We Need to Rethink Suicide Prevention, Starting Long Before Crisis

When I tell people I work in suicide prevention, they often assume I spend my days answering crisis calls or serving as a counselor. Those roles are essential. But the assumption reveals something deeper about how we, as a society, think about suicide prevention. We picture it at the moment of crisis. We rarely picture everything that comes before. For decades, our national approach to suicide prevention has leaned heavily on intervention and treatment. We search for warning signs and utilize screening tools that inform us if someone may be struggling. We build hotlines and crisis teams. We train people to respond when someone reaches a point of such despair that they want to die.  These tools save lives every day, and we must continue to strengthen them. But if we want fewer people to reach that point of despair in the first place, we need to expand our vision for what suicide prevention is and what it can be. We’ve built a system that waits too long Our current paradigm is often belatedly deployed only once a suffering person reaches a breaking point. We provide training to help people notice and support someone who may be in crisis, then attempt to plug them into a mental health system that is too often inaccessible and overburdened. We have placed the greatest weight on the most fragile moment. The field of public health offers a roadmap for a better way. There was a time, in the 1960s and 70s, when heart disease prevention focused almost entirely on emergency interventions like CPR and cardiac surgery after a heart attack. We have drastically reduced deaths due to heart disease by 66% in the U.S. from 1970 to 2022. However, CPR training, better surgical techniques, and putting defibrillators in shopping malls were only a part of this success. Improving nutrition, reducing tobacco use, and establishing social and cultural norms around exercise created an environment that better prioritized overall health. Mental health requires the same shift. We cannot simply counsel or legislate our way out of the crisis. Downstream interventions will always matter, but upstream prevention must become a central pillar of our national strategy, not an afterthought. The phrase “upstream prevention” comes from a classic public health parable, in which rescuers pull drowning people out of a river at the edge of a waterfall, eventually moving upstream to stop people from falling into the river in the first place. In practice, upstream suicide prevention means changing the conditions that either promote wellbeing or drive despair, not waiting to respond only once people are in pain. The economic case for this shift is strong; when we improve the conditions that keep people well, we reduce costly emergency care, hospital stays, and crisis-driven interventions, generating returns that far exceed the initial investment. We need a both/and model: a comprehensive approach that supports people in crisis, while also building the conditions that prevent the crisis in the first place. Humanize before we pathologize When we talk about mental health, we often do so through a lens of mental illness. We jump quickly to diagnosing and pathologizing, rather than understanding our struggles as a natural part of what it means to be human.  Feelings like sadness, fear, anger, or anxiety are not negative emotions, they are human ones. And we need more dialogue about what helps us humans navigate the difficulties that life brings our way. These experiences become overwhelming when we face them alone, when our environments are unsafe or isolating, or when we lack the tools, skills, and relationships to help us navigate the storms of life when they come.  There is a meaningful difference between the diagnosis and treatment of mental illness and the cultivation of mental health. A thriving society invests in both. This is where upstream prevention is crucial. To shift the trend line, we must focus on the leading causes of life: connection, hope, purpose, belonging, and the sources of strength that give depth to our lives. These protective forces help us to navigate life’s hardest moments. They are not replacements for therapy or crisis care. They are the foundation that makes healing, growth, and resilience possible. The evidence is growing, and it is compelling This is not just theoretical. We now have promising data that demonstrates the potential of upstream approaches to make a measurable impact. Colorado recently recorded its lowest youth suicide rate since 2007, the lowest rate in the lifetime of today’s teens. That progress wasn’t driven by a single program or policy. Instead, Colorado made upstream efforts a core part of its comprehensive strategy, not an afterthought. Recent research findings echo this pattern. In a randomized controlled trial involving more than 6,000 U.S. high school students, Sources of Strength, an upstream, peer-led prevention program that I help lead, significantly reduced new suicide attempts by 29% over two school years. A pooled analysis combining three randomized control trials spanning over a decade with over 40,000 student years of exposure to Sources of Strength showed lower suicide mortality in participating schools compared with controls. This is the first universal intervention to demonstrate reductions in attempts and deaths amongst youth through randomized trials. These findings focus on youth outcomes, but the protective forces they highlight are universal. Trusting relationships, positive social norms, healthy coping skills, a sense of belonging, and environments where people feel valued matter at every age. When we feel supported in these ways, we navigate distress differently, whether we are 15 or 55. The National Action Alliance for Suicide Prevention recently released new guidance on moving upstream, affirming the importance of connection, belonging, economic stability, and community-level protective factors. This is real progress. The next step is translating that guidance into action at scale. Stable housing, economic supports, safe communities, inclusive policies, supportive workplaces, and compassionate classrooms are not abstract ideals. They are fundamental components of effective suicide prevention. A new goal for suicide prevention Effective suicide prevention cannot be limited to keeping people alive when they are at their lowest point. Our goal must be to prevent those moments of suicidal despair from forming in the first place. It must be to help people heal, and to build lives of beauty, purpose, connection, and joy. Progress in suicide prevention has always come from a community: survivors, people with lived experience, clinicians, researchers, educators, advocates, and policymakers who drive this lifesaving work forward. We will always need crisis lines, mobile response teams, and evidence-based treatment. But if we want to see meaningful and lasting change, upstream prevention must stand alongside these tools as a central pillar of our national approach. If you or someone you know may be experiencing a mental-health crisis or contemplating suicide, call or text 988.