Suicide is a complex issue involving numerous factors and should not be attributed to any one single cause. Not all people who die by suicide have been diagnosed with a mental illness and not all people with a mental illness attempt to end their lives by suicide.
People who experience suicidal thoughts and feelings are suffering with tremendous emotional pain. People who have died by suicide typically had overwhelming feelings of hopelessness, despair, and helplessness. Suicide is not about a moral weakness or a character flaw. People considering suicide feel as though their pain will never end and that suicide is the only way to stop the suffering.
Many factors and circumstances can contribute to someones decision to end his/her life. Factors such as loss, addictions, childhood trauma or other forms of trauma, depression, serious physical illness, and major life changes can make some people feel overwhelmed and unable to cope. It is important to remember that it isnt necessarily the nature of the loss or stressor that is as important as the individuals experience of these things feeling unbearable.
Suicide is Complex:
How Can Suicide Be Prevented
The majority of suicides can be prevented. There are a number of measures that can be taken at community and national levels to reduce the risk, including:
At a more personal level, it is important to know that only a small number of suicides happen without warning. Most people who die by suicide give definite warnings of their intentions. Therefore, all threats of self-harm should be taken seriously. In addition, a majority of people who attempt suicide are ambivalent and not entirely intent on dying. Many suicides occur in a period of improvement when the person has the energy and the will to turn despairing thoughts into destructive action. However, a once-suicidal person is not necessarily always at risk: suicidal thoughts may return but they are not permanent and in some people they may never return. Source: World Health Organziation (WHO) How can suicide be prevented?
Promoting Hope and Resiliency is Central to Suicide Prevention:
Hope and Resiliency should be reflected in all suicide prevention activities and messaging.
Suicide Prevention is Everyones Responsibility:
How We Talk About Suicide Makes a Difference:
Prevention, Intervention, and Postvention (Hope, Help, and Healing) are the three areas of focus when working in the area of suicide.
They can be understood as the before, during and after experiences of thoughts of suicide, attempts or death. Everyone has a role and contribution to preventing suicide in one or more of these areas. You dont have to be an expert. You do need to know how to take care of yourself and help another person get to safety if the need arises.
Certain Segments of Our Society, Especially Those Who Have Been Marginalized, are at Greater Risk of Suicide:
Societal Attitudes and Conditions Have a Profound Effect on Suicide and Suicide Prevention:
Suicide Prevention Should be Imbedded Into the Mosaic of Community Resources:
Suicide Prevention is Strengthened When it is Guided by the Principles of Trauma Informed Care:
Knowing When and How to Ask about Suicide Saves Lives:
Suicide Prevention Strategies and Programming Must be Knowledge-Based:
Suicide Prevention Leaders and Supporters Encourage Diverse Points of View:
Commitment to a Community Based Approach:
Suicide & Mental Illness
There is no single mental illness diagnosis that is exclusively responsible for death by suicide. The majority of people who live with a mental illness do not attempt nor die by suicide. Some estimated facts:
Risk for death by suicide is increased
if a person suffers from depression alongside schizophrenia,
bipolar illness, substance abuse, anxiety disorders. Those
who struggle with a diagnosed personality disorder can be up
to 3x more likely to die by suicide than those without and,
risk is increased if they also struggle with a substance
abuse disorder. It is important to get treatment for a
of Suicidal Crisis
The Houston study interviewed 153 survivors of nearly-lethal suicide attempts, ages 13-34. Survivors of these attempts were thought to be more like suicide completers due to the medical severity of their injuries or the lethality of the methods used. They were asked: How much time passed between the time you decided to complete suicide and when you actually attempted suicide? One in four deliberated for less than 5 minutes! (Simon 2005).
Duration of Suicidal Deliberation:
24% said less than 5 minutes
A study from Deisenhammer asked people who were seen in a hospital following a suicide attempt how long before their suicidal act they first started thinking about attempting it. 48% said within 10 minutes of making the attempt. The full distribution is as follows:
Less than 5% between 11-2=-30, 31-60, 1-6 hours, 6-24 hours, then 10% for 1-7 days, 1-4 weeks and 1-12 months.
Hawton K. Restricting access to methods of suicide. Crisis. 2007;28 (S1):4-9.
Simon, T.R., Swann, A.C., Powell, K.E., Potter, L.B., Kresnow, M., and OCarroll, P.W. Characteristics of Impulsive Suicide Attempts and Attempters. SLTB. 2001; 32(supp):49-59.
Personal communication, Thomas Simon, March 15, 2005.
Williams, C., Davidson, J., & Montgomery, I. Impulsive suicidal behavior. Journal of Clinical Psychology. 1980;36, 90-94.
de Moore GM, Plew JD, Bray KM, and Snars JN. Survivors of self-inflicted firearm injury. A liaison psychiatry perspective. Medical journal of Australia. 1994;160(7):421-425.
Peterson L, Peterson M, OShanick G, and Swann A. Self-inflicted gunshot wounds: Lethality of method versus intent. American Journal of Psychiatry. 1985;142:228-231.
Eddleston M, Karunaratne A, Weerakoon M, et al. Choice of poison for intentional self-poisoning in rural Sri Lanka. Clinical Toxicology. 2006;44:283-6.
Deisenhammer EA, Ing CM, Strauss R, et
al. The duration of the suicidal process: how much time is
left for intervention between consideration and
accomplishment of a suicide attempt? J Clin Psychiatry.
With the news this week of the deaths of Kate Spade and Anthony Bourdain, reactions and commentary are pouring in on social media. People who never met them are grasping for answers as to why these icons could meet such a tragic end. Specifically they may be asking, How could they do this? Its a common question in the aftermath of a suicide that, though typically innocent in nature, is loaded with crucial misunderstandings about suicide and, in some cases, mental illness.
What exactly is the problem? Partly its in the language. Asking how someone could do this puts responsibility on the victim, just as the phrase committed suicide suggests an almost criminal intent. Depression and other mental illnesses are leading risk factors for suicide. This is why mental health advocates usually employ the term died by suicide, as it removes culpability from the person who has lost their life and allows a discussion about the disease or disorder from which they were suffering.
That said, suicide is rarely caused by one single factor. According to a Vital Signs report, Centers for Disease Control (CDC) researchers found that 54 percent people who died by suicide were not known to have a mental illness diagnosis. While many cases of suicide are attributed to mental illness diagnoses, other issues like relationship and financial stress and substance abuse contribute to rising rates of suicide.
IN THE MOMENT, WHAT SEEMS IRRATIONAL CAN FEEL COMPLETELY RATIONAL
In interviewing people who have [survived] suicide, what becomes apparent is that suicide in the moment that they attempt to enact it seems to them a very logical solution to their problems, says Dr. Anna Lembke, an associate professor of psychiatry and behavioral sciences (general psychiatry and psychology-adult) at Stanford University Medical Center. Most often their problem is feeling profoundly unworthy, profoundly depressed and profoundly burdensome to others. What seems irrational from the outside in their mind is, in that moment, completely rational. And this thought of being a burden is a recurring theme that comes up again and again.
Dr. Rebecca Bernert, a suicidologist and the director/founder of the suicide prevention research laboratory at Stanford School of Medicine adds that research suggests that people at greatest risk for suicide may perceive themselves to be a burden or feel a lack of belongingness, even if this may be a harmful misperception.
Because this feeling of being a burden is so strong, suicide can be viewed as not a selfish act but almost a selfless act, by its victims, Dr. Lembke explains. Theres a gross underestimation of the psychological impact of what a suicide will be, even to loved ones, and an irrational sense that [ones death] will help people, even those they love the most. This thinking is deeply informed by being in an altered mental state caused usually by depression or depression and psychosis.
NOT EVERY DEPRESSED PERSON DEVELOPS SUICIDAL THOUGHTS AND NOT EVERY PERSON WHO DIES BY SUICIDE IS DEPRESSED
Not everyone who suffers from depression will have suicidal thoughts. And not everyone who has suicidal thoughts will act on them. Why are some people more at risk than others? Theres no one answer for this complicated issue.
Suicide is a complex outcome of medical illness and a diverse interplay of risk factors, says Dr. Bernert. Though a symptom of depression, suicidal behaviors exist on a continuum of risk, ranging in severity from suicidal thoughts to attempts to death by suicide. Only a small fraction of those with depression will go on to die by suicide.
Dr. Urszula Klich, a clinical health psychologist who implemented suicide prevention training program in a previous role at Shepherd Center in Atlanta, Georgia, notes that in her current experience treating chronic pain patients (which she notes as a very high-risk category for suicide), Some patients, no matter how depressed they are, never have suicidal thoughts and never does their depression manifest to their being at risk for suicide.
Just as a depressed person may never become suicidal, a person who has never been depressed can become suicidal seemingly out of the blue. But there is almost always, Dr. Klich says, some form of working up to the act. Sometimes a loved one can detect and intervene (successfully or not); sometimes they cant.
If we take a look at the acquired ability or the so-called capability a person has when completing suicide, we know they work up to the act. We see some things unfolding. They may have talked about it with someone, and that person will later recall them saying something odd. But we also see suicidal patients doing some sort of rehearsals, she says. They may not even be planning suicide, but theyre playing around with the idea. Maybe, if they have a gun, they will take it out and load it and then unload it and put it away. Or, in the case of overdoses, theyll take out pills and count them, Dr. Kilch says.
These planful behaviors, as Dr. Bernert puts it, signal a heightened risk, even if the act itself may appear differently.
IF YOU KNOW SOMEONE AT RISK, GET SPECIFIC WITH YOUR QUESTIONS
To be clear, this doesnt mean that survivors of loved ones who died by suicide missed warning signs, because you cant miss signs if you dont know theyre there; and as Dr. Klich points out, certain suicidal behaviors can only be aptly picked up on by trained professionals, especially in the case of those mentally rehearsing or visualizing symptoms that can occur without the persons full awareness that this is indeed a kind of suicidal thinking. Additionally, because millions of Americans have depression and dont have with suicidal thoughts, it can be hard if not impossible to tell who is at risk and who is not.
But if youre concerned about a loved one being at risk, you can possibly help by speaking up.
Speak with your loved one about how they are feeling and encourage help-seeking by way of the many resources available, including the American Association for Suicide Prevention and American Association of Suicidology and confidential helplines, says Dr. Bernert.
And be direct in your conversations when you can. Dr. Klich finds that because suicide is so stigmatized (and also, just a really tough thing to talk about), people tend to skirt around the issue, or even unintentionally steer victims of suicidal thoughts toward a reassuring answer.
Very often people will say, you wont do anything, right? she says. I see this even in the medical field. Professionals will say to patients, you havent thought about self-harm or suicide, right? Who would answer positively in response to that? Not many people.
Maybe a better way to ask is to leave it open-ended and nonjudgmental. You might want to say, Are you having suicidal thoughts or imaginings?
AN ONGOING STRUGGLE TO UNDERSTAND
When were grieving this kind of death, we'll likely have questions. Even now, perfect strangers are trying to put together a puzzle of what happened to result in these celebrity deaths, of what they missed, of why we had no idea of their possible struggles (not that they are any of the publics business).
But if someone you did know has died by suicide caused by a mental illness and are looking for a way to understand it, consider Dr. Lembkes moving analogy.
We talk about death with cancer and heart disease but not death when associated with mental illness, says Dr. Lembke. But some people do die from it. Suicide is like a massive heart attack of the brain.
If youre feeling triggered or at risk, please follow Dr. Bernerts advice:
Confidential support is
available 24 hours a day, 7 days a week by way of the
National Suicide Prevention Phone Lifeline (1-800-273-TALK)
or text (273TALK) or the Crisis Text Line, (741741)
she says. These are available to anyone, whether in
crisis or concerned about a loved one who is experiencing
More than two months later, it remains cold and abandoned as his teammates try to move on with football practice about a mile away. The front door also has a hole on the side where the knob should be, allowing the spring chill to blow inside until its finally repaired for new occupants.
Nobody knows why Hilinski came back to this place to do what he did that day.
The Washington State quarterback was in the process of moving into a new apartment with new roommates nearby. And then he never returned, leaving behind a team that is still coping with his suicide..
Nobody was living there, so he knew nobody was going to be there, said Peyton Pelluer, a senior linebacker who was going to be Hilinskis new roommate this semester.
More: QB Luke Falk pushes for suicide awareness, remembers Tyler Hilinski at Senior Bowl
More: College football's last-placed teams headed for better things in 2018 season
Thats their reason for where he went. They cant find a reason for his final act. And nobody ever will a fact that many of them have had trouble accepting as they go through a healing process that includes spring practice here this month.
Just like his family, were all still looking, and Ive kind of come to terms where Im not going to find an answer, said Nick Begg, a defensive lineman who also was going to be Hilinskis roommate this semester. And if all of us keeping looking for an answer, were just going to beat ourselves up. Theres no easy way to put it, but youre not going to find an answer, and youve just got to come terms with that I guess. Yeah. I feel for his family for that.
The tragedy happened Jan. 16, shortly after the start of the new semester. Hilinskis roommates at his old apartment had graduated from the team and moved away. Hilinski was halfway into the move into his new home with Begg and Pelluer, getting ready to start a year that was supposed to be his best yet.
Hilinski, 21, was the runaway favorite to be the teams new starting quarterback after combining to throw 209 passes as a freshman and sophomore playing behind Luke Falk. His head coach, Mike Leach, described Hilinski as very talented, very upbeat, one of those guys that cared about others and didnt like conflict.
It was another kind of conflict, hidden inside him, that led Hilinski to take an unnamed teammates rifle without his knowledge. When Hilinski didnt show up for a team weightlifting session that afternoon, the police were summoned and Hilinski soon was tracked down at his old apartment where a forced entry was made to get to him.
Department officials called a team meeting as soon as news got out about his death. Police said the cause was a self-inflicted gunshot wound to the head.
We felt like that it was very important that we bring everyone together so that theyre together, said Sunday Henry, Washington States director of athletic medicine. In this day and age of social media, we had to act very quickly, as soon as we found out what had happened.
'You dont want to be by yourself'
The meeting erupted with sadness and shock. Meanwhile, Leach was stuck trying to get back to Pullman from his time off in Key West, Fla. Bad weather in Atlanta created scores of canceled flights, which left Leach stranded, clinging to his phone as he tried to reach out to people thousands of miles away. It was a horrible deal, Leach said.
He arrived a couple days later and found some hope amid the grief.
When everything happened, there were counselors around our team and everybody within minutes, Leach told USA TODAY Sports. The response time was outstanding.
Henry, clinical psychologist Kate Geiger and counselor Jerry Pastore helped reach out across the athletic department to offer access to help such as counseling and therapy. The football team also went through a new round of mental health screening, and some players were identified as especially in need of support, with common problems such as sleep loss.
Support also came from former players, some of whom flew in from tout of town.
We hung out at our place, just kind of all together, Begg told USA TODAY Sports. I dont know how to explain it, but we just talked about it together and just kind of bonded together, because none of us wanted to be alone. You know what I mean? Thats not what you want to do in a situation like that. You dont want to be by yourself.
Suicide is the second-leading cause of death for those in the age group of 15 to 24, according to the most recent data reported by the Centers for Disease Control and Prevention. It also is the 10th leading cause of death in the U.S. overall, with about 45,000 dying by suicide each year, according to the American Foundation for Suicide Prevention. The foundation estimates the numbers are actually higher than that because the stigma associated with suicide leads to underreporting, much like mental health issues are underreported and unsupported.
Athletes in particular are supposed to be tough and not show any weakness, and mental health tends to be seen as a weakness, Henry said. It tends to be seen different than an ankle sprain or ACL tear, so they tend not to come forward. If they recognized it and came forward and took care of it, they would be stronger, happier people, just like with (getting help for) an ankle.
Thats the challenge, Henry said. To make it OK to tell somebody and get help.
Thats the opportunity we have here, to take this really sad thing that happened and turn it into a positive, she said.
'Be kind to people
This suicide stood out in particular for several reasons. Hilinski, from Claremont, Calif., was a high-profile college athlete with no apparent advance warning signs. He also was a leader of the team in a sport that glorifies toughness, shuns weakness and often has encouraged players to mask their pain. Depression and anxiety can be particularly tempting to keep secret if it might risk a loss of acceptance or status.
You definitely have got to be tough to play football, and its definitely a culture, Begg said. But stuff thats going on in your head, youve definitely got to talk about those things.
The first practice without Hilinski was March 22, kicking off a spring practice season that lasts for several more weeks. Then preparations begin later this year for the season opener at Wyoming Sept. 1. Each is a step.
Its been a process, Pelluer said. I think we made it over the hump, so to speak. Its never going to be perfect. The hardest part was finding that new normal.
And trying to understand it.
A suicide note was found, but Pullman police said state law restricts the note's details to family members. Hilinskis family recently took out a half-page ad in The Seattle Times thanking Cougar fans for their support and saying the family didn't learn a motive.
The reality is we simply dont know, the ad said. He didnt quit. He didnt give up on you. For some reason, he had no choice but to leave us. Dont waste a second thinking he was weak.
Another death in the Cougar family added to the grief in February when one of the athletic departments strength coaches, David Lang, 49, died suddenly of causes that werent immediately announced. We saw things crop back up again, Henry said of the reaction among athletes.
For the football team, its not yet clear how it plans to memorialize Hilinski. The pieces are still being picked up, even at his old apartment, where the door appeared newly installed, without the knob yet as of March 28, replacing the old door that apparently was forced down.
Nobody has the answers, and thats not for us to worry about, Pelluer told USA TODAY Sports. You never know what demons, so to speak, people are dealing with on a daily basis. Thats why its so important to live each day with a positive mindset. Just try to be the best version of yourself and be kind to people, because you just dont know what kind of day theyre having.
New players are competing in spring practice, including at quarterback. And Leach still makes the hour-long walk to campus from his home and back, taking a shortcut through a field of garbanzo beans, the perfect time and space to clear his head.
Everybody I talked to that has
some experience with (suicide), they say it never makes
sense, Leach said. This isnt any
When someone says he or she is thinking about suicide, or says things that sound as if the person is considering suicide, it can be very upsetting. You may not be sure what to do to help, whether you should take talk of suicide seriously, or if your intervention might make the situation worse. Taking action is always the best choice. Here's what to do.
Start by asking questions
The first step is to find out whether the person is in danger of acting on suicidal feelings. Be sensitive, but ask direct questions, such as:
Asking about suicidal thoughts or feelings won't push someone into doing something self-destructive. In fact, offering an opportunity to talk about feelings may reduce the risk of acting on suicidal feelings.
Look for warning signs
You can't always tell when a loved one or friend is considering suicide. But here are some common signs:
For immediate help
If someone has attempted suicide:
If a friend or loved one talks or behaves in a way that makes you believe he or she might attempt suicide, don't try to handle the situation alone:
Departments Can Help Prevent Suicide among At-Risk Patients:
Five Brief Interventions
This nine-minute video describes the unique role that emergency department (ED) professionals can play in preventing suicide by providing five brief interventions prior to discharge. It outlines the following interventions and provides tools to support their implementation:
Brief Patient Education: Help the patient understand their condition and treatment options and facilitate adherence to the follow-up plan. For more information. See the ED Guide. (57 page PDF - page 9)
Emergency Deparment professionals are in a unique position to improve outcomes for those at risk for suicide. They can play a critical role in preventing future suicides and attempts by attacking suicide risks through
Source: Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments www.sprc.org/edguide
Safety Planning: Work with the patient to develop a list of coping strategies and resources that they can use before or during a suicidal crisis. See the ED Guide. (57 page PDF - page 10)
Lethal Means Counseling: Assess the patients access to firearms, prescription and over-the-counter medications, and other lethal means and discuss ways to limit access until they are no longer suicidal. See the ED Guide. (57 page PDF - page 12).
Rapid Referral: Schedule a follow-up outpatient mental health appointment for the patient that ideally occurs within 24 hours of discharge. See the ED Guide. (57 page PDF - page 14)
Caring Contacts: Follow up with the discharged patient via postcards, letters, e-mail or text messages, or phone calls. See the ED Guide. (57 page PDF - page 14)
Settings: Health Care, Emergency Departments
Strategies: Effective Care/Treatment,
Treatment, Safety Planning, Care Transitions/Linkages,
Reduce Access to Means
Although were relatively good at knowing if someone has longer term risk factors for suicide, we are not as good at assessing if someone is at risk within hours, days or weeks. In addition, the time between someone having a suicidal idea and engaging in suicidal behavior can sometimes be very short. Predicting short-term, or imminent, suicide risk when a person is in an emergency department or clinicians office can be difficult. We cant rely solely on a person self-report of suicidal ideation.
Dr. Igor Galynker developed a tool to identify when a person is in what he calls a suicide trigger state. According to Dr. Galynker, the main elements of the suicide trigger state (STS) include ruminative flooding and frantic hopelessness. Ruminative flooding refers to when a person has rapid and repeated negative thoughts that are both confusing and difficult to stop. Frantic hopelessness refers to the feeling that life will always be painful and unchangeable, along with an overwhelming feeling of being trapped. This combination of thoughts and feelings can trigger suicidal behavior.
Is there a tool that can accurately measure when a person is in an acute, or short-term, suicidal state?
Dr. Galynker developed the Suicide Trigger Scale or STS-3, a 42-item scale that assesses both longer term, as well as more immediate, thoughts and feelings related to suicidal behavior. The scale would be used in emergency departments and doctors offices to help predict short-term suicide risk.
The STS-3 scale is unique in that it is designed to measure the elements associated with the trigger state, and not suicidal ideation per se. In fact, the scale does not ask about self-harm or suicidal ideation at all. Instead, it asks about uncontrollable, negative and hopeless thoughts (ruminative flooding), and the feeling that nothing will change (frantic hopelessness).
During a study to assess the effectiveness of the scale, 175 adult psychiatric patients ages 18-65 were invited to participate. The STS-3 was administered on admission to the hospital for suicidal ideation or attempt, and again two to six months after discharge. 161 participants completed the scale on admission, and 54 completed follow-up assessments.
Importantly, participants did not know that the study was specifically focused on suicidal ideation and behavior. The Columbia Suicide-Severity Rating Scale was used to assess recent suicidal ideation and behavior, and the National Death Index and hospitalization data were used to document any deaths.
Overall, 13 of the 54 participants (24.1 percent) made a suicide attempt during the course of the study. Dr. Galynkers STS-3 scale proved to be a significant predictor of suicide attempts among patients within six months of their release from a psychiatric inpatient setting. This confirmed the results of a previous study using STS-3 in an emergency department setting.
It may be possible to identify people who may be at short-term risk of suicidal behavior. Early identification offers an opportunity to save lives.
Grant Related Publications
Zimri Yaseen, Curren Katz, Matthew S Johnson, Daniel Eisenberg, Lisa J Cohen, Igor I Galynker (2010): Construct Development: The Suicide Trigger Scale (STS-2), a Measure of Hypothesized Suicide Trigger State, BMC Psychiatry, 10: 110. http://www.biomedcentral.com/1471-244X/10/110
Zimri Yaseen, Evan Gilmer, Janki Modi, Lisa J Cohen, Igor I Galynker (2012): Emergency Room Validation of the Revised Suicide Trigger Scale (STS-3): A Measure of a Hypothesized Suicide Trigger State. PLoS ONE 7(9): e45157. doi: 10.1371/journal.pone.0045157
Zimri Yaseen, Irina Kopeykina, Zinoviy
Gutkovich, Anahita Bassirina, Lisa J Cohen, Igor I Galynker
(2014): Predictive Validity of the Suicide Trigger Scale
(STS-3) for Post-Discharge Suicide Attempt in High-Risk
Psychiatric Inpatients. PLoS ONE 9(1): e86768. doi:
Commission Gives Patient Suicide Prevention Tips to
In the case of Latino immigrants in particular, suicide (or its ideation) may be stigmatized as a sin or as a sign of cowardice. It is rarely spoken about as a health concern.
"Many people think that suicide is a reaction to something bad that happens to a person, but actually it has well-defined biological basis, said Dr. Maria Oquendo, president of the American Psychiatric Association, and professor and chairman of Psychiatry at the Perelman School of Medicine at the University of Pennsylvania.
While the primary suicide trigger remains unknown, Oquendo said, "we know that suicide has a genetic basis and runs in families."
"In those families where there have been suicides, the children have a higher susceptibility," she added. "It is the same as, for example, hypertension or diabetes. It is not one hundred percent certain that they will have the disease, but it does increase the probability."
Among the Latino population, Dr. Oquendo says, adolescents are the most vulnerable.
"We know that teenage girls have a certain vulnerability due to family conflicts because of the cultural clash they experience. In some cases, they are required to behave in a more traditional way at home, and outside of the home it is very different. Like every teenager, [the Latina adolescent] wants to fit in."
Those who leave the home whether because they marry at an early age, leave to study or simply seek a different way they dont necessarily escape suicide ideation, however, because they are sometimes abused, or exposed to abuse.
Waleska Maldonado of the Philadelphia Department of Human Services, who for many years worked as a social worker at the Latino community organization Congreso, says that many teenagers who seek help for suicide prevention are affected by drug addiction, domestic violence or a poor socio-economic status.
"Money is lacking in many homes," Maldonado said, "but the truth is, that if they understand where to look for help, things can improve."
"Many of the girls we worked with gained confidence and trust through therapy. And they themselves tell of their experiences because that is one of the ways in which the treatment works, she said.
Maldonado is convinced that the mental health of immigrants, especially Latinos, can improve through open communication.
"It is on us those of us in these posts, in the press and the victims themselves to speak out and to create a kind of network, by word of mouth, so that when these little girls arrive in this country for the first time, they know what to do and where to go for help, Maldonado said.
Organizations that offer mental health services, she said, need to not only inspire confidence in their patients but also help them maintain it.
"The Hispanic community in Philadelphia needs help and each case depends on the respective circumstances. We know that sometimes circumstances push people into suicide, but we also know that many people are willing to fight for a better outcome. Nevertheless, they sometimes dont know or understand what they should do because of language barriers, Maldonado said.
According to Erika Almirón, director of the Latino immigrant advocacy organization Juntos, the immigration experience itself can create "imbalance" among people who do not have the proper authorization to be in the country. "With the issue of raids and checkpoints, many people come to us with traumas. It's hard to explain. We know that the children of the detainees, for example, suffer and are too young to understand what is happening.
She said that during her visits to the Berks County Detention Center in Leesport she has heard several teenagers talk about suicide. "It's not something we work with, but as much as we can, we refer them to centers that offer mental health services at a low cost or for free."
In 2016, Dr. Andrés Pumariega, chief of the Department of Psychiatry at Cooper University Hospital and a specialist in pediatric and adolescent psychiatry, traveled to several detention centers around the country as part of a government task force. The aim was to investigating immigration detention policies and offer mental health recommendations.
Pumariega said the committee ultimately determined that the Immigration and Customs Enforcement agency should "close these places." He said that while there are no concrete statistics on suicidal ideation in detention centers, it is common among the detainees.
"It's a very tragic situation for the women detained with their children," he said. "Those mothers feel desperate and do not know what will happen. Sometimes they do not have information and feel isolated."
"They have gone through a journey that many of us would not survive," he added. "They travel across Mexico, cross the border, are abused, stripped of any money and even worse. They are lucky simply to be alive They put on a brave face, but many think of suicide, and their children do, too. There are adolescents we wrote about in the report [the task force filed] who told us they were going to hang themselves with their ID [lanyards].
Treatment and Help
The light at the end of the tunnel can be found in the innovative approaches to illness or mental health problems that have arisen in recent years. According to Dr. Oquendo, there is a new "very impactful" protocol to treat suicide "safety planning."
"It's basically giving people the tools to deal with the strong emotions they are experiencing, she said. "They outline for you, step by step, what you can do to feel better, starting with simple things such as distracting yourself by running, shopping or even watching a movie," before moving on to other more complex and heroic steps.
Another form of treatment is therapy accompanied by medication. According to Ana Ortíz, a clinical psychologist who works at the Asociación de Puertorriqueños en Marcha (APM), "psychotherapy is like a school, that together with medication and learning positive reinforcement skills, helps people achieve their goal, to continue living."
She added that medication is important because it enables health care providers to work on the physiological aspect of emotions to help attain a type of stability.
But for every expert looking at the
problem of suicide in the immigrant community, three
elements form the core of any and every treatment: Speaking
up. Seeking help. Telling your story.
Evidence-based prevention includes:
Engaging in Evidence-Based Practice
Evidence-based practice has been defined as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of communities and populations in the domain of health protection, disease prevention, health maintenance and improvement (health promotion)."1
Conducting sound evaluation
Disseminating what is learned
These processes and activities are a part of SPRC's strategic planning approach to suicide prevention, which recognizes that suicide prevention efforts are more likely to succeed if they are guided by the best evidence available.
Using Evidence to Select or Develop Programs
One of the key steps in strategic planning is to make decisions about the programs and practices that will be a part of your comprehensive approach to suicide prevention.
Good sources of information regarding evidence-based programs are registries (lists of programs that have been evaluated) and literature reviews (articles that summarize findings from different studies).
See these pages of our website for information and resources:
SPRC's Designation: "Programs with Evidence of Effectiveness"
Some programs in SPRCs Resources and Programs page are designated as programs with evidence of effectiveness. These are programs that have been evaluated and found to result in at least one positive outcome related to suicide prevention.
Programs labeled as evidence-based may have stronger or weaker evidence. At SPRC, we use the phrase "programs with evidence of effectiveness" to refer to programs with any level of evidence. See each listing for the source of the program, specific outcomes reviewed, and evidence ratings.
SPRCs sources for programs with evidence of effectiveness:
Things to keep in mind about evidence-based programs:
Adapting or Developing a Program
Even if you cant find an evidence-based program that meets your needs, your efforts can still be informed by evidence.
When adapting a suicide prevention program or developing a new one, make sure that it:
Using culturally competent approaches is another important key to success. One challenge is that many evidence-based programs for suicide prevention have not been assessed in diverse populations, so their effectiveness with these populations is not known. When implementing an evidence-based program that was done with a population different from the one your program will be targeting, consider doing a small pilot test first.
Practice-based evidence (PBE) is a term sometimes used to refer to practices that are embedded in local cultures and are accepted as effective by the community. Practitioners of PBE models draw upon cultural knowledge to develop programs that are respectful of and responsive to local definitions of wellness. In some cases, PBE also refers to a participatory, "ground up" approach to designing programs, as opposed to a "top-down" process in which programs are developed by academic researchers and then disseminated to local communities. To the extent possible, PBE programs should be evaluated, so that they can add to the evidence base for suicide prevention. For more information, see Emerging Evidence in Culture-Centered Practices in NREPP's Learning Center.
Our Settings section provides information and resources for conducting suicide prevention activities in various settings. For information on practices that are culturally appropriate for American Indian/Alaska Native settings, see our Promising Prevention Practices page.
1. Jenicek, M. (1997). Epidemiology, evidence-based medicine, and evidence-based public health. Journal of Epidemiology, 7, 187-197. Retrieved from: https://www.jstage.jst.go.jp/article/jea1991/7/4/7_4_187/_pdf
2. Brownson, R. C., Fielding, J. E., & Maylahn, C. M. (2009). Evidence-based public health: A fundamental concept for public health practice. Annual Review of Public Health, 30(1), 175201.
Learning More about Suicide: Responsible Reporting
Suicidal ideation and behavior are influenced by a combination of feelings we have about ourselves and our future (internal affect) and feelings we have about others and the world around us (external affect). Recent life experiences can also contribute. In order to fully understand how suicidal thoughts and behavior emerge and also go away individuals must be studied over time.
Ecological momentary assessment (EMA) is a tool that can be used to assess thoughts and behaviors over time, using a smartphone. In a study conducted by Dr. Lori N. Scott at the University of Pittsburgh, EMA was used to look at the specific relationship between participants emotions, interpersonal experiences, and suicidal ideation and behavior over time. One way to intervene and prevent suicide is to understand the sequence of thoughts and feelings close to the moment of risk, and learn what role recent interpersonal experiences play leading up to it. This study was one of the first to look at real-time changes in emotions, experiences, and suicidal ideation and behavior.
How, and under what circumstances, do emotions and interpersonal experiences combine to provoke suicidal ideation and behavior?
Dr. Scott recruited 63 young women ages 18-24 from the Pittsburgh Girls study, which was a study that had assessed at-risk girls and women in the community repeatedly over many years. These individuals were known to have impulsive aggressive behavior, which is a risk factor for suicide, so this was an important group to study. Women and men have different avenues to becoming aggressive so it is beneficial to study them separately.
The participants selected for Dr. Scotts study had experienced suicidal or self-injurious thoughts or behaviors (SITB) in the previous month and were thus considered at-risk for near-term future SITB. Participants were assessed at baseline (meaning the beginning of the study) for depression, self-injurious thoughts and behavior, and personality disorders.
Over a 21-day period, participants responded to six text prompts per day to share the feelings and experiences they had had over the previous 15 minutes, rating the degree to which they experienced each thought or behavior on a scale from one (not at all) to five (extremely). The assessments covered internalizing negative affect (feeling sad, anxious, scared, lonely, ashamed), and externalizing negative affect (feeling angry, hostile, irritable, annoyed, mad). They were also asked about any suicidal ideation and behavior, as well as aggressive behavior, they had experienced. Once per day, they were also asked about their experiences of feeling rejected or of being criticized.
Over the course of the study, 89 percent of the participants reported feeling rejected at least once, and 79 percent reported feeling criticized at least once. In addition, almost 10 percent of their responses to the texts referenced rejection, and seven percent referenced criticism.
With regard to suicidal thoughts and behaviors over the three-week period:
Internalizing negative affects like sadness and guilt were associated with suicidal ideation and behavior, but externalizing negative affects such as anger were not. Negative external feelings were found to be associated with aggressive behavior. This suggests that suicidal ideation and behavior were more associated with the negative feelings people had towards themselves (internal affect) than with their negative feelings towards others (external affect).
In addition, feeling rejected, excluded, abandoned, or left out was related to suicidal ideation and behavior, but feeling insulted or criticized was not related.
Preventing access to lethal means can save lives, particularly for those with impulsive suicidal thoughts. Lowered rates of suicide in areas that have erected barriers on bridges are one example.
Conversely, media reporting on suicide can give rise to a contagion effect, also known as the Werther Effect, whereby a publicized suicide can precipitate suicidal behavior in those at risk. Media coverage and published articles with certain keywords and opinions toward suicide can have an impact on suicide rates.
The Bloor Street Viaduct in Toronto, Canada is a site that had a high rate of suicide, making the construction of a barrier a critical prevention effort. Media reporting surrounding the bridge was frequent, and increased in the four years after the building of the Bloor Street Viaduct in 2003. The suicide rate would seem to have been met by two opposing forces: on the one hand, the barriers would potentially reduce the rate. On the other, media reporting would possibly increase the rate.
A study conducted by Dr. Mark Sinyor looked at the effect of a barrier limiting access to lethal means on the rate of suicide, as well as the impact of media attention.
Does the way media reports on suicide impact rates of suicide?
The first goal of Dr. Mark Sinyors study was to look at elements of media reporting and their relationship to suicide. Records from the Office of the Chief Coroner of Ontario of those who had died by suicide were examined and categorized by suicide method. Next, media reporting on suicide by local and national publications in the Toronto media market were examined, along with special attention paid to keywords related to suicide. If articles were related to the Bloor Street Viaduct, they were coded in relation to: 1) the Bloor Street Viaduct, 2) negative views about suicide barriers, and/or the cost of the barrier, 3) suicide deaths from a bridge other than the Bloor Street Viaduct, and 4) inclusion in the reporting of a hopeful message that suicide is preventable. Suicide rates before and after the barrier was erected were compared. Suicide rates were also examined in relation to media reporting.
The second goal of the study was to test for the effect of media reporting about the suicide barrier on suicide rates, both shortly after the barrier construction, and eleven years later.
There was an increase in suicide deaths shortly after construction of the barrier. Media articles mainly tended to focus on the cost and use of the barrier. In the long term, however, suicide rates on bridges, as well as by other means in Toronto, decreased after the Bloor Street Viaduct barrier was constructed. Media reports that contained hopeful messages were associated with decreased suicide rates. The study thus concluded that negative reporting initially led to a temporary increase in the suicide rate in the area, but that the barrier, in conjunction with the more positive reporting that accompanied the declining rates, ultimately had a positive effect.
In 2016, there were roughly 10 suicides per 100,000 residents, and more than half were gun-related. Yet despite the statistics, only about half of emergency-room doctors in the U.S. ask patients at risk of suicide if they have access to guns at home.
A new Washington University program aims to tackle this issue directly by working with patients at risk of suicide before theyre discharged from the hospital. The Counseling on Access to Lethal Means (C.A.L.M.) program helps patients temporarily store dangerous items they may have at home, including guns and prescription medication.
"Its a distinctly proactive approach," said Kristen Mueller, a Barnes-Jewish Hospital emergency-room doctor and C.A.L.M. program coordinator.
As a physician, I got into the game to help save lives, said Mueller. Theres only so many patients I could take care of in the emergency department before we started to say, 'Enough is enough.' What can we do to start preventing this from happening in the first place?
The program, which is funded through grants from the Washington University Institute for Public Health and the Barnes-Jewish Hospital Foundation, trains research coordinators using online materials from the Suicide Prevention Resource Center.
As part of the program, research coordinators work one-on-one with patients to help identify if they have access to guns at home.
You do your best to get an assessment of whats immediately available, said registered nurse and C.A.L.M. research coordinator Chris Kriedt. Ill ask, Do you have a firearm readily available? Is it loaded? If you were in a crisis moment, would you be able to reach over and just pick it up?
During the initial assessment, Kriedt helps patients who have access to guns come up with a plan for storing them. Patients may opt to store their guns temporarily at a local gun range, for instance, or in the home of a friend.
Research coordinators have worked with 15 patients through the C.A.L.M. program since its inception in December. Kriedt said a key component of the program is following up with patients two to three days after they have left the hospital.
I believe that some kind of support after the fact, after the hospital, after the emergency room, is important. Because people, I think, feel like theyre left high and dry, said Kriedt. Theyre told to follow up, but they dont have anybody to help them along the way.
Suicide prevention initiatives often face a number of challenges, including the stigma associated with mental health issues.
Mueller hopes the C.A.L.M. program will help normalize the idea that its not a weakness to have mental health issues or signs of depression.
Many people are perfectly comfortable talking about child safety seats in their cars, talking about whether or not they wear their seatbelt, talking about whether theyre smoking or not smoking, said Mueller. This is just another aspect of personal and public health.
There are also deep-seated misconceptions about suicide risk. The rate of gun-related suicide varies substantially based on demographics, with white males over the age of 55 at the highest risk in Missouri.
Men are also seven times more likely to die by gun suicide than women in Missouri, according to the Centers for Disease Control and Prevention.
The C.A.L.M. program at Barnes-Jewish Hospital will continue through December, after which organizers will conduct an assessment and determine whether to continue the program long term.
The benefit would be even if one
person from this entire study stores their firearm safely
and doesnt commit suicide, to me, that makes it worth
it, Mueller said.
(Editor's note: C.A.L.M. is SPRC`s free self-paced online course to improve your knowledge and skills in suicide prevention. It is especially for clinicians and other service providers, educators, health professionals, public officials, and members of community-based coalitions who are responsible for developing and implementing effective suicide prevention programs and policies.)
note two: People ask why physicians are treating
psychosocial issues and social workers are seemingly not
involved. Possibly because it is NOT a requirement for
psychologists and mental health professionals (therapists,
social workers, etc) to have suicide prevention training as
part of their license or as continuing education. Of course
some may take it as an 'option', but it is NOT required.
Oregon tried to change that to make is mandatory in this
2017 legislative session with SB 48 but there was too much
resistance from CO and some of the legislators that it was
changed to a suggestion and passed. Our thought: if you
suffer from anxiety, depression, suicide thoughts and want
help from a mental health professional, don't assume that
just because they have an professional looking license to
practice, that they have the necessary training in
suicidality to help keep you from killing yourself. It is
too big of a risk.)
national suicide hotline moves a step closer
Introducing the legislation on the Senate floor in May, Sen. Orrin Hatch said constituents have told him that friends and family who've struggled with suicidal thoughts don't always know where to turn.
Calls to suicide hotline spike after VMA performance
"To make matters worse, the national suicide hotline number, 1-800-273-TALK, is not an intuitive or easy number to remember, particularly for those experiencing a mental health emergency," the Utah Republican said.
Hatch gave the example of one young Utah woman who tried to call her counselor before her suicide -- but couldn't reach her.
"I believe that by making the National Suicide Prevention Lifeline system more user-friendly and accessible, we can save thousands of lives by helping people find the help they need when they need it most," he said.
(Editor's note: I believe that the Portland, OR area has a 9-1-1 text service to match the 9-1-1 phone service. This service is for extreme crisis and will bring emergency service as would the 9-1-1 phone call. Texting to a crisis line that's easy to remember like 741741 is still for a crisis but gives the texter a trained counselor to text with instead of bringing in 9-1-1. It has proven to be very successful to reach teens in crisis since so many of them won't call a suicide phone line. They don't even talk on their cell phones. But they do text.)
Record increases in suicide rate
The suicide rate in the United States has seen sharp increases in recent years. It's now the 10th leading cause of death in the country, according to the American Foundation for Suicide Prevention. Young people are particularly vulnerable: In Hatch's home state of Utah, suicide is the leading cause of death among teens.
The existing crisis phone line, and the crisis text line, is staffed by a mix of paid professionals and unpaid volunteers trained in crisis and suicide intervention. When people use it, the risk of suicide declines sharply, studies show. The confidential environment, the 24-hour accessibility, a caller's ability to hang up at any time and the person-centered care have helped its success, advocates say.
The bill would require the Federal Communications Commission to work with the Health and Human Services Department and the Department of Veterans Affairs to study the existing system, suggest ways to improve it -- and recommend a new three-digit number. The bill passed the Senate unanimously in November, and the House Energy and Commerce Committee is considering an identical bill with strong bipartisan support, according to its sponsors.
"Too many of us have experienced the tragic loss of life and heartbreak that results from suicide. Those who have experienced this tragedy have expressed to me that, while there are many resources for individuals experiencing a mental health crisis, it can be difficult to find these resources during a time of need," bill co-sponsor and Utah Republican Rep. Chris Stewart said.
"The National Suicide Hotline Improvement Act works to streamline and provide easy access to potentially life-saving resources."
Renewed attention on the current number has increased calls, according to program managers. Rapper Logic put 1-800-273-Talk in a song. After he performed it on MTV and while surrounded by survivors at the Grammy Awards in January, there was an immediate spike in calls.
Two million people called the crisis line in 2017, up from 1.5 million in 2016. In January, calls were up 60% from January 2017.
'We know it works'
"People want access to these lines. We have seen calls increase every year since they have been in operation, and this is an extraordinary time in which more people are reaching out for help, and we are very pleased with that because we know it works, but it does come with some challenges," said the Lifeline's executive director, John Draper.
The challenges, according to John Madigan, vice president of public policy at the American Foundation for Suicide Prevention, are funding and infrastructure. He hopes the new legislation will improve that quickly.
"What we have now is a critical nationwide system, but as you might imagine, it is being overwhelmed," Madigan said. When callers are able to connect, there is a 76% de-escalation in risk of suicide once they start talking and working collaboratively with counselors. But, he added, "picture the little boy with the finger in the dike."
Madigan thinks a budget for the civilian crisis line "needs to be ramped up substantially."
He agrees that a streamlined number would be a big improvement. "Three digits, if you are in crisis, would help. Everyone, even 1- and 2-year-olds, know to call 911" if there's an emergency.
"It's high time we make it as easy as
possible to get help."
Between 1999 and 2014 the rate of suicide in the United States increased an alarming 24%. In 2016, the last year for which data was collected, the rate crept up another 1.2 percentage points, and suicide is the tenth leading cause of death in the country. The problem is clear, but gaining support for solutions has been hard to come by, says Christine Moutier, chief medical officer of the American Foundation for Suicide Prevention, the largest private funder of suicide research in the country.
Moutier helped launch Project 2025, an ambitious AFSP program that aims to reduce suicides by 20% in the next seven years. The bulk of the program focuses on roles that physicians and health systems can play. The most promising way forward, she believes, is to help clinicians identify patients at risk and provide care that can slow this epidemic.
Q: How did you get involved in suicide prevention?
A: When I was a dean at the University of California San Diego School of Medicine, we lost 13 faculty physicians to suicide over 15 years. That got us asking questions: What drives up suicide risk, especially for physicians? Can risk spread in a community? Can suicides be prevented? Our investigations helped shape a suicide prevention program at the school that is now in its tenth year.
Q: Why does Project 2025 focus on the role of physicians?
A: The data show that, nationally, quite diverse groups are at high riskmiddle-aged white males and females, veterans, active-duty military, LGBT populations, the geriatric population, young Native American males and Latina teenagers. Trying to target all these groups separately is really challenging. We realized that the greatest opportunity is to employ evidence-based interventions in the settings where clinicians encounter all these at-risk groups: in emergency departments, primary and behavioral health clinics, and correctional facilities.
Q: How did you come up with a national strategy?
A: We gathered a panel of 25 experts that included scientists, clinical and policy experts, people who have experience of attempted suicide, and the survivors of those who have died by suicide. Together we surveyed the literature. We looked for what approaches clearly work to reduce suicides, if you can expose enough at-risk people. We found, for example, that treating someone who shows up in the ER after a suicide attempt with proven approachessuch as cognitive behavioral therapyreduces repeat attempts and hospitalizations by about 50% for the following 12 to 24 months.
We specifically sought out interventions that could feasibly be implemented, either regionally or, ideally, at a national level.
Q: How is that different from past approaches?
A: The most common prevention approach has been community education and raising awareness, but measuring the impact of education on suicide rates is difficultand talking about suicide in graphic or sensationalized ways can encourage contagion. Other approaches have included screening, but not necessarily with an emphasis on follow-up care.
Q: What kind of training can help a clinician prevent suicide?
A: Clinicians can learn how to think about suicide prevention as a continuous quality and safety practice, always running in the back of their minds. You make it a priority to recognize changes in risk that a patient faces over the continuum of care. When you identify that someone is at risk, or if the risk has recently increased, you focus on helping that person stay alive. You involve families when possible, and you employ safety planning and counseling about lethal means as part of every encounter. All these steps are known to reduce risk.
As basic as it is, you can also follow up by phone or another method. That has been robustly shown to reduce suicide rates for at-risk patients, particularly following discharge from the ER or a psychiatric unit.
Q: Suicide rates climbed a bit in 2016. That seems like a curveball in Project 2025s goals, doesnt it?
A: One likely possibility contributing to rising rates is that as the stigma associated with suicide goes down, the more often coroners and medical examiners will correctly label suicide deaths. Based on a limited amount of data, it is estimated that 10% to 15% of suicides are not called suicides. We are also committed to helping end that stigma. So even if the actual rate stays the same or begins to fall, it may look like its climbing for a period of time.
Its also important to note that
at the federal level, funding for suicide prevention
research remains far too low. The total federal annual
allocation for suicide-related research, including National
Institutes of Health and other funders, is approximately $50
million, versus in the hundreds of millions to billions for
many other leading causes of death. We do believe that if we
use those dollars wisely and scale up the key interventions
that have been proven to reduce suicide risk, we can begin
to move the needle.
Practices For Covering Suicide
Report on suicide as a public health issue, not a crime.
than Mental Health: Reaching Men at Risk for Suicide
Make connections with nontraditional prevention partners. Both the CDC data and SPRC report show that men who are struggling may not be seeking behavioral health care services. Based on the key risk factors for this group, suicide prevention programs need to engage agencies and organizations that men may connect with when they first encounter adversity or challenges. These include substance abuse prevention and treatment programs, domestic violence intervention programs, organizations that serve military and veterans, family and criminal court systems, and workplaces. These agencies and organizations may be able to help mitigate some of the stressors associated with suicide deaths, and can also be important places to identify men who may be struggling and connect them with help.
Improve suicide detection and supports across other health care systems. Even if the majority of those at risk for suicide are not seeking behavioral health treatment, they may still be engaging with other kinds of health care systems. The Action Alliance report Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe (23 page PDF) outlines basic and attainable steps to better identify and support those at risk for suicide across health care settings, including emergency departments and primary care. These steps, including simple safety planning and post-discharge follow-up, can have a big impact for someone at risk. We also know that crisis services have an important role to play in a coordinated and effective response to someone who is at imminent risk.
Advance safer suicide care in behavioral health. Since almost half of those who died by suicide did have a known mental health disorder, improving suicide care in behavioral health care settings is still a critical tool in our prevention toolbox. Men are less likely to receive behavioral health care services than womenbut not for the reasons you might think. We tend to assume that men are generally less likely to seek help for any problem, and its true that there are strong cultural expectations that men be self-reliant and conceal their emotions. However, there are also other issues at play. Clinicians may not detect depression or other mood disorders in men, and even evidence-based treatment may be less effective, since the large majority of clinical trial participants for mental health and suicide interventions are women. Fortunately, we have a robust model for improving suicide care in behavioral health care systems: Zero Suicide is continuing to spread and helping to ensure those at risk dont fall through the cracks.
Offer culturally appropriate assistance for those who are struggling. Since so many of those who die by suicide do not have a mental health diagnosis, and prevailing male cultural expectations discourage help-seeking, we need to consider alternative ways to reach men at risk for suicide that are more attuned to their preferences. The SPRC report, Preventing Suicide among Men in the Middle Years recommends building coping skills and connectedness by creating peer-to-peer, community-based groups that can enhance self-worth, meaning in life, and a sense of purpose for men. The report offers examples of this kind of program, such as Mens Sheds, which originated in Australia and have been replicated in the U.S. and other countries; DUDES Club in Canada; and the Mens SHARE Project in Scotland. There has also been recent progress in working with the gun-owning community to find culturally appropriate ways to talk about keeping each other safe during times of crisisanother way men can rely on peers to help them through troubled moments.
It is also important to acknowledge
the toll that suicide takes on other groups, including
women, men of other ages, LGBTQ individuals, American
Indian/Alaska Native communities, and others. Those with a
diagnosed mental illness are also at increased risk for
suicide. However, as we aim to reverse the trend of
increasing suicide rates in our country, we need both
behavioral health care and community-based interventions to
support all who may be struggling, including those who fall
outside of the traditional safety net we have been working
Man Therapy provides men
approaching crisis, and the people who care about them, a
place to go and learn more about mens mental health,
examine their own mental health, and consider a wide array
of actions that will put them on the path to help, treatment
and recovery, all within an easy-to-access online portal at
www.mantherapy.org. Visit this page to take the 18-point
head test, find local resources, and learn valuable tips
about topics like fighter jets, how to make guacamole, and
what to do when you or someone you care about is in a
Educators Need to Know About Suicide: Contagion, Complicated
Grief, and Supportive Conversations
As suicide rates have continued a multi-year trend of gradually increasing, the prevention community has expanded its focus beyond mental health providers and counselors by seeking to embed resources and knowledge among other members of the community, including educators, said Doreen Marshall, vice president of programs at the American Foundation for Suicide Prevention.
"In schools, there's been more emphasis over the past four to five years over training other gatekeepers, like teachers," Marshall said. "What we're starting to see is a shift to suicide prevention being more of a shared responsibility among the community, where there's a sense that we look out for each other."
The organization has developed resources for teachers, parents, and youth-oriented groups to help guide conversations and explain mental health concepts that may be unfamiliar to some adults. Among the biggest goals, helping people feel comfortable talking about a topic that has long carried a painful stigma.
People "have this thought that if I mention suicide, it's going to put the idea in someone's head," Marshall said. "If anything, it's going to open the door to a very important dialogue."
at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741
What Schools Should Know About Suicide Contagion
Two recent celebrity suicides have led to an increase in media coverage about the topic. And, while designer Kate Spade and celebrity chef Anthony Bourdain were both middle-aged, it's likely that the talk of their deaths have made their way into the conversations of younger people, who consume media more regularly and independently than their parents did as teenagers.
Such coverage, if handled inappropropriately, can spark a contagion effect, particularly for people who are already vulnerable to suicidal thoughts, including some teens. Developmentally, teens are at a phase where they "look more to the external world to get messages about who they are," which can make them particularly receptive to problematic messages, Marshall said.
Prevention organizations were particularly troubled by coverage of actor Robin Williams' suicide in 2014, which led to a spike in calls to suicide helplines.
Contagion concerns also flare up after a suicide in a community or student body, or when suicide is portrayed in popular media. AFSP released a discussion guide after Netflix's 13 Reasons Why, which portrays suicide, became popular among teens.
Some of the same principles that drive responsible media coverage can help guide one-on-one and classroom conversations:
How to Help a Student Who's Lost Someone to Suicide
Schools may also encounter conversations about suicide if a student has a friend or loved one who takes their own life. This creates special considerations for grieving and processing the event that differ from other kinds of death.
"Schools need to pay some extra mind about how that student is making sense about what has happened, where their supports are," Marshall said.
Children who lose a parent to suicide are more likely to die by suicide themselves, and prone to other psychiatric concerns, Johns Hopkins University researcher Holly C. Wilcox found in a large-scale study published in Journal of the American Academy of Child & Adolescent Psychiatry in 2010. But support and resources can help counteract those effects, in the same way that strong connections to adults can buffer the effects of other forms of childhood trauma, researchers say.
Educators should also be careful not to assume that this is the first time a student has been impacted by suicide, Marshall said.
"All of this goes back to how important it is to just ask directly," she said. "If they have been impacted before, you might get some really important information about how the student is making sense about what has happened."
The American Foundation for Suicide Prevention has assembled resources to help parents, educators, and the public understand and discuss suicide:
Children, Teens and Suicide Loss provides resources for helping young survivors.
The More Than Sad curriculum teaches students about mental health issues.
The After a Suicide Toolkit helps schools respond to the aftermath of a suicide death.
1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741
Suicide? What Id Say to a Jumper
I can also speak with a little bit of authority on this subject because as a bridgetender I cross paths with people attempting suicide several times a year. Ive never actually spoken to one of these people. Either the police rescue them before they jump or they make good on their attempt.
Ive often thought about what Id say if I came upon a jumper on my bridge and no one else was there. Im not trained in any way so Im probably the last person that should be thrust into that situation, and Id avoid it if I could, but if I had no other choice, what would I do to try to convince them not to take that last irreversible step?
First Id introduce myself and ask for his or her name. Then I would say, I dont know why youre here, and I dont know why you want to jump. Im sure you have your reasons, and theyre none of my business. But Id like to tell you that this is probably the most important conversation Ive ever had in my life, because I think you are important in this world. I think you have value. I really believe that every day you impact and influence people and you probably dont even realize it. Some day, a month, a year, a decade from now, someone will cross your path who will need your influence. If youre not there to do so, that person may never have the future he or she deserves.
I also think that things can change on a dime. You never know what tomorrow will bring. But if you jump, youll never get to find out. One thing tomorrow can bring for you is help. Someone to talk to. People who will take you seriously. And they are out there. I promise. Well make sure you get a chance to talk to those people, if only you stick around to do so.
The fact that youre still listening to me means that you are having second thoughts. Thats good. That means you still have choices. You can still not jump, and then you have a whole world of possibilities. I can tell you this. Every single jumper, without exception, screams on the way down. That means they regret their decision the minute they step into thin air. But by then its too late. And that sentiment has been universally confirmed by the rare people who survive jumping off a bridge. They say they wish they had never done it. Can you imagine that feeling of terror? Wanting desperately to take something back but not being able to do so? Would you want that to be the last feeling you have? I dont want that for you.
I can also tell you that its not as easy a way to go as you might think. See that concrete and wooden fender system down there? Ive heard jumpers hit that thing, and you can hear their bones break all the way up here. That sound will haunt me for the rest of my life, and now that I know your name, it would be even worse. But even if you miss the fender system its bad. Your organs are lighter than your skeleton, so when you hit the water, your skeleton rushes past your organs, forcing them all to move up into your chest cavity. I cant imagine that type of pain. Its a horrible, horrible way to go.
I dont have all the answers. In fact, my life is pretty messed up. But I really do believe theres more out there for you than this. You wouldnt be feeling so hurt or scared or depressed or angry about your situation if you didnt believe you deserved more, too. Dont take away your chance to find out whats out there. Right now you can go in any direction you want. Left, right, forward, backward, up or down. If you jump, all youll be left with is down. If you feel like you have no hope now, imagine how youll feel when youve only got one direction left to go.
I dont know. Maybe that would be the wrong thing to say to a jumper. Maybe it would do no good. But thats what Id want to say.
17 thoughts on Contemplating Suicide? What Id Say to a Jumper
Sometime, knowing that someone else sees your pain is all it takes. Those that reach the edge are in a fog so thick they cannot see anything in any direction. But if someone reaches out their hand just long enough for their words to reach the heart, lives can be saved. Thank You to the person who reached me.
DECEMBER 3, 2013 AT 6:28 AM REPLY
The View from a Drawbridge
And my great appreciation to that person as well. The world would be a much bleaker place without you, Carole.
DECEMBER 3, 2013 AT 6:42 AM REPLY
Very thoughtful. I do want them to put little kiosks on the bridge where people who are thinking of jumping can answer a few quick questions oh man I am going to do a post about this I will give you credit
DECEMBER 4, 2013 AT 9:26 AM
Pingback: Pardon me, but before you leap to your watery doom, would you mind filling out this questionnaire first? | The View from a Drawbridge
The View from a Drawbridge
Heres the blog entry my friend Art mentioned. https://theviewfromadrawbridge.wordpress.com/2013/12/04/pardon-me-but-before-you-leap-to-your-watery-doom-would-you-mind-filling-out-this-questionnaire-first/
DECEMBER 5, 2013 AT 8:22 AM REPLY
I agree with Carole . It does take for someone to help pull that person out of the dark and help them ground themselves. You get so lost you dont even know who you are anymore. You are shocked by your reaction to things, become disappointed and there goes the cycle that makes self worth seem like nothing. Idk I think when it gets to the point where a person is taking their own life, at that moment they feel like there is no support for them . Even when he/she has a contact full if friends and family that wants to called. Barb, you would be able to save a life . You have done so already.
DECEMBER 5, 2013 AT 12:09 PM REPLY
I agree with Carole . All it takes is for someone to reach out and help ground the person. You get so lost in the dark that you dont know who you are anymore. You become shocked by your reaction to things and then become disappointed that you view life in this negative way . Then the cycle hits you and at times you feel like it cant get better. The deepest depression will make you feel like you have no connection to the world . Even when you have a contact book full of supportive family and friends that await your call. Support is big Just being there to listen is big. Barb you are always a life saver
DECEMBER 5, 2013 AT 10:27 AM REPLY
The View from a Drawbridge
You are going to be a positive force in the world, M, just give yourself the chance. Love you.
DECEMBER 5, 2013 AT 12:10 PM REPLY
That picture looking down from the tower scares the @#$%^&* out of me.
I support the right of a person to
decide when their life will end, but I think theres a
lot of times that isnt really the best choice, and I
wish theyd leave bridges out of it. We have a high one
in this town that is famous for such incidents, and the DOT
just put up barriers on it so you get your view as if
through a cage. Of course, making the social changes that
will make it possible for people to get the help they need,
and not fall into bad situations in the first place,
thats out of the question
The plunge, at a speed of more than 60 miles per hour, would surely kill him.
Detectives Marc Nell and Everald Taylor, tethered to the bridge and to their rescue truck with nylon harnesses and heavy rope, knew to resist the urge to pull the man to safety. It was not time yet.
Tell me your name, Detective Nell said, tapping into the emotional and psychological arsenal that he had acquired in training. Talk to me. Think of your family.
Sometimes the detectives do most or all of the talking. It does not always matter. What the detectives are probing for is not necessarily conveyed in words. They are looking for an opening. A moment of doubt.
Once you see that light, you see their facial expression change, their body posture change, and you think: Oh, I got them. O.K., they are not going anywhere, Detective Nell said. Its like when a boxer gets that shot and he knows that the opponent is wobbly and he just keeps going at that same spot.
In this case, Detectives Nell and Eddie Torres, a third officer who had joined the rescue, did what they refer to as the Grab. They seized the man, pulling him off the ledge and over a guardrail.
Each year, the Police Department receives hundreds of 911 calls for so-called jumper jobs, or reports of people on bridges and rooftops threatening to jump. So far this year, that number is on track to surpass last years total, 519.
The departments Emergency Service Unit responds to those calls. The roughly 300 officers in the unit are specially trained in suicide rescue, the delicate art of saving people from themselves; they know just what to say and, perhaps more important, what not to say.
You wouldnt want to say, Yeah, things are bad and who knows if they can even get better, Inspector Robert Lukach, the units executive, said. You always have to be positive. I like to tell my guys: Bring yourself into it. If he says, Oh, Im having problems with my wife, say: Yeah, I have problems with my wife, too. My wife just yelled at me yesterday for not doing the dishes.
The officers goal is to form a rapport with the person and seize upon the one emotional chord that will get him or her to climb down from the edge. You have to understand and extend yourself because your obvious goal is to save someones life, Inspector Lukach said. So if you have to give a little, you give a little. Thats the sacrifice you make.
The mental gymnastics can go on for hours, and do not always pay off.
On a cold day this past winter, Detective Taylor was talking to a psychiatric patient who had squeezed through a sixth-floor bathroom window at Bellevue Hospital Center. The mans toes barely fit on a building lip below, so he mostly clung to the window ledge by his fingers. He told the detective that he had killed somebody a few years back and could no longer live with the guilt.
O.K., we all make mistakes, Detective Taylor said he told him. That doesnt mean you should take your life. Were all human beings. None of us are perfect.
Why dont you just push me? Why dont you just end it for me? the man goaded the detective, who recounted his words.
Thats not my purpose for being here, Detective Taylor gently told him.
For nearly three hours, Detective Taylor leaned out a seventh-floor window, talking, buying time, as other officers cut away window glass to create an opening large enough to make a grab. Detective Taylor sensed the man was ready to come in. He was shirtless and cold; his muscles quivered. He asked for a blanket, the detective recalled.
Fatigue set in, he said. He was extending his arms to me, but I couldnt reach him. At that point, he panicked a little bit, and thats when he kind of groaned and said, O.K., and he left fell. Detective Taylor, who has worked in emergency services for 12 years, spoke in a low voice, pausing pensively between words.
That was my first failure, he said. That was the one and only time that I lost someone I was talking to.
On a recent afternoon, the pathways on the Brooklyn Bridge buzzed with tourists and bicyclists enjoying a golden early fall day. Traffic hummed along. Then two words broadcast over police radios across the city brought the flow to a halt: Jumper up.
A young man had climbed out on the bridges outer beam. From his perspective, midway along the south side, the man saw his life at a low point. As they always do in the midst of a rescue, the police stopped traffic in both directions and shut down pedestrian and bicycle pathways.
Many of the people and drivers on the bridge below resented the interruption. Come on! Jump already, yelled a bicyclist stuck at the foot of the bridge in Lower Manhattan. He let loose a string of expletives. A rumor spread among the crowd that the man was up there eating a sandwich. He just wanted a nice perch to eat his lunch like some crazy guy, a pedestrian said.
Drivers threw up their hands and tap-tapped their car horns. Taxi passengers, dressed in business attire, took out their cellphones; they would be late.
On building rescues, the reactions of onlookers are as varied as the citys neighborhoods. In Midtown Manhattan or the financial district, for instance, pedestrians are more likely to yell, Jump!; in residential areas, like Harlem or Brooklyn, where the would-be jumper might be a familiar face, residents will provide officers with information about the person. They will cheer and applaud officers who make a successful grab, Detective Taylor said.
On this day, Detective Peter Keszthelyi, a member of the unit for 12 years, needed to focus. He stood on a catwalk that stretched across the bridges car lanes and carefully made his way over to the man.
Traffic was horrible, Detective Keszthelyi recalled. Everybody was yelling at me. New York is Hurry up and move or get out of my way.
The 40-year-old detective tuned out the angry din and zeroed in on the man before him. Im not here to hurt you in any way, he offered gently.
The detective asked the mans story, what brought him out here, and a dialogue began. The man, in his early 20s, explained that he had no job and no place to live, Detective Keszthelyi said.
You might seem like you are alone, but you are not really alone, he told him.
Lots of people lose jobs and find others they like better, he said.
You just have to find something in life that you enjoy doing, and when you find that special thing in life, you are going to be successful at it, Detective Keszthelyi assured him.
The man wanted to know what would happen if he came down. The officers know to be truthful. In my experience, you dont want to lie to somebody like that, Detective Keszthelyi said.
The detective told him that he would be escorted into an ambulance and taken to a hospital, where he would be evaluated and assigned a social worker and therapist. The man thought it over and then said: I want to give it another chance. I want to come down.
Detective Keszthelyi and other officers secured the man to their safety lines and walked him off the beam and down the ladder. He was honestly one of the nicest kids, the detective said in a telephone interview two hours after the rescue. He was just in a bad place, and it didnt seem like he had anybody to turn to. I felt really bad for him.
THE Emergency Service Unit is among the most coveted assignments in the Police Department. Officers must have five years of patrol experience before they are eligible for the unit. They must pass an oral interview, a physical agility test and a swim test. Officers who are selected then go through at least six months of training. Rescuing would-be jumpers is only part of their portfolio: They also learn how to properly suppress a fire, extricate an accident victim from a crushed car, rescue people in swift waters and anchor and tie ropes for bridge and building rescues.
There are several specialized teams within the unit. The Apprehension Tactical Team, for instance, brings in violent felony suspects; the detective involved in the shooting of an unarmed man on Thursday on the Grand Central Parkway was assigned to that duty and was part of a team that had just executed a warrant in the Bronx. Unit officers also take a three-week course to become certified emergency medical technicians and a weeklong emergency psychological course.
The opportunity to help people, affording them a second chance, feels like a privilege, said Detective Dennis Canale, of Emergency Truck 5 on Staten Island.
Detective Canales squad supervisor, Sgt. Anthony Lisi, said he repeatedly stressed to his officers that if a person jumped, it was not their fault.
Thats not necessarily a failure on our part, Sergeant Lisi said. That was their stronger will to want to hurt themselves. You dont want to take that home with you, that you were the cause of someones demise, which you were not.
On jobs that last for hours, officers try to rotate talking to the person.
If you have the ability to switch off, its good to do because your brain can wear on you, said Detective Nell, who worked in emergency service from 2001 to 2010. Your brain can get tired, and it could be cold, raining. It could be hot. I had a guy who just didnt say anything to us. Hes just sitting there. We would constantly ask him questions over and over. We had an officer speaking Spanish just in case there was a language barrier. He wouldnt say a word. You waited and you just kept talking and talking and pleading with the guy. It went on for hours.
Finally, he was distracted, the detective added, and one of the guys just grabbed him, but he never said a word to us the whole time.
There have been times, however, when an officer has established a rapport with someone who then refused to talk to anyone else. In that case, the officer must continue talking, or stay online, as the officers call it.
Its just you and that person for as long as it takes, Detective Nell said.
Some people will ask officers to bring a loved one to the scene. Officers are trained to redirect the conversation, offering, Well see what we can do.
Sometimes when someone asks for a specific person to be brought there, especially a person they are upset at, they are looking to do the act in front of them, so you dont want to take that chance, Detective Nell said.
Sergeant Lisis squad responds to emergency calls on the Verrazano-Narrows Bridge. The walkways up the bridges main cables are so steep that officers in the squad said they often have to stop to catch their breath while scaling them. It is nearly 230 feet from the water to the bridges upper deck, and almost 700 feet to the top of the towers. The chances of surviving a leap from the Verrazano are minuscule. It is unlike the more forgiving and much lower Brooklyn Bridge, and emergency service officers were hard-pressed to recall anyone who had survived the Verrazano, at least in recent years.
A dramatic rescue unfolded on the Verrazano in July, when officers talked down a man from an outer ledge, mid-span, who told officers he was distraught over arguments with his teenage daughter. The officers determined that he spoke Cantonese and brought in an officer from the Fifth Precinct, Yi Huang, to help interpret.
During four hours of negotiations, Detective Canale shared his own hardships with the man, divulging his anguish and despair when his son was found to have brain cancer. The boy, now 6, beat back the disease.
I explained to him that my son was sick, gravely sick, Detective Canale said. I told him everybody goes through issues. You cant give up in this world. You have to fight on.
Detective Canale said the man hugged him and shook Officer Ralph Stallones hand just before leaving in an ambulance. At the top of each bridge he climbs, Officer Stallone leaves a purple rubber wristband in memory of a 15-month-old nephew who died of a genetic disorder in 2010.
Detective Nell said he sometimes wondered what happened to those he had helped: Did they get their lives together? Did they try to kill themselves again?
He recalled a Bronx man who plunged off an apartment balcony on the 32nd floor of a Co-op City building in December 2005. The mans foot got caught in the railing of a balcony on the 31st floor and he was dangling by his ankle. Detective Nell, along with other emergency workers, grabbed him by the shirt and pulled him up. The detective remembered how a female paramedic touched the mans shoulder and said, It wasnt your time.
There are those who, even after having been rescued, do not seem grateful. Maybe they will down the road, said Detective Darren McNamara, who recently dived into the Hudson River and swam out to a suicidal woman. As he grabbed her, according to the detective, she looked at him flatly and said, Why did you do that?
And while potential jumpers often wait for officers to arrive because they may want to be talked out of killing themselves, there are those who never give officers the chance. Detective Canale recalled a man who leapt from a lower stretch of the Verrazano and struck the rocks below. The man was still alive when the detective got to him, though many of his bones were broken, his internal organs ruptured.
As the mans shattered body was
secured to a long board and he was administered oxygen, the
man, in some of his final words, said he regretted jumping,
the detective recalled. I cant get this right,
either, the man said, according to Detective Canale.
I told him: Were going to get you to the
hospital. Were going to try to make it better.
reveals its veteran suicide statistic included active-duty
However, the statistic has long been misunderstood, according to a report released this week.
The VA has now revealed the average daily number of veteran suicides has always included deaths of active-duty servicemembers and members of the National Guard and Reserve, not just veterans.
Craig Bryan, a psychologist and leader of the National Center for Veterans Studies, said the new information could now help advocates in the fight against military and veteran suicide.
The key message is that suicides are elevated among those who have ever served, Bryan said. The benefit of separating out subgroups is that it can help us identify higher risk subgroups of the whole, which may be able to help us determine where and how to best focus resources.
The VA released its newest National Suicide Data Report on Monday, which includes data from 2005 through 2015. Much in the report remained unchanged from two years ago, when the VA reported suicide statistics through 2014. Veteran suicide rates are still higher than the rest of the population, particularly among women.
In both reports, the VA said an average of 20 veterans succumbed to suicide every day. In its newest version, the VA was more specific.
The report shows the total is 20.6 suicides every day. Of those, 16.8 were veterans and 3.8 were active-duty servicemembers, guardsmen and reservists, the report states. That amounts to 6,132 veterans and 1,387 servicemembers who died by suicide in one year.
The VA's 2012 report stated 22 veterans sucumbbed to suicide every day a number thats still often cited incorrectly. That number also included active-duty troops, Guard and Reserve, VA Press Secretary Curt Cashour said Wednesday.
VA officials determine the statistic by analyzing state death certificates and calculating the percentage of veterans out of all suicides. The death certificates include a field designating whether the deceased ever served in the U.S. military.
Information in the 2012 report wasnt as complete as the newer ones. At the time, only 21 states shared information from their death certificates. California and Texas, which have large veteran populations, were two of the states that didnt provide their data.
Since that report was released, we have been closely collaborating with the [Department of Defense] to increase our level of accuracy in reporting, Cashour wrote in an email.
Following the release of the new National Suicide Data Report on Monday, some veteran advocates responded on social media with questions. One person said the community was thrown off.
Bryan said the situation highlights a common source of confusion regarding who is and who is not considered a veteran.
Heidi Kar, a project director at the nonprofit Education Development Center and a clinical psychologist with expertise in veteran suicide, said she had previously understood the statistic to be a veteran-only number.
Overall, Kar thinks the VA put more emphasis in its latest report about suicide as a public health issue that requires the help of multiple agencies and community-based groups. The report shows that of the 20.6 veterans and servicemembers who died by suicide every day, six had recently used VA health care services. The suicide rate among the people who didnt receive VA care increased faster than ones who did.
The biggest message is that suicide prevention is everyones job, Kar said. Its a problem for active duty, its a problem for vets, its a problem for the elderly and for young people. So, the response has to be multidimensional, and different sectors have to problem-solve together.
The VA said in a statement that its working with the Defense Department and the national Centers for Disease Control and Prevention to publish 2016 suicide statistics in the fall. The agency said its part of an ongoing review of millions of death records that could lead to improvements in the VAs suicide prevention programs.
To contact the
Veterans Crisis Line, veterans, servicemembers or their
families can call 1-800-273-8255 and press 1. They can also
text 838255 or visitveteranscrisisline.net for
Married veterans face greater risk of suicide
Researchers reviewed survey responses from 772 Iraq and Afghanistan veterans and found variations in suicide risk based on age, income, marital status and religious beliefs. Being married significantly increased the risk, researchers concluded.
It certainly makes sense when you think about it, said Crystal Park, a psychology professor at the University of Connecticut and one of the co-authors of the study. There are added pressures that come with maintaining a relationship and meeting household needs. People may have expectations when theyre away, and when they return its not what they imagined, the romance may not be there. Its just the daily grind and that can drive up stress levels and increase feelings of despair.
The study was funded
by the VA and published in the Archives of Suicide Research.
(48 page PDF)
Study of Suicide Loss Survivors in
The experience of suicide loss and bereavement is more prevalent among the US population than most realize. Previous studies demonstrate that suicide loss survivors are likely to experience significant health problems; this new data suggests that large numbers of suicide loss-survivors are in need of mental health services and support.
Perhaps the knowledge of how common the experience of suicide survivorship is could help decrease the sense of isolation and stigma many loss survivors experience. Knowing that they are not alone that their experience of this type of loss is far from rarecould encourage more people who have lost a loved one to suicide to speak more openly about their loss, and connect with others who have also experienced this type of loss. The knowledge about prevalence and impact could also lead to greater sophistication among healthcare providers, clergy and other community members, so that enhanced support for suicide loss could become much more available.
To read more about the study, click
We investigated lifetime suicide exposures and bereavement among a representative sample of American adults from the 2016 General Social Survey.
Questions on lifetime suicide exposures, bereavement and mental health status were administered to 1432 respondents. Suicide exposed and bereaved respondents were compared to non-exposed respondents on three different measures of mental health functioning with cross tabulations and means comparison tests.
51% of respondents had exposures to one suicide or more during their lifetimes, and 35% were deemed bereaved by suicide, having experienced moderate to severe emotional distress from their losses. Findings suggested more exposures and bereavements were associated with greater numbers of bad mental health days and more expectations of having nervous breakdowns but with no clear associations with CES-D scores.
These findings suggest suicide
exposures and bereavement are far more pervasive than
commonly thought, with more than half of the population
exposed and a third bereaved. Health professionals need to
more actively assess for suicide exposures and bereavements,
and be vigilant for significant impacts of suicide even when
the suicide decedent is not a first degree family relative,
helping to reduce the mental health distress presently
associated with these experiences.
This month, the Centres for Disease Control (CDC) released a report suggesting that Americas suicide rate increased by 25% between 1999 and 2016. The climb is from a historic low at the turn of the millennium and American suicide rates overall are still not significantly above those of other high-income countries. Nonetheless, World Health Organisation estimates suggest that out of its 183 member countries the United States had the seventh largest percentage increase in suicide rates between 2000 and 2016. Every suicide can have multiple causes, and the CDC does not offer a simple explanation for the rise. But other research suggests that one factor behind the rising suicide rate is an erosion of the privileged status of white men.
Nearly 45,000 Americans took their own lives in 2016, and suicide is an important part of the rising number of deaths of despair (also including drug overdoses and liver disease) described by Anne Case and Angus Deaton, economists. These causes of death have increased the overall mortality rate amongst white men without a college degree. Both absolute levels of suicide per 100,000 people and recent increases are particularly high amongst those aged between 45 and 64. The male suicide rate remains almost four times that for women, and suicide rates for whites are higher and have been climbing faster than those for other racial and ethnic groups.
Relative status over time appears to play a role in suicide trends. The relationship between average income and reported suicide rates across countries is weak, but inequality, recessions and unemployment are all associated with higher rates. Rising unemployment during the financial crisis was associated with increased suicide rates across Europe, for example, even while it was associated with reduced overall mortality. In America, work by Mary C. Daly and her colleagues at the Federal Reserve Bank of San Francisco suggested suicide risk rises for individuals when they see their income decline relative to the average in their county. Ms Daly has also found that richer countries in which citizens report higher average subjective wellbeing or happiness see higher suicide rates and the same is true across America's states. Discontented people in a happy place may feel particularly harshly treated by life, they suggest.
The link between erosion of relative status and suicide may also involve gender and race. A 35-country study by Allison Miller of Griffith University and colleagues suggested rising female labour force participation is associated with increased male suicide rates. Carol Graham and colleagues at the Brookings Institute find that controlling for factors including income, gender, marital status, education and employment, whites are considerably less optimistic, report lower life satisfaction and more worry and stress than Latinos and blacks. They also find an association between deaths of despair and these subjective wellbeing measures. The researchers argue that one factor behind their results may be that poor whites have fallen in status in relative terms, so that they are doing worse or no better than their parents while poor minorities have still seen some progress even if they remain disadvantaged. The combination of fear of downward mobility, weak safety nets, and eroding social cohesion likely contributes to the high levels of desperation, they suggest.
What can be done? The CDC suggests
that a range of interventions can lower the suicide rate.
These include better coverage of mental health conditions in
health insurance and treatment for people at risk alongside
reduced access to lethal means amongst that
populationnot least, guns, used in 49% of suicides.
But given that more than half of suicides involve people not
diagnosed with a mental health condition, the CDC suggests
the need for a greater focus on non-mental health
factors further upstream including causes of financial
distress. That suggests that a strengthened safety net
alongside improved insurance coverage might help both the
old poor and the new hopeless cope better.
suicide attempt killed a grad student who wanted to help
kids with depression
Perceptions and Suicide
Researchers used data from a nationally representative U.S. sample of 2,855 participants to examine their perceptions of the following work-related characteristics:
Motivational work characteristics, including job autonomy (i.e., freedom to make important decisions at work) and task variety (i.e., amount of time spent doing the same thing repeatedly)
The analysis controlled for
demographic characteristics and history of depression and
suicidal behaviors. It found that motivational work
characteristics, work-family and family-work conflict, and
job satisfaction were all directly associated with
depression and suicidal ideation, with an indirect
connection to suicide attempts. Although few employees will
attempt suicide, this research has implications for creating
supportive workplace policies as part of a comprehensive
approach to suicide prevention.
Access to Means of Suicide
Why It's Important
Here are some of the reasons why reducing access to lethal means is important:1
What You Can Do
Families, organizations, health care providers, and policymakers can take many actions to reduce access to lethal means of self-harm. Some of these are general household health and safety precautions that should be used regardless of suicide risk. Examples include limiting access to medications and storing firearms safely when not in use.
Other actions may be more appropriate when a person is at risk for suicide. If someone in the home is feeling suicidal, has recently attempted suicide, or is experiencing a crisis, it is safest to remove lethal means from the household entirely until the situation improves. For example:
Some communities also focus means restriction efforts on local suicide hotspots, such as bridges. As part of strategic planning, states, tribes, and communities should examine their data to identify what suicide means they should address.
Families, organizations, health care providers, and policymakers can take make many actions to reduce access to lethal means of self-harm.
Obtain and share knowledge about the issue and how others can help.
Collaborate with others in your community to increase safety.
Harvard T. H. Chan
School of Public Health. (n.d.). Means matter website.
Retrieved from www.hsph.harvard.edu/means-matter
Statement for the
American Association of Suicidology Regarding the Role of
Firearms in Suicide and the Importance of Means of Safety in
Preventing Suicide Deaths
Although firearms are involved in a disproportionate amount of American suicide deaths, it is vital to note that evidence consistently indicates firearm ownership is not associated with suicidal thoughts. In other words, owning a firearm does not prompt an otherwise non-suicidal individual to suddenly develop thoughts of suicide. Instead, firearms increase the risk of death by suicide. Only a small minority of individuals who think about suicide go on to make a suicide attempt and emerging evidence indicates that, in order for an individual to make that relatively rare transition, he or she must be capable of suicide. Such capability involves, in part, access to and aptitude with lethal means for suicide. Along these lines, it appears that firearms increase the risk for death by suicide among suicidal individuals by facilitating their transition from thought to action, with that action almost universally resulting in death (whereas access to less deadly methods could facilitate a non-lethal suicide attempt). This unique role a facilitator of action within the context of already existing suicidal thoughts is highlighted by decades of research demonstrating that firearm access is associated with death by suicide even when accounting for who an individual is (male/female, young/old), how that individual is feeling (depression symptoms, substance use, social isolation), whether that individual has access to proper care (population density, socioeconomic status), and whether that individual has been suicidal in the past (prior suicidal thoughts, prior suicide attempts). Firearm access increases suicide risk among all members of a home where a firearm is present, and risk is greatest when household firearms are stored unlocked and loaded.
Fortunately, lessons learned from other public health struggles, as well as emerging evidence specific to firearms and suicide, present a blueprint for success in addressing this problem. Means safety defined as actions that render a specific method for suicide less deadly or less accessible during a suicide attempt represents a promising path towards reducing firearm suicides and, consequently towards lowering the overall suicide rate. This approach is often referred to as means restriction; however, research has demonstrated that use of the word restriction decreases the willingness of firearm owners to engage with the intervention.
Means safety has been applied to a range of suicide methods. For instance, the detoxification of domestic gas resulted in substantial reductions in the overall suicide rate in the UK in the mid-20th century. Reducing access to the most highly human-toxic pesticides in Sri Lanka led to a 50% drop in the overall suicide rate, driven by a drop in poisoning suicides.. When means safety is effective, it reduces the overall suicide rate by reducing the method-specific suicide rate, while suicide rates by other methods either remain flat or only marginally increase. The goal is to prevent individuals from dying, not to simply change the method by which they die. Reductions in overall suicide rates highlight the fact that, when an individual is prevented from using a specific method to die by suicide, they do not simply find another way. The effect of means safety, however, hinges upon the lethality, popularity, and accessibility of the targeted method. As such, means safety efforts in the United States must focus specifically on firearms in order to have optimal effects because firearms are the leading method, the most lethal, and easy to access.
Means safety specific to firearms can take several forms, each of which has varying levels of evidence supporting its efficacy as well as varying degrees of plausibility depending in part upon geographic location. In recent years, suicide prevention experts have collaborated with the firearm owning community to develop gun friendly materials, messaging, and curriculum aimed at gun-owning families. These interventions do not vilify firearms or firearm owners; they capitalize on the existing culture of gun safety and the shared goal of preventing suicide death. The primary focus of these programs is to encourage voluntarily storing firearms away from the home when a household member is at risk for suicide or otherwise making them inaccessible to the at-risk person. These programs also encourage routinely storing guns locked, not only during times of crisis. Such approaches are akin to successful efforts to curb drunk driving and to reduce the overall motor vehicle fatality rate (e.g. friends dont let friends drive drunk). They are non-coercive and focus on preventing an unwanted outcome rather than demonizing firearms and risking a lack of buy-in from the firearm owning community. The collaborative approach has yielded partnerships with high profile firearm organizations (e.g. National Shooting Sports Foundation), which in turn lends credibility to such projects and increases the plausibility of large scale dissemination and implementation.
Research considering the suicide prevention potential of legislation (e.g. universal background checks, mandatory waiting periods; extreme risk protection orders) indicates that states with certain laws in place tend to exhibit lower overall suicide rates and a less severe suicide rate trajectory across time. Given the magnitude of the effect sizes reported in this research, such legislation may represent one useful tool in efforts to prevent suicide. That being said, in areas of the country in which firearm ownership is substantially more common, the political feasibility of such legislation is lower, rendering the potential reach of at least certain forms of the intervention limited.
Research examining the effectiveness of non-legislative means safety approaches is currently lacking and such data should be a focus of suicide research in the coming years. As research is conducted in this area, other potentially fruitful avenues for increasing effectiveness and reach include promoting the use of lethal means counseling; improving locking technologies; and increasing access to and knowledge about safe and legal options to temporarily store firearms during times of crisis. An important consideration is the target population for such interventions. One possible route is to focus on high risk individuals such as those seeking mental health care and/or endorsing suicidal thoughts. Such approaches would focus on ensuring that individuals we have identified as being at high risk for suicide take steps to reduce their access to specific methods for suicide.
Although these are certainly valuable
groups to consider, an argument could be made that a better
approach is to aim for population level implementation
regardless of known risk. Recent research indicates that we
have not improved in our ability to prospectively predict
suicide risk since the 1950s. This failure has many
explanations, but one component is likely that the
individuals most likely to die by suicide, particularly
those who would die using a firearm (e.g. men in general,
middle aged or older white men, military personnel) tend to
avoid mental health care altogether and to underreport
thoughts of suicide. Because of this, we are typically ill
equipped to identify individuals at risk for suicide until
they are dead. By implementing means safety at the
population level, we can diminish our reliance upon
correctly identifying individual risk levels and instead
ensure our communities as a whole are at lower risk of
suicide death regardless of current suicidal thoughts. As
such, although we do not oppose approaches that target high
risk individuals, we would see such efforts as needing to be
one component of a multifaceted approach that also includes
population level prevention initiatives.
In recent years, suicide risk among lesbian, gay, bisexual and transgender (LGBT) people has become a growing focus of public discussion and concern. While some of that visibility has been informed by solid research and facts, other aspects of the discussion have inadvertently contributed to misinformation about suicidal behavior in LGBT populations, potentially increasing the risk of suicide in vulnerable individuals.
The importance of public education about suicide cannot be overstated. When individuals and organizations talk about suicide safely and accurately, they can help reduce the likelihood of its occurrence; however, talking about suicide in inaccurate or exaggerated ways can elevate that risk in vulnerable individuals.
This second edition of Talking About Suicide & LGBT Populations provides facts about suicide and LGBT people, as well as ways to talk about suicide safely and accuratelyand in ways that advance vital public discussions about preventing suicide among LGBT people and supporting their health and well-being.
Talking About Suicide & LGBT Populations (August 2017)DOWNLOAD 4 page PDF
En los últimos años, el riesgo de suicidio en personas lesbianas, gays, bisexuales y transgénero (LGBT) ha cobrado mayor atención en el debate y la preocupación del público. Si bien parte de esa visibilidad se basa en hechos e investigaciones sólidas, otros aspectos del debate han contribuido involuntariamente a generar información errónea acerca del comportamiento suicida en las poblaciones LGBT, lo que posiblemente aumenta el riesgo de suicidio en personas vulnerables.
No se debe subestimar la importancia de la educación pública en torno al suicidio. Cuando las personas y las organizaciones hablan del suicidio de forma segura y precisa, pueden ayudar a reducir la probabilidad de que ocurra; sin embargo, cuando se cometen exageraciones o inexactitudes al hablar del suicidio, se puede elevar el riesgo en personas vulnerables.
Esta segunda edición de Cómo hablar sobre el suicidio y las poblaciones LGBT trata sobre la realidad del suicidio y las personas LGBT. Ofrece maneras de hablar sobre el suicidio con seguridad y precisión, que buscan fomentar el debate público vital sobre su prevención en personas LGBT, y apoyar su salud y bienestar. .
Conversaciones sobre el suicidio y las poblaciones LGBT(Agosto de 2017) DOWNLOAD
Recommendations for Reporting on Suicide (2011) (American Association of Suicidology; American Foundation for Suicide Prevention; Annenberg Public Policy Center; Canterbury Suicide Project - University of Otago, Christchurch, New Zealand; Columbia University Department of Psychiatry; ConnectSafely.org; Emotion Technology; International Association for Suicide Prevention Task Force on Media and Suicide; Medical University of Vienna; National Alliance on Mental Illness; National Institute of Mental Health; New York State Psychiatric Institute; Substance Abuse and Mental Health Services Administration; Suicide Awareness Voices of Education; Suicide Prevention Resource Center; The Centers for Disease Control and Prevention (CDC); and UCLA School of Public Health, Community Health Sciences)
Suicide and Suicide Risk in Lesbian, Gay, Bisexual, and Transgender Populations: Review and Recommendations (Journal of Homosexuality, Volume 58, Issue 1, January 2011)
Safe and Effective Messaging for
Suicide Prevention (Suicide Prevention Resource Center)
Suicides in the U.S. have been on the rise. In 2013, suicide was the 10th leading cause of death among all Americans. In 2014, the Centers for Disease Control and Prevention (CDC) reported that the rate of suicide was the highest it had been in 25 years. The annual suicide rate in the U.S. is 12.93 per 100,000. (Editor's note: There were 47.173 suicides in the U.S. in 2017 up from 42,826 in 2014.).
What Are Suicide Rates?
The suicide rate is the number of completed suicides (those that result in death; attempted suicide is not counted in the suicide rate) per 100,000 people. The Centers for Disease Control and Prevention gathers data from hospitals on cases of self-harm and of suicide each year. Data covers all age groups and demographics . However, the number is considered by some to be low, and that the stigma still surrounding suicide results in underreporting.
Suicide Rate Statistic Breakdowns
When the suicide rate is broken down by demographics, we learn important information. For example:
Broken down by age group across all racial and ethnic groups, suicide as a leading cause of death ranked as follows:
Suicide is expensivecostly not only in the emotional toll it takes, but also for it's real financial impact. It is estimated that each year the estimated medical costs and work lost is $51 billion.
Depression and Suicide
Depression and suicide are linked, but a study by the Mayo Clinic in 2000 found that the number of people suffering from depression who commit suicide is not as high as originally thought.
Prior to the study, it was believed that as many as 15 percent of people diagnosed with depression committed suicide; however, after analyzing suicide studies over a 30 year time period, Mayo Clinic researchers found that the rate of suicide among depression patients was lower, between 2 and 9 percent.
The difference in these numbers is due to the methods used for calculating the statistics and because of a change in how depression has been defined. Depression in 1970, for example, only accounted for those patients with serious mental illnesses that were diagnosed with depression (such as manic depression). The definition has expanded today and includes those with mild to moderate symptoms who can be treated with therapy and medication.
Depression and Suicide Warning Signs
There are warning signs you can watch for in hose who may be at risk of attempting suicide. Though there is no single type of person who may commit suicide, and the symptoms below are not exhaustive, these are the most common signs observed among people who may be contemplating taking their own life.
Overdoses May Be Suicides
The researchers describe suicide as a "silent contributor" to the nation's opioid overdose death rate.
It's hard to know exactly how many Americans have intentionally overdosed on opioids in recent years, said report author Dr. Maria Oquendo, a professor of psychiatry at the University of Pennsylvania. The analysis of the issue is published April 26 in the New England Journal of Medicine.
One problem, she explained, is that there are different ways of establishing a "manner" of death across the country. "Manner" refers not to the cause -- a drug overdose, for example -- but whether a death was a homicide, suicide or accident.
Unless there's a suicide note, or documented history of depression, it may be impossible to establish a drug overdose as a suicide.
In the end, Oquendo said, many overdose deaths are classified as "undetermined."
One suicide expert explained why.
"If you're a coroner, it's not easy to discern intent," explained Jerry Reed, executive committee member of the National Action Alliance for Suicide Prevention, in Washington, D.C.
However, he said, it's known that both suicides and opioid overdose deaths have been rising.
According to the U.S. Centers for Disease Control and Prevention, the national suicide rate rose by 24 percent between 1999 and 2014 -- from 10.5 deaths per 100,000 people, to 13 per 100,000.
Meanwhile, the opioid toll keeps growing. Recent research has found a leveling off in Americans' abuse of prescription opioid painkillers -- like Vicodin, OxyContin and codeine. But abuse of illegal opioids, like heroin, is also rising.
And overall, opioid overdose deaths are still climbing.
Last year, a U.S government study highlighted the impact that heroin alone is having: Between 2002 and 2016, deaths from the drug soared by 533 percent nationwide -- from just under 2,100 deaths to more than 13,200.
How many deaths might be suicides? No one knows, Oquendo said.
But some research suggests opioids are behind a growing number of suicides, at least based on deaths that are officially classified as such. One study found that the proportion of U.S. suicides that were attributed to opioid overdose rose from 2.2 percent in 1999 to 4.3 percent in 2014.
It's vital to understand how often people with opioid abuse problems are suicidal, Oquendo said.
"The interventions for those people would be much different," she explained.
The best treatment for opioid addiction involves medication -- such as buprenorphine or naltrexone -- that blocks the effects of opioids. But, Oquendo said, people who are suicidal need other types of help, such as treatment for underlying depression.
Reed agreed. "If you treat it only as an opioid problem, you won't address the underlying issues."
People get hooked on opioids through different routes. Some start with a legitimate prescription for pain relief, then spiral into abuse. Some use the drugs illegally from the start.
But in general, Reed said, "these people don't want to be addicts. They want to alleviate pain, whether it's physical or psychological."
Similarly, he said, people who are suicidal do not want to die, but want to end their pain.
As it stands, Oquendo said, doctors do not routinely screen for suicide risk in scenarios where they might spot people who are vulnerable to an intentional opioid overdose.
That screening, she said, could happen in emergency rooms, when people are brought in for an opioid overdose -- or when people start medication treatment for opioid abuse.
But, Oquendo added, screening should ideally be broader than that. For example, she said, doctors could screen for suicide risk when they are prescribing opioids to a patient -- especially for chronic pain.
However, access to specialized care is a major obstacle, both Oquendo and Reed said.
In areas where the opioid epidemic is most acute -- including rural areas -- people may not be able to find a doctor who can prescribe opioid-abuse medications, let alone a mental health professional.
"The lack of access to interventions that work is lethal," Reed said. "We need to figure out how to make these interventions more readily available."
For now, he has some advice for families of people with opioid abuse problems: If they land in an ER with an overdose, make sure they have a full evaluation there, including screening for suicide risk.
More generally, Reed said, "try to stand by them. They need connection, support and love from the people around them."
He also recommended that people in
crisis call the National Suicide Prevention Lifeline, at
1-800-273-TALK (8255) or text "SOS" to the National Crisis
Text Line 741741.
dots: How the opioid epidemic affects suicide in teens and
A 14-year-old girl with a parent addicted to opioids tried to choke herself with a seat belt. A 12-year-old transgender child hurt himself after being bullied. And a steady stream of kids arrived from the city's west side, telling him they knew other kids - at school, in their neighborhoods - who had also tried to die.
"I think there's an increase in suicidal kids in Cincinnati," Nelson told a colleague. "We need to start mapping this out."
So Nelson and his colleagues collected the addresses of 300 children admitted to Cincinnati Children's Hospital with suicidal behavior over three months in early 2016, looking for patterns. Almost instantly, a disturbing one emerged: Price Hill, a poor community with a high rate of opioid overdoses, was home to a startling number of suicidal kids.
"This is who is dying from opiates - people in their 20s and 30s. Think about what that population is," Nelson said. "It's parents."
Now Nelson is working with county coroners across the nation to try to corroborate his theory, that trauma from the nation's opioid epidemic could help explain an extraordinary increase in suicide among American children. Since 2007, the rate of suicide has doubled among children 10 to 14, according to the Centers for Disease Control and Prevention. Suicide is the second-leading cause of death between the ages of 10 and 24. The suicide rate among older teenage girls hit a 40-year high in 2015, according to newly released data from the National Center for Health Statistics.
Cincinnati has been particularly hard hit. In 2015, five children died from suicide in Hamilton County, where Cincinnati is located. Last year, 13 children under 18 were lost to suicide - a rate nearly three times the national average. This year, nine kids have died by suicide, a majority of them under 15. The youngest, a resident of Price Hill, was 8 years old.
Nelson, who has been practicing for two decades, says many of his patients come from families with addiction problems. In a program he runs for preschoolers who have been severely abused, over 60 percent have an opioid-addicted parent.
"At any given time, at least 25 percent of my hospitalized kids have a parent actively struggling with addiction," Nelson said. "Early childhood trauma has been proven to set the stage for a lot of mental and physical illness. It's a pretty simple scale."
The epiphany about Price Hill came unexpectedly, when he saw a map of overdoses in Hamilton County. The overdoses clustered in the same places as his suicidal kids. "They laid over each other almost exactly," he said.
"We do worry that a neighborhood with a high rate of opioid overdoses is also seeing this suicide cluster," said Marilyn Crumpton, Cincinnati's interim health commissioner. In particular, she is concerned about the increasing number of children being orphaned by the opioid epidemic and the despair it is causing in communities. "It's very easy to see the relationship."
Child psychiatrist Dan Nelson
Child psychiatrist Dan Nelson at the clinic where he treats addiction patients in Cincinnati. (Luke Sharrett for The Washington Post)
Price Hill overlooks the basin of downtown Cincinnati. Once a buzzing, wealthy suburb with its own cable railway, it is now pockmarked with shuttered businesses and boarded-up homes.
Nelson drove a reporter to Carson Elementary School, and its playground was desolate during summer break.
"I'm thinking if I live in a community where my friends' parents are dying, if I'm in a class of 25 with 15 families challenged by addiction, even if my family isn't directly challenged, I suddenly become affected," he said. "Kids are coming in with all these traumatic experiences. Resources are stretched. Teachers aren't able to teach the same. It could be a contagion effect in a community."
In January, 8-year-old Gabriel Taye, a third-grader at Carson, died by suicide at his home in Price Hill. He had been bullied by kids at the school.
The coroner initially asked police to investigate the death as a murder because she didn't think an 8-year-old could hang himself. Now, she was trying to figure out from Gabriel's iPad where he learned how to do it.
"They called me in when Gabriel died," Nelson said. "It's the youngest kid who completed suicide that I can remember in a long while."
Nelson drove a few blocks to Western Hills High, a 1,200-student school that had two suicides last year: A 16-year-old sophomore boy and a girl who had just finished school. In March, the school lost another teen. About a dozen of the suicidal kids on Nelson's map went to this school, which shares grounds and a medical clinic with Dater High, which had another student die of suicide recently.
"They've had four kids that died of suicide in the last two years between the schools," Nelson said. "Across the street from here, there is a junior high called Midway, where a 12-year-old died last year."
Inside Western Hills, a group of students were painting the long wall by the school gym gold. Rihanna blared from a boombox.
Nelson walked into a classroom where a strike team addressing the school's suicide problem was seated at a long table.
Susan Shelton, a founder of MindPeace, a youth mental-health organization that has brought professional mental-health services to nearly 100 Cincinnati schools over the past 15 years, was helping train school staffers to spot childhood trauma - a strong predictor of future depression and suicide risk.
Others around the table represented Lighthouse, a youth and family service agency whose psychologists and counselors work with students out of a room just down this corridor.
Nelson had met with the group this spring, when they raised the alarm about students reporting suicidal thoughts. He'd shown his suicide and opioid overdose maps on a large-screen television. "They got it immediately," he said.
Weeks after that meeting, Western Hills lost another teenager to suicide.
"The worst thing a principal can face on any given day is to come into their school building and find out one of the students has committed suicide," said Kenneth Jump, the school principal.
Nelson said: "When a child dies, everybody is affected. No matter how hard you try, you feel like you're failing."
One of Nelson's patients, Samantha Potter, came to his clinic at age 12, after the first of two suicide attempts and two years after her father killed himself.
"We were celebrating my 10th birthday at Grandma's house when my dad passed away from suicide," Samantha said over tea in a bookshop cafe just across the river from Cincinnati in Florence, Kentucky.
"When they told us, we were sitting together on the loveseat," her sister Emma said. "I remember we held hands because we were scared."
Suicide - especially among children - can be contagious. Research suggests that about 5 percent of youth suicides are influenced by contagion from suicidal peers or cultural depictions of suicide. That's one thing that worried Nelson about his patients in Price Hill and across the region.
After she attempted suicide, Samantha said, "that night I slept with my mom and had horrible nightmares. I didn't know what to say to the nurses and doctors. I was terrified. Because when you're trying to commit suicide, some people forget this, but there's still a part of you that doesn't want to. Not only are you scared of dying, but you're scared of yourself. You're scared of what's possible at that moment in time."
After Sam was diagnosed and treated for post-traumatic stress disorder in her early teens and became more comfortable speaking out about suicide, she turned into a magnet for others in crisis.
"Suicide notes, calls for help started falling out of my locker," she said. "Some said, 'I have pains in my chest from anxiety.' Others would tell me they were cutting themselves. Some would just say, 'So-and-so needs a friend.' "
Now 19 and just starting college, Sam has an armory of coping skills, and she started Rob's Kids, named after her dad, to help other children deal with their trauma.
Like Nelson, she'd been puzzling over the cause of this tidal wave of depression and suicide among her peers. "Multiple classmates of mine at school had tried," she said. Emma, who is 17, nodded in agreement.
"Have you seen that show '13 Reasons Why'?" Sam asked. She was incensed about the series. The Netflix TV show about a high school teenager dying by suicide has become the focus of alarm for school superintendents and doctors.
Their fear is that it will stoke the problem of youth suicide through contagion, particularly among kids already struggling with depression. A study published in July found a 19 percent increase in internet searches about suicide, including "how to commit suicide," after the series debuted.
In addition to his pediatric practice at the children's hospital, Nelson runs an addiction clinic that serves poor families. The waiting room is crammed.
One patient, a father addicted to opioids, had walked for more than two hours from Kentucky to be there. An anxious couple were waiting to get a prescription and ask advice on what to do about their child, who had been taken away by protective services.
A young mother in recovery chastised her toddlers, who were happily exploring the office on all fours. "Can I give them a C-R-A-C-K-E-R today?" Nelson asked with a smile.
Then he walked out to greet the next family.
"I encourage them to bring and talk about their children," he said, during a short breather between patients. "Treating the addiction helps reduce psychosocial stress for the kids."
One of Nelson's patients, Scott Emmon, was born and raised in Price Hill, where he now works in security. He's been clean for about a year.
Last year, his brother died of a heroin overdose. He left behind two daughters, a 19-year-old who attended Western Hills and a 4-year-old who is now in foster care.
"I've been to 24 funerals and only two weddings," said Emmon, 37. "It's so sad to say, but it's the truth. I see people die all the time. It's like a normal thing now."
Price Hill locals have seen the epidemic of overdoses in their neighborhood, and many worry about how it is affecting their children.
Jeremy Bauer, parish operations manager at Holy Family Church in East Price Hill, witnessed three overdoses within the span of three weeks - a woman slumped across the street from the church; a second woman curled up in a McDonald's parking lot when he was with his two children; and a man in an alleyway behind the church.
In June, Bauer decided to hand out kits of Narcan - an antidote to acute opioid overdose - to families at a church community event, in an effort to combat the heroin epidemic in the area.
Bauer says kids are certainly aware of what they are seeing. "They see the overdoses. They hear about it - on the news, on Facebook. They see the squads," he said. "I can be out in my front yard with my kids working on my flower beds, I see people walk up and down and I can see they're high."
He continued: "Imagine being a young person in this community who looks around and sees this devastation, people in the throes of addiction, people slumped over or high on the street. That's got to sap their energy and passion. If they're living in this community, where walking down the street they see so many people trapped in a lifestyle, how can they have an ambition to be something bigger?
"How can we expect them to process it
when we can't even process it as adults?"
A paper by Princeton University's Anne Case and Nobel laureate Angus Deaton found that white, non-Hispanic Americans aged 45-54 have seen an increase in all-case mortality, which was largely led by increases in deaths by suicides, drug and alcohol poisonings, and chronic liver diseases.
In the same timeframe, mortality rates for midlife black non-Hispanics, Hispanics, and those older than 65 in every racial and ethnic group continued to fall.
Additionally, although all education groups among non-Hispanic whites aged 45-54 saw increases in poisonings and suicide, those with less education saw the most marked increases in external cause mortality.
A Bank of America Merrill Lynch team led by Beijia Ma used the data from Case and Deaton to put together a chart showing the change in mortality by cause among middle-aged white, non-Hispanic Americans.
As you can see in the chart, deaths by poisoning mostly alcohol and/or drug poisoning, according to Case and Deaton shot up dramatically from 2000-2013. Meanwhile, death by suicide and by chronic liver disease, which is associated with obesity, alcohol abuse, and hepatitis, also increased significantly.
On a somewhat positive note, the death rate from lung cancer (correlated with cigarette smoking) decreased, while death by diabetes did not significantly change.
Notably, Case and Deaton write that the increased midlife mortality rates for this demographic group was "paralleled by increases in midlife morbidity."
"Self-reported declines in health, mental health, and ability to conduct activities of daily living, and increases in chronic pain and inability to work, as well as clinically measured deteriorations in liver function, all point to growing distress in this population," the economists wrote in the paper.
Moreover, the paper's authors also commented on a potential correlation between these trends and the financial downturn. Via their paper:
Although the epidemic of pain, suicide, and drug overdoses preceded the financial crisis, ties to economic insecurity are possible. After the productivity slowdown in the early 1970s, and with widening income inequality, many of the baby-boom generation are the first to find, in midlife, that they will not be better off than were their parents. Growth in real median earnings has been slow for this group, especially those with only a high school education.
A somewhat bleak implication here is that this generation of adults might enter into old-age healthcare programs like Medicare in worse health than their predecessors, note Case and Deaton.
"This change reversed decades of
progress in mortality and was unique to the United States;
no other rich country saw a similar turnaround," the duo
wrote in the report.