Q&A: Suicide prevention entails ‘shift from reactive to proactive’ methods

September 12, 2025

7 min read

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Key takeaways:

Suicide affects virtually all demographics in the United States.
Patients, clinicians, immediate family, health care and government must be involved to mitigate risk.

According to a survey from the federal Substance Abuse and Mental Health Services Administration, in 2024, 14.3 million U.S. adults had serious thoughts of suicide, 4.6 million made a suicide plan and 2.2 million attempted suicide.

In observance of September being Suicide Prevention Awareness Month, Healio spoke with Paul Nestadt, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins Medicine and medical director of the Johns Hopkins Center for Suicide Prevention.

Nestadt provided insight into the state of suicide prevention nationwide, as well as what individuals and health care professionals can do to minimize the risk of suicide.

Healio: What are you seeing in terms of trends with suicide in the United States that might cause the most concern for academics and clinicians?

Nestadt:I should probably preface it by saying that we actually don’t have the newest data up through 2025, and this is relevant. The CDC does the best job of tracking suicides and alerting us to these trends, but the teams working on this have been decimated this year.

We don’t know conclusively about national trends after 2023, which is 2 years ago. With that in mind, in the trends we have been seeing, there’s been a troubling increase in suicides by firearm, especially since firearms have always been the most common method of suicide in the United States. But the proportion of suicides by firearm have only increased, as 55% of suicides in the latest data are by firearm.

That’s concerning, especially among young people and in rural communities where the trends have been increasing the most, not only because firearms are so lethal, but because firearm suicide is a preventable cause of suicide that we could be doing more about.

There also are many opiate overdose suicides. Opiates are very lethal in overdose, whether used accidentally or with the intent to die, but many of those intentional deaths are not called suicides.

It is very difficult for a medical examiner or a coroner to be sure whether someone that overdosed did so accidentally or purposefully to end their life. And so, they’re often either called “accidents” or called “undetermined manner,” and those don’t go into our suicide numbers. It’s a blind spot for us.

We’ve done studies that have found that there is a bias in the folks who die by overdose who are not called a suicide. We undercount specifically people of color and women, two populations that tend to more often use overdose and then are undercounted.

Healio: Which groups among those you previously mentioned would be the most vulnerable to suicidality or suicide itself?

Nestadt: Young people, especially adolescents. Young adults are a key area of concern.

They’ve had a particular increase in firearm suicide and suicide in general. Within that population, young African Americans have been showing a dramatic increase in suicide, again, driven by firearm suicide.

There always has been a disproportionate burden of suicide among indigenous communities that has only increased. There also are worrying trends in suicidality, meaning suicidal behavior and suicidal thoughts. The LGBTQ-plus population has a much higher rate of suicidal thoughts and attempts, although it is hard to be certain if their suicide death rate is higher than in their heterosexual peers because that is not documented very well in CDC data anymore.

Middle-aged men and older men, especially men over 85, still have the highest suicide rate in the country.

We talk about vulnerable populations. It is not just about demographics. We’re talking about race and age and sex here, but it’s also about the vulnerability that comes with access to lethal means or vulnerability because of lack of social support or structural barriers to care. So, people that don’t have the resources to seek mental health care or stigma against seeking mental health care remain very vulnerable to suicide as well.

Healio: Have you or any of your colleagues seen anecdotal evidence of a rise in depression, suicidality or despair given currentpolitics?

Nestadt: I would never want to over-attribute something as complex as suicide to any one aspect of people’s lives. We were prone to do that during the COVID pandemic.

It is a heterogeneous group of decedents that come to suicide through different pathways. That said, polarization and uncertainty can absolutely exacerbate stress and mental health challenges, especially among groups who feel marginalized – or whose rights are being

debated – and may experience heightened distress.

On the other hand, when the political discourse leads us to reconsider firearm policies or expand access to healthcare, then we see positive effects on suicide prevention.

Although many federal programs have been cut dramatically, including ones that made it easier for people who were suffering or who were vulnerable, there haven’t been as many cuts to, for instance, 988, the crisis line.

The line is a valuable resource for families who are worried about a loved one to call and say, “Hey, how do I handle suicidal thoughts I suspect are present in my loved one, my child, my spouse?”

988 can often refer people to therapy, to providers, and they can give advice. For instance, a patient’s family member recently told me that they had been worried about the patient and called 988, which informed them about how, in Maryland, we have a red flag law, an extreme risk protection order (ERPO) law. This was a patient who had a gun. The family was able to get information about how to file a petition to have the gun removed from that person who was at risk, and it was arguably lifesaving.

I wouldn’t pin suicide increases on politics so much. I think mental health care plays a much bigger role. We know that 90% of suicide deaths are precipitated by or predisposed to by having a psychiatric illness, and we know those illnesses are treatable. I prefer to focus on psychiatric illness because it’s something we can do a lot more about than we can about the political situation.

Healio: How would friends, siblings, parents and other care partners of those who are suffering best help those who may be considering suicide?

Nestadt:The most important step is to take any mention of suicide very seriously.

If you have a loved one who is reporting that they’re feeling that they want to end their life, acting quickly is important. So right off the bat, help by referring them to care, referring them to treatment.

If someone that you care about is seeming different, down, drinking more, using drugs, not seeming to enjoy things they used to enjoy, or withdrawing, you shouldn’t be afraid to ask directly, “Are you thinking about suicide?”

There is a myth that you can plant that idea in someone’s head, that if someone is depressed, then I don’t want to ask them about suicide because, what if that makes them start thinking about suicide? That’s not how it works. People are not that malleable. You want to encourage people to seek professional help.

A safety plan is also something that can be done just by an individual. Help the patient to come up with a list of things that might be warning signs of their suicidality increasing, or that might indicate acute risk. Then, list what they might do about it, like a list of who they might call? Then, list things they might do to help alleviate those thoughts.

For some people, it might be taking a walk or listening to music or doing something else that relaxes them. It’s going to be very individualized, but it’s good to have that written down so, in the acute moment, you can go to it. Then finally, the last part of a safety plan is making sure that the environment is safe. Remove dangerous weapons or poisons.

Healio: On a macro level, what plans, initiatives or programs would you suggest can address the major themes of suicide in the U.S.going forward?

Nestadt: The overall theme of what I would suggest is seeing suicide as a public health problem as opposed to a fully medical problem. When I was in med school, car accidents were a leading cause of death for young Americans. Over the last 20 years, car accident deaths have really gone down.

Unfortunately, suicides now have overtaken them as leading cause of death for young people. But the way we were able to work on car accident deaths was not with individual approaches like identifying who’s at risk of a car accident. It was at a whole population level. Every car needs to have airbags, and every state must have laws about seat belts and highway speed limits. These things worked at a population level, not to decrease car accidents, but to make those accidents, which are hard to predict, less fatal.

If we do population level intervention, what may work is having policies that make it harder to immediately access guns, things like waiting periods, background checks, permits to purchase, and extreme risk protection orders.

Since 2018, 21 states have enacted red flag laws, as have Washington, D.C., and the US Virgin Islands. More and more of those states are bringing clinicians in to help to be potential petitioners, not just the police or family members, but clinicians who are a little bit better identifying that kind of a risk.

We recently published a study that found that states that included clinicians as filers for their ERPO petitions had a further 15% decrease in firearm suicides overall, with Black firearm suicides dropping even further, by 24% in the model.

There’s also growing interest in other population level approaches like school-based prevention, intervening early in a school career, for elementary age kids. Things like the “good behavior game” have been shown to teach kids how to deal with emotional stress and develop positive social skills, which echoes out into suicide prevention at a population level, not just the kids they think might be at risk for suicide, which we can’t predict.

Workplace interventions, or making sure that workplaces have employee assistance programs, and public health surveillance systems that integrate medical examiner data also would help. Public health surveillance is really important.

The purpose of all these things is to shift from reactive to proactive suicide prevention so that suicide prevention just becomes a routine part of public health practice.