variations in common suicide methods suggest that these patterns are linked closely to differences in the availability and lethality of specific approaches.19 Suicides by pesticide poisoning (case fatality up to 75%) have been common in many Asian and Latin American countries where there are large agrarian populations,20 whereas many individuals killing themselves in cities and city states jump from high places (70% lethality).21, 22 Indeed, jumping has accounted for more than 50% of suicides in Hong Kong and 80% of those in Singapore in the past 20 years.21
Thomas and colleagues23 described the large increase in suicides in the UK, first in men and later in women, after carbon monoxide gas from coalmines became widely available in the first half of the 20th century. Gas rose to become the primary national method of suicide. The replacement of coal gas with natural gas from North Sea wells between the late 1950s and early 1970s led to a gradual reduction in the carbon monoxide content of domestic gas, which in turn was followed by a steady and prominent decrease in fatal gassing and the overall suicide rate in the UK.23, 24 This decline in the overall rate was directly caused by the reduction in suicide with domestic gas. Thomas and colleagues23 showed that the number of fatal gas poisonings in the UK rose in the early 1980s, but it later fell after the introduction of catalytic converters into car exhaust systems.25, 26, 27, 28, 29
The increased use of pesticides during the second half of the 20th century was associated with an increase in suicides in many agrarian societies.30 Prevention strategies have sought to substitute less lethal, newer generation compounds,31, 32, 33 and to install double-lock boxes34 to remove access to potentially lethal but commonly available chemicals. Enforcement of gun-control policies lowers numbers of firearm suicides.35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52
An individual’s choice of method is not only dependent on ready access to a specific means of suicide, but also on its socio-cultural acceptability.53 Local norms and traditions, moral attitudes towards suicide, knowledge about past suicides, and personal experience and accessibility all potentially shape a person’s suicidal actions. In turn, means restriction should shape contextual factors, promoting healthy decisions.
Jump to SectionIntroductionTheory of means restrictionSuicide rate, method availability, and lethalityMeans substitution after restrictionThe role of the mediaExamples of means restrictionThe social dilemmaLimitationsConclusionSearch strategy and selection criteriaSupplementary Material

Means substitution after restriction

A common concern about means restriction has been that individuals will simply switch to other methods of suicide—ie, so-called means substitution. Such concern could be a result of distressed individuals being considered by clinicians as equally at risk of suicide by any method when they are assessed as being very suicidal. However, studies5 have shown that restriction of one method of suicide does not inevitably lead to a compensating rise in the use of others (as shown in the UK in the 1970s), just as the emergence of a new method (eg, domestic gas in the UK in the first half of the 20th century, or the burning of charcoal in confined spaces to generate toxic amounts of carbon monoxide in Hong Kong in the late 1990s) does not result in a substantial decline in the use of long-available means.
The occurrence of substitution varies between regions and is associated with individual characteristics such as age and sex (appendix).25, 46 The effectiveness of means restriction differs between the sexes; women seem to be more responsive than are men, and method substitution is more common in men than in women (appendix).46 Where means restriction has been implemented in Asia—typically of pesticide and charcoal—substitution has been reported rarely.31, 33, 54, 55 The cause of this apparent difference is unknown; characteristics of the populations affected or the restricted methods might play a part.
At the population level, means restriction proves most effective when the method is common and highly lethal, accounting for a substantial percentage of deaths.15, 18 Common methods that have been restricted, such as domestic gas and pesticides, are available in the home. The likelihood that a specific method will lead to death is related to both its lethal properties and its accessibility. When reduction of access to a highly lethal method is possible, people who do attempt suicide with less dangerous means have an increased chance of survival. If the overall population rate of suicide is to be substantially reduced by means restriction, the fatality rate of alternative methods should be lower than that of the restricted method of suicide (appendix).15
Jump to SectionIntroductionTheory of means restrictionSuicide rate, method availability, and lethalityMeans substitution after restrictionThe role of the mediaExamples of means restrictionThe social dilemmaLimitationsConclusionSearch strategy and selection criteriaSupplementary Material

The role of the media

Nowadays, publicly available media—whether in print, on television, or on the internet—might affect the creation or alteration of suicide methods, and hence affect suicide rates. The deaths of celebrities have been publicised.56 Perhaps most importantly, this type of rapid dissemination most often involves members of the public dying in extraordinary circumstances.57 For example, the media introduced and quickly disseminated reports on the burning of charcoal in a confined space in Hong Kong and Taiwan, which then rapidly increased and spread to other Asian regions in the late 1990s.23 An ethnographical investigation in Hong Kong58 established that people chose charcoal burning because they were reminded of the method by newspaper reports. An interview-based study in Taiwan59 showed that 87% of individuals who attempted suicide with charcoal burning reported that the media pointed them towards this method. Suicides by charcoal burning have been recorded in the UK.60 Whether charcoal burning would have spread so quickly had initial graphic reports, pictures, and diagrams not been presented in Hong Kong tabloids in 1998 is unknown. Therefore, in addition to sensationalising suicide, the media can provide precise instructions about how a method can be implemented, further complicating prevention initiatives.
New online social media can be used to disseminate information within minutes or hours, rather than slow diffusion of models or methods that was the norm previously, such as when domestic gas was introduced.61 As yet, little research has tested whether all forms of today’s media can be used to positively affect vulnerable individuals or populations in a way that promotes good mental health or adaptive help seeking at times of distress.62
Jump to SectionIntroductionTheory of means restrictionSuicide rate, method availability, and lethalityMeans substitution after restrictionThe role of the mediaExamples of means restrictionThe social dilemmaLimitationsConclusionSearch strategy and selection criteriaSupplementary Material

Examples of means restriction

Implementation of means restriction can be viewed as a continuum, ranging from complete elimination or removal of a potentially fatal substance or compound (eg, changes in the composition of domestic cooking gas), through impeding or interfering with access (eg, barriers to jumping and packaging changes), to promotion of educational and social interventions to enhance safety (eg, education of clinicians to encourage families to remove potentially lethal means from the home). We believe that removal of an agent would have the greatest effects on broadly measured suicide rates, whereas social-educational interventions would be least potent, especially because they necessitate concerted and sustained actions by many individuals.
Legislation to restrict the quantities of paracetamol and other analgesics (eg, aspirin) sold was enacted in the UK in 1998. Early data suggested that mortality and morbidity associated with paracetamol overdose declined as a result,63, 64 with little evidence for substitution to other kinds of analgesics, such as ibuprofen (a compound that is safer than is paracetamol).64 Subsequent studies65 have cast doubt on these early findings. Implementation of such legislation does not depend on specific actions of individuals, but is done during manufacture and with widely applied sales regulations. Further research is needed to establish whether people attempting suicide hoard their paracetamol supplies until they have sufficiently lethal amounts, and whether they have the patience to open blister packs to obtain enough pills. Such findings would point to carefully planned suicides and would potentially suggest that other prevention measures are needed.
In 2010, Yip and colleagues55 described the results of a controlled community experiment in Hong Kong, in which they moved bags of charcoal from easy self-service access on store counters to locked storage, so that customers had to ask store attendants for assistance. This measure did not prohibit purchases, but sales became a source of attention and slightly more time consuming than they had been previously. Compared with a district with a similar population size (500 000 inhabitants), area, and socioeconomic status that had no change in method of shelving, a measurable and significant decline in suicides was reported.55
Unlike repackaging of paracetamol, agreement of the managers of supermarket chains and day-to-day implementation by store employees was necessary to move the bags of charcoal. Such a high level of cooperation could pose substantial challenges, and many community members might resent or resist such constraints.
On the island of Cheung Chau in the Islands District of Hong Kong, deaths from poisoning by charcoal burning in holiday houses increased from three to four per year to the high of 14 in 2002.54Most suicides were of visitors. The community reported negative effects on the island in terms of resort business and general wellbeing after a series of suicides.54 Island residents and businesses developed a self-help organisation to restrict access to holiday flats for distressed or suicidal individuals; owners refused to rent to people on their own. Store employees were alert to visitors who wished to purchase charcoal and beer but no food. The police cycled around the island to identify anyone deemed to be at risk of suicide and irregularities in the community. Of 40 000 residents, the number of suicides on the island declined to two in 2005, without any substantial increase on nearby islands.54 These findings emphasise that means restriction must be embedded into other efforts to modify environments, such as the restriction of access to rental units. Cohesive community action was the central part of this initiative; means restriction—like other elements of the Cheung Chau programme—was a result of concerted and widespread commitment.
Jump to SectionIntroductionTheory of means restrictionSuicide rate, method availability, and lethalityMeans substitution after restrictionThe role of the mediaExamples of means restrictionThe social dilemmaLimitationsConclusionSearch strategy and selection criteriaSupplementary Material

The social dilemma

Application of universal measures for means restriction might be considered intrusive by many members of the community. Moreover, the benefits for most people will be small or non-existent. Thus, use of widely applied prevention measures could be met with substantial resistance, even though data support large population effects. Many community members express common misunderstandings that, despite data showing powerful population-level effects, a seriously suicidal person will inevitably find a way to die and that all methods have roughly equal case fatalities. In many community discussions about means restriction—whether control of access to bags of charcoal safety doors on subway platforms, or bridge barriers54, 55, 66, 67, 68, 69, 70, 71, 72, 73—many participants believe that removal of access to one method of suicide would force people to use another.
On the basis of the data for relocation of bags of charcoal in supermarket chains in Hong Kong,55prevention strategies should gain support from senior managers of affected companies, as well as having supporting scientific data. With appropriate media coverage and endorsement by community leaders, means restriction could gain greater acceptance and less resistance from the public than it does presently. The fundamental premise of means restriction is based on the assertion that it is both a community-level intervention and a community-supported initiative.
We suggest that policy makers and advocates consider several a priori criteria when assessing the potential benefits of means restraint. First, the method in consideration should contribute substantially to the mortality from suicide in the region because of its high lethality. Second, the method should be suitable for elimination or constraint, ideally with broadly applicable policy actions rather than day-to-day implementation by individuals, either alone or collectively. Third, they should assess whether a method is socially important or recognised (eg, suicides from iconic sites or bridges), when the preventive intervention would be noticed by many people, even though the overall contribution to regional rates might be marginal. Fourth, they should be able to monitor the implementation and effects of an intervention.
Jump to SectionIntroductionTheory of means restrictionSuicide rate, method availability, and lethalityMeans substitution after restrictionThe role of the mediaExamples of means restrictionThe social dilemmaLimitationsConclusionSearch strategy and selection criteriaSupplementary Material

Limitations

Glasgow’s 2011 report74 emphasised that bridge barriers—however effective they might be at individual sites—do not lower regional suicide rates when people jumping from those bridges contributed little to the rates before the barriers were put in place. Although placement of such barriers might not lower regional rates—even when it prevents deaths at specific sites—the action conveys a powerful public message, expressing important community values and serving to promote help-seeking. Such committed political will to save lives could be one potential way to counteract media-driven contagion, because it affords opportunities for widespread discussion and collective community action.
Constraint or elimination of access to commonly used suicide methods of low lethality (eg, fairly non-toxic prescription or over-the-counter drugs) would have a negligible effect on rates and also might inadvertently force individuals attempting suicide in the future to use more lethal methods.75When high-lethality methods have been constrained, some substitution with low-lethality means has been reported.76 Such findings do not indicate what exactly would happen if low-lethality methods were eliminated.75 For methods of intermediate lethality, such as charcoal burning, the potential gains from constraints that cannot entirely eliminate access should be assessed carefully (appendix).
Hanging, jumping from heights (particularly from individuals’ own apartments or houses), and fatal shooting with firearms in countries with relatively non-restrictive gun laws such as the USA cannot be readily restricted. However, safety planning for firearm storage is potentially a form of means restriction when effectively applied as part of routine procedures. Similarly to the decision to place bags of charcoal behind shop counters, such changes need committed leadership, corporate co-operation, and consistent individual action to attain sustained, widespread implementation. In clinical practice, physicians and other health professionals should speak with family members about the removal of potentially lethal methods from the reach of vulnerable kin. This type of intervention necessitates an alert clinical provider, a vigilant family, and a cooperative patient, but too often one or several of these components could be absent.
Jump to SectionIntroductionTheory of means restrictionSuicide rate, method availability, and lethalityMeans substitution after restrictionThe role of the mediaExamples of means restrictionThe social dilemmaLimitationsConclusionSearch strategy and selection criteriaSupplementary Material

Conclusion

Restriction of access to a specific suicide method can have a widespread effect when the method is highly lethal and common, and the means restriction is supported by the community. Newly emerging methods might have large effects as they spread through communities, and in the internet era, the results can be sudden and pronounced. Once a method of suicide has become common, it is especially difficult to eradicate. If faced with similar emerging methods in the future, policy makers should seek support from formal media outlets to restrain spread and lessen the effects, although informal media now makes such interventions even more challenging than previously.
It is beyond the scope of this report to define elements necessary for promotion of the type of collaborative community discussions that address the balance between the imperative of constraining potentially lethal methods of suicide and the wishes of most community members who are not at risk and might be inconvenienced. But just such discussions are necessary if further, meaningfully broad-based interventions are to be implemented. Although we have expressed concerns about the media’s potential to serve as a powerful vector for spreading contagion, these venues of information dissemination can effectively pass on scientific knowledge and protective guidance. As with discussions about means restriction, broad community participation and dynamic social leadership are necessary.
No one measure, however effective, can sufficiently address the many factors that contribute to regional or national suicide rates. A frank and open discussion of a community’s abiding values, legislative or policy changes, continuing community education, consultation about the challenges posed by suicide and its antecedents, and effective clinical management of individual cases are all necessary for prevention programs.

Astute readers of obituaries know that “died unexpectedly” is a common euphemism for “died by suicide”. The family and friends of suicide victims are often reluctant to openly discuss the cause of death because of profound sadness, sense of privacy, embarrassment, or cultural taboos. Public discourse on suicide is also limited, perhaps because of unease with the topic of self-destruction or cultural bias against suicide. The news media generally pay scant attention to suicide other than celebrity suicides1 and suicide clusters.2 Yet, we are all affected by suicide.

There are few among us who have not been touched by the loss of a loved one, friend, colleague, or patient who has chosen to end their life by suicide. It occurs in all countries and all cultures. It can happen in any family, including your own. Suicide has been reported in children as young as 6 years old,3 the very old,4 and all ages between. For the victim of suicide, it is a life needlessly lost. For the survivors of suicide victims, the family and friends, there is an enormous toll in terms of grief, guilt, and a lifetime of unanswered questions.5 Suicide is an act that is contrary to what is perhaps the strongest of human instincts—survival.

To voluntarily end one’s own life is incomprehensible for most of us.
In The Lancet, three reviews help us to better understand the incomprehensible, each with the aim of contributing to strategies to reduce the risk of self-destructive behaviour. Keith Hawton and colleagues6 review the current state of knowledge for self-harm and suicide in adolescents; Alexandra Pitman and colleagues7 do the same for suicide in young men. The third article by Paul S F Yip and colleagues8 is devoted to prevention of suicide by means restriction—ie, the limiting of access to highly lethal methods of suicide. The articles are informative for health-care providers and provide a context for the development and modification of suicide prevention strategies. Although each article addresses different aspects of suicide, there are some common themes, either implied or explicitly stated, that are worthy of further elaboration.

These include the complexity of factors that lead to suicidal behaviour, pain as a unifying feature in the framework of suicide, and means restriction to prevent suicides.

Among the many risk factors for suicide are mental illness, physical illness, previous suicide attempt, substance abuse, family history of suicide, impulsiveness, hopelessness, isolation, and loss (relationship, social, work, financial).9 Most of us who encounter such challenges learn to cope with them or find ways to overcome them, going on to survive and sometimes flourish. However, an individual with limited psychological reserves who faces the same challenges might come to feel that suicide, however undesirable, is preferable to living. Although there is no simple explanation for such counter-intuitive human behaviour, social and cultural factors, media exposure, and availability of lethal means are woven in a complex web with other risk factors that can lead to suicide.6, 7, 8

The complexity of risk factors for suicide suggests that many approaches to suicide prevention should be considered and customised to accommodate local circumstances.

Memory wall dedicated to those lost to suicide, Hazleton, PA, USA

Jamie Pesotine/AP/Press Association Images
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Suicide and pain are closely linked.10 Suicide might be chosen as the ultimate solution to end psychological pain (eg, from depression or bullying) or chronic physical pain when there is a perception that no other option for relieving the pain is available. Pain is also a consequence of suicide. The family and friends of suicide victims suffer from psychological pain in ways that are mostly silent but nevertheless profound, and they themselves are at high risk for suicide due to the loss they have experienced.11 Pain management is good medical care for these people and might reduce the risk of suicide.12

There is strong empirical evidence that restriction of access to lethal means reduces suicides.13 The benefit of this approach is predicated on the impulsivity of suicide. It is commonly a very short time, often minutes to hours, between the decision to attempt suicide and the act of suicide, with the urge to die by suicide rapidly dissipating if not completed. Many who die by suicide do not provide advance warning and do not seek help from others.14

When a common and highly lethal means of suicide (eg, handguns in the USA, pesticides in Asian countries) is easily available, a suicide attempt is likely to result in death. When access to highly lethal means is thwarted (eg, waiting period for purchasing a handgun in the USA, restricted access to pesticides in Asian countries), another chosen means (eg, drug overdose) might be less likely to result in death. Of those who survive a suicidal impulse or a suicide attempt, many go on to live long and productive lives. Means restriction is an effective population-based approach that should be considered for inclusion in all comprehensive suicide prevention strategies.
EML and SAM are the father and fiancée, respectively, of a victim of impulsive suicide. They both declare that they have no conflicts of interest.

One hypothesis about bipolar disorder treatment is that antidepressants may be safer and more effective in patients with type II bipolar disorder than in those with type I bipolar disorder.
These authors studied 21 patients with type I bipolar disorder and 49 patients with type II bipolar disorder who had acute major depressive episodes and were treated with antidepressants plus mood stabilizers to euthymia sustained for 2 months. The patients were then randomized openly to continue or discontinue antidepressants for up to 3 years.
At follow-up after an average of 1.64 years, both subgroups showed improvement in depressive episode frequency with continued use of antidepressants. But more improvement was seen in bipolar disorder-I patients than in bipolar disorder-II patients.
Those with bipolar disorder-II who continued on antidepressants had slightly more depressive episodes, but fewer manic/hypomanic episodes, than those with bipolar disorder-I. There were no differences in time to recurrence of mood episodes or total time in remission.
The authors concluded that long-term antidepressant treatment in patients with bipolar disorder-II does not lead to better outcomes than in patients with bipolar disorder-I, except for a somewhat lower risk of manic/hypomanic episodes.
RESULT: Antidepressants in Type II Versus Type I Bipolar Depression: A Randomized Discontinuation Trial. Journal of Clinical Psychopharmacology. | Oct 1, 2015 (Free abstract. Full Text $53.35)
Although benzodiazepines are often prescribed for bipolar disorder, little is known about which subtypes of bipolar disorder may respond better to benzodiazepine use. These authors examined the prevalence of and factors associated with benzodiazepine use among 482 patients with bipolar I or II disorder; 81 patients were prescribed benzodiazepines.
Bivariate analyses found that benzodiazepine users were prescribed a significantly higher number of other psychotropic medications and were more likely to be prescribed lamotrigine or antidepressants as compared with benzodiazepine nonusers. Also, benzodiazepine users were more likely to have a diagnosis of bipolar I disorder and comorbid anxiety disorder, but not comorbid alcohol or substance use disorders. In addition, benzodiazepine users experienced more anxiety and depressive symptoms and suicidality, but not irritability or manic symptoms.
In a multivariate model, anxiety symptom level, lamotrigine use, number of concomitant psychotropic medications, college education, and high household income predicted benzodiazepine use.
The authors stated that benzodiazepine use in patients with bipolar disorders is associated with greater illness complexity, regardless of a comorbid anxiety disorder diagnosis.

The Tip sheet below lists factors that may help identify uni polar depression.

■ Prepubertal onset of symptoms
■ Brief duration of depressed episodes
■ High frequency of depressed episodes
■ Seasonal pattern
■ Postpartum symptom onset
[b]■ Multiple antidepressant failures[/b]
[b]■ Nonresponse to antidepressant treatment[/b]
■ Rapid response to antidepressant treatment
■ Erratic response to antidepressant treatment
■ Dysphoric response to antidepressant treatment with agitation and insomnia
■ Family history of bipolar disorder
■ History of unstable interpersonal relationships
■ Frequent vocational problems
■ Frequent legal problems
■ Alcohol and drug use

■ Bipolar I disorder, with episodes of full-blown mania, is usually easier to diagnose than bipolar II disorder, with episodes of subtler hypomania
■ Recognizing that the primary mood state may be irritability rather than euphoria increases the likelihood of diagnosis
■ Focusing more on overactivity than mood change further improves diagnostic accuracy
■ Bipolar disorder is associated with a significantly elevated risk of suicide
■ Bipolar patients often use highly lethal means for suicide

■ Early age at disease onset
■ The high number of depressive episodes
■ History of antidepressant-induced mania
■ Traits of hostility and impulsitivity