Why Suicide Prevention May Depend Less on Prediction—and More on Safety

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For clinicians who study suicide, one of the most difficult questions is also one of the most important: Who is likely to die by suicide soon?

Paul Nestadt, a psychiatrist who treats suicidal patients, has co-authored scores of research papers on suicide and teaches graduate courses on the subject. Yet he says he cannot identify which of his patients will die by suicide in the next six months.

That uncertainty is not unusual. Research indicates that predictions of who will become suicidal are only slightly better than a coin toss, and that performance has not improved over the past 50 years.

A prevention strategy that does not depend on perfect prediction

The limits of prediction have encouraged researchers to focus on interventions that can help without first identifying every person at immediate risk. One central approach is limiting access to lethal means—the methods people may use to attempt suicide.

Those measures can include barriers on buildings and bridges, limiting the number of pills someone can buy or receive at one time, and reducing access to guns. Nestadt has said that reducing access to firearms would save the most lives.

Preliminary federal data cited in the reporting show that more than 28,000 people died by firearm suicide in the relevant year, accounting for more than half of all suicide deaths in the United States. Gun suicides reached record highs for five consecutive years even as the overall suicide rate recently declined.

What extreme risk protection orders can—and cannot—do

Extreme risk protection orders, often called red flag laws, have been adopted in some form in 22 states and the District of Columbia. They allow judges to temporarily remove firearms from a person when evidence indicates that the person may pose a danger to themself or others.

Research suggests these laws are more effective at preventing suicide than at preventing mass shootings, although mass shootings have often prompted their passage. Studies across other states have found that one suicide is averted for every 10 to 20 firearms removed under such orders.

Michael Anestis, of the New Jersey Gun Violence Research Center, cautions that these laws are designed to target specific people identified as being at high risk. They may not reach people who are quietly suicidal and have not raised concerns with family members or clinicians.

That gap matters. Studies indicate that people who die by suicide using firearms are less likely to have sought mental health care in the past. Most veterans and service members who die by firearm suicide also do not tell anyone about suicidal thoughts in the months before their deaths.

Population-level safety measures

Nestadt compares this approach with road safety. Speed limits, seat belt requirements, airbags and shatter-resistant windshields do not require officials to predict which individual driver will crash. After such measures were introduced, the rate of crash deaths declined significantly.

A similar public-safety strategy for suicide prevention could include permits and background checks for gun purchases, as well as waiting periods before a purchase is completed.

Research from two states illustrates why these policies remain part of the debate, while also underscoring the limits of drawing conclusions from individual studies. One study found that Connecticut’s adoption of a permit-to-purchase law was associated with a roughly 15% decrease in firearm-suicide rates. Another found that repealing Missouri’s permit-to-purchase law was linked to a 16% increase in firearm-suicide rates. These findings describe associations, not proof that a single policy caused the entire change.

Broadening the prevention conversation

Medication and therapy are lifesaving measures, but clinicians, researchers and people who have lost loved ones to suicide have argued that prevention must extend beyond treatment alone.

Firearm suicides have increased for several years while suicides by suffocation—the second most common method mentioned in the reporting—have decreased. That contrast reinforces the researchers’ broader point: changing access to lethal means may reduce deaths even when it is impossible to know exactly who is at risk.

The goal is not to replace mental health care or individual support. It is to add safety measures that can protect people during periods of crisis, including periods that may not be visible to the people around them.

AI tools were used to assist with the preparation of this article.