Do Suicide Hotlines Work?
Just because calls increase doesn’t necessarily mean suicide rates decrease.
“If you ask people in the ER after a suicide attempt why they tried to kill themselves, it’s not I wanted to be dead because I want to go to heaven,” says Matthew Nock, a Harvard psychology professor who studies suicide. “It’s, I was in what I perceived to be unbearable pain and I wanted to escape. Sort of like being in a burning building. It’s important to help people because those thoughts, we know from many different studies, are rarely persistent. It’s often a temporary condition.”
This is why, researchers say, rapid intervention is so crucial.
In the days following the deaths of Kate Spade and Anthony Bourdain last week, calls to suicide hotlines increased by about 25 percent, according to John Draper, director of the National Suicide Prevention Lifeline (NSPL). Crisis professionals see this as a positive thing. In part, the uptick is due to news organizations posting the number to the national hotline at the end of their suicide-related stories: “ If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK) …”
“Whenever the media puts this number out there, especially following major events—suicides or those kinds of scenarios—calls go up,” Draper says. For people reading or watching a news story, who might be having some of the same feelings, “they could call at any time, for free and confidential help to prevent suicide.”
But while calling might bring someone comfort in the moment, there’s no scientific evidence that suicide hotlines actually prevent suicide in the long run. “There is no evidence that this is helpful or the right thing do,” Nock says.
Draper says that the hotline has consistent success with reducing a caller’s distress in the moment, and even their suicidal feelings. Hotline operators will often follow up with a caller after the initial call, and there’s research to support the idea that a call can make someone feel better and keep them safe in the few weeks that follow. But there have been no comprehensive scientific studies showing that calling a suicide hotline prevents deaths by suicide over time. “It’s an important question. I wish we could answer it more concretely,” Draper says. “You could say you saved lives,” in the moment of the call, he adds. “But by the same token, you don’t know if they’re going to be okay later. We like to presume they are.”
“On the one hand, of course we should encourage people who are suicidal to reach out to someone—that just seems like common decency,” Nock says. “But wouldn’t it be great to know if it was effective? And wouldn’t it be great to know what aspects are effective so we can make it even stronger? Or stop doing the things that don’t work?”
Despite the lack of evidence, the NSPL encourages media outlets to include the hotline number when reporting on suicides. Anecdotally, an increasing number of outlets appear to be doing so. “It’s important for each story to include the number,” Draper says, “because when you’re talking about a person who died by suicide, you’re also reaching people who may themselves be suicidal.”
Yet many news organizations have ignored the other recommendations for media coverage, from the World Health Organization, NSPL, and other groups—namely, to avoid sensational headlines, discussion of a suicide note and the method used. (The example the NSPL uses is to go with a headline along the lines of Kurt Cobain Dead at 27 instead of Kurt Cobain Used Shotgun to Commit Suicide.)
These recommendations do have data behind them, as years of research support the idea that suicidal behavior can be “contagious,” showing an increase in suicide rates following media stories on suicide. One review from 2013 points to more than 50 studies on “nonfictional stories reported in newspapers, on television, and more recently on the Internet” that have yielded consistent findings that suicide rates increase when reporting on it goes up—especially when that reporting involves dramatic headlines, description of the suicide method and other details, and prominent story placement. (Stories about how people coped with suicidal feelings, meanwhile, are not associated with a subsequent rise in suicides.)
Many other mental health programs that were once thought to be innovative and helpful, turned out, after comprehensive study, to either do nothing or even cause harm. The substance abuse prevention program D.A.R.E. (Drug Abuse Resistance Education) is still being taught in schools despite the body of research that shows it does nothing to prevent teens from using drugs, and may even increase their likelihood to drink alcohol and smoke cigarettes. Critical Instance Stress Debriefing, a post-trauma technique that encourages people to talk through feelings after experiencing a traumatic event like a school shooting, now looks like it worsens symptoms of PTSD, according to recent studies.
Nock doesn’t put suicide hotlines in the same category, though. “Like with clergy, mental health counselors, Alcoholics Anonymous—having supportive people there to talk to you when in need, seems like a humane, logical thing to do even in the absence of evidence,” he says. When asked if he recommends including the hotline number at the end of this story, he says, “I would. I do think it’s a valuable service. But I also think it’s a shame that there’s not more evaluation.”
Suicide hotlines have been around for more than 50 years. The national hotline is a portal to local call centers, there are more than 160 around the country. Lack of funding makes it difficult to establish across-the-board standards of care and consistent follow-up with callers. Operators are usually trained volunteers, and according to Draper, typically follow a five-step guideline that the NSPL also posts online for anyone to use, advising the recommended way to talk to someone who is suicidal. “These are very human steps anyone can do,” he says, including listening and connecting them with professional mental health support.
Last year the NIH spent about $35 million on suicide prevention—the same amount as they did on eczema research. While the CDC’s latest report says that suicide rates have gone up by nearly 30 percent in the past 15 years, rates rise and fall over time. Today’s rate is nearly identical to the suicide rate in 1916. Death rates by cancer and HIV/AIDS—both at one time whispered and stigmatized—have dropped significantly after increased funding for research.
At his Harvard lab, Nock and his colleagues are developing studies to look at the efficacy of hotlines, and how to track callers’ progress, like following them on an app or through medical or death records. (They have not begun to do this yet). The anonymity of suicide hotlines creates an additional obstacle, as does the fact that it’s difficult to determine if the person calling was genuinely at risk for suicide in the first place.
The “holy grail,” as Nock puts it, is finding out who is at the most risk of dying by suicide. “Right now, it’s impossible to know for sure,” he says. “Once someone makes a suicide attempt, then we say, ‘This person’s at risk, let’s treat them.’ What would be much better is if we have methods of identifying people before they’re suicidal, not relying on them to come and ask for treatment.”
Facebook has developed an algorithm, using machine learning to detect posts that indicate someone might be at risk. They use two classifiers: the user’s posts—for example, “I’m so sad,” or “Goodbye”—coupled with comments to the page: “Are you OK?” or “Do you need help?” The company has worked with emergency responders and done wellness checks on individuals identified as at risk. Facebook did not, however, confirm if they have any data to support the program’s efficacy, and declined to be interviewed for this story.
Once a person has elected to get treated, there are scientifically supported interventions that are promising for people who are suicidal. Current research supports targeting suicidal thinking directly (as opposed to solely treating depression or anxiety), like suicide-focused cognitive therapy, and dialectical behavioral therapy, which, among other things, teaches patients how to manage painful emotions, and has shown to lower rates of suicide re-attempts.
Nock and his team have developed a game-like app, Tec-Tec, that uses aversion therapy, like images of spiders and snakes, to decrease self-harm and suicidal behaviors in users who play. Randomized controlled trials show it to be promising. There are medications, like lithium, for people with bipolar disorder, that have been linked with decreased risk of suicidal behavior and suicide death. And ketamine shows promise in reducing suicidal ideation within a few hours.
The challenge is getting the newest research and innovations into the hands of clinicians. “There’s a huge science-to-practice gap,” Nock says. “With pharmaceuticals, you can create a pill, test it out, it works, bottle it up and people can dispense it. It’s trickier to transport psychological interventions.”
Draper says that about 25 percent of the people who call the national suicide lifeline are suicidal; some tell the operators that they are in the process of killing themselves while on the call. “If we can get them in that moment [of trying to kill themselves],” he says, “it can make a difference. Because people are often extremely ambivalent about killing themselves.” The operators can point callers to other mental health services in their city, and help them develop coping plans for future crises. “A number of callers say, ‘No one has ever talked to me about how I can take care of myself,’” Draper says.
One of the simplest things a friend or family member can do, Nock says, is to ask someone if they are having suicidal thoughts. Bringing up the word doesn’t cause harm, it doesn’t make someone suicidal, and research supports that.
“There’s a lot that people are doing in the name of suicide prevention,” Nock says. “And it’s great that it’s being done. But it would be better if it were being evaluated. I think suicide researchers and service providers need to be held more to account for demonstrating the evidence base that we’re operating on.”
If you are struggling with a mental health issue in USA call the National Suicide Prevention Lifeline at 1-800-273-8255 . In Canada, visit suicideprevention.ca for more information on how to get help.