- Half of those who die by suicide had no diagnosed psychiatric risk factors like depression.
- The absence of genetic risk factors for depression suggests something "meaningfully different" was in play.
- The study couldn't say how many of those who died by suicide were depressed but not diagnosed.
It’s not uncommon when someone dies by suicide for bereft loved ones to ponder — and sometimes beat themselves up over — how they missed the signs leading up to the death.
A new study from the University of Utah offers both comforting and frustrating new evidence that there might not have been any traditional signals of a struggle. While a death by suicide for some is preceded by suicidal ideation and behavior, including survived attempts, about half of those who take their own lives have no documented suicidal thoughts or behaviors and no known mental health conditions linked to suicide risk, such as depression.
There were no clear indicators of risk.
Those are the findings of a genetic study in which university researchers teamed up with the Utah Office of the Medical Examiner to try to learn more about the drivers of suicide, using genotyping data from 2,769 de-identified electronic health records and clinical notes of individuals who died by suicide. They thoroughly analyzed the genetic data of those who died to analyze genetic risk.
The findings are published in JAMA Network Open.
The study showed that those who died by suicide without earlier suicidal behaviors had fewer psychiatric diagnoses and underlying genetic risk factors for mental health conditions than those who exhibited warning signs, according to Hilary Coon, a professor of psychiatry in the Spencer Fox Eccles School of Medicine at the University of Utah and the study’s first author.
She told Deseret News that the sheer number of suicide deaths with no previous indicators, including depression diagnosis, suggests it’s not just a matter of many not having sought treatment or due to gaps in screening or care. It indicates that paying attention to mental health remains very important, but that emphasis alone is not likely to identify all who may ultimately end their own lives.
“Maybe we need to think about what people struggle with in a more broad way,” she said.
Suicide a multifaceted issue
The Centers for Disease Control and Prevention reported that in 2023, 49,000 individuals in the U.S. ended their own lives, making suicide the 11th leading cause of death nationally.
Coon describes suicide as a complicated behavior. She noted that what’s going on with someone who is young and impulsive or dealing with significant depression is different from someone later in life who has chronic health conditions or other stressors, for instance. She spoke of suicide survivors who said they were not depressed or anxious, but rather were in situations that felt unmanageable.
She also noted that at some point everyone experiences traumas and events that are challenging and most don’t take their lives. But the difference between those who do and those who don’t is hard to untangle.
Traditional screening is likely ineffective in many cases, she said.
“Prior suicidality is the most robust estimator of suicide death, but the association with this estimator is imperfect, and many suicide deaths occur in its absence,” per the study.
Regarding clinical interventions, the study said “a focus solely on mental illness risk reduction may be less effective for individuals for whom this underlying liability may be substantially lower.” It added that “further understanding of clinical characteristics, underlying genetic liabilities, and external exposures” in those cases without known previous suicidal behaviors or mental health challenges “will be required to direct more targeted interventions.”
“Clinicians do a good job of understanding people who have warning signs. The others, we don’t know who they are,” Coon said.
Screening risk factors
When they looked at the genetic data, the researchers found those without earlier suicidal ideation and behavior had fewer risk factors for a variety of psychiatric conditions — not just depression, but also anxiety, Alzheimer’s disease and post traumatic stress disorder. They appeared to have less genetic vulnerability to other conditions, like heart disease. In a news release about the study, the researchers said that “this group isn’t any more likely than the general population to have milder conditions like depressed mood and neuroticism,” either.
The researchers note some limitations, including that some with previous suicidal notions may not have had those captured in the data.
They also noted most of those in the data were of European ancestry, so findings might not be generalizable to all groups.
Coon said that future research will try to tease out some of the hidden risk factors, including links between suicide and chronic pain or major medical issues.
She and her colleagues are also trying to figure out what factors might be protective against suicide. People in similar situations have different degrees of resilience.
Coon is careful to point out that genetic risk factors that may play a role still have a very small effect on risk overall and that none of them actually cause suicide. As the background material notes, “Environmental and societal contexts are crucial contributors to risk, and understanding the interplay between the environmental and underlying biology will be essential to discovering who’s at risk.”
She’s hoping the research they’ve done will help identify other factors and their contexts outside of mental distress that contribute to risk so that suicides can be prevented.
“We hope our work will begin to define subsets of individuals at risk, and also the contexts in which these risk characteristics may be important,” Coon said in the news release. “If people have a certain type of clinical diagnosis that makes them particularly vulnerable within particular environmental contexts, they still may not ever say they’re suicidal. We hope our work may help reveal traits and contexts associated with high risk so that doctors can deliver care more effectively and specifically. ”
Coon also suggested resources for those who may be struggling:
Call 988 to reach a 24/7 free, confidential support line for suicidal crisis or emotional distress. On the Wasatch Front, the Huntsman Mental Health Institute Crisis Care Center offers 24/7 walk-in mental health services for adults. Additional information and assistance can be found through the Utah Chapter of the American Foundation for Suicide Prevention.