What leads to death from suicide: mental illness, or opportunity? An article in the New York Times Magazine suggests that it’s firearms and poorly designed high bridges — easy and effective means — that kill. The model is called “the British coal-gas story”; when England turned to fuels with lower carbon monoxide content, so that you could no longer suffocate yourself by “sticking your head in the oven,” the suicide rate dropped by a third.

The “coal gas” perspective is important, but it’s hardly news. In April 1983, my psychiatry residency mate, Jeffrey Boyd, contributed a widely-cited essay titled "The Increasing Rate of Suicide by Firearms" to the New England Journal of Medicine. Boyd suggested that the key to death reduction might be a restriction in handgun sales — on the model of reducing the carbon monoxide content of gas used in households.

Firm numbers are hard to come by, but the standard figure in the mental health literature has it that perhaps half of people who commit suicide were depressed at the time. That figure explains why it is difficult to affect suicide rates through changes in medical care alone. Much of the effort doctors make involves trying to prevent this pending attempt, here and now, in the belief that mitigating suicidality in the short run saves lives in the long run. This philosophy is in accord with the one the journalist, Scott Anderson, reports on in the Times. In fact, the magazine piece echoes what doctors have long been taught.

Final note: despite the very partial contribution of mental illness to suicides, the role of concrete factors like handguns, and the importance of “secular trends” (unexplained or socially mediated fluctuations in rates over time), researchers were able to identify reductions in the suicide rate in connection with the introduction of the newer antidepressants, like Prozac and Celexa. After the medications became available in a locality, suicides tended to drop, including suicides by adolescents. (I list the relevant studies on pages 300-301 of Against Depression.) This finding is extraordinary; historically, perhaps no other change limited to the realm of medicine, narrowly taken, has made suicide rates budge. Of course, doctors can, and do, define their field more broadly. We understand public health initiatives, like gun control, as medical.

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