Suicide is a complex and tragic social and epidemiological problem that affects all strata of American society. Unfortunately, data from the National Vital Statistics system indicates that suicide rates in the US are rising for both males and females1.

The recession of 2006-7 is correlated in particular with a steeper increase in rates, which have risen some 24% from 1999-2014. Although suicide rates have gone up for all ages, middle-aged men (45-64) and young women (10-14) saw the greatest increases2.

Over half of male suicides were completed with a firearm, while poisoning/overdose was the leading cause of death, involving about 34% of women.

What is causing this increase, and how can the American people turn these numbers around?

Suicide is a complex issue, involving economic and cultural struggles, unattended mental health and addiction problems, and social stigma. Overall, not all Americans are getting adequate mental health care, and this is having a direct causative effect. Because primary care or general practitioner doctors often find themselves at the forefront of mental health problems, tools that can extend the abilities of their practices can help doctors and patients alike.

Research has shown that patients experiencing psychiatric symptoms can be hesitant to discuss their experiences face-to-face with doctors3, and so computerized screening tools can be of tremendous use4.

Programs like GreenLight can be loaded onto tablet computers and given to patients while they are waiting to be seen for primary care complaints. These tools have been designed by professionals to:

  • Quickly screen for symptoms of depression, anxiety, and other major behavioral or mood disorders   
  • Evaluate patients for symptoms of substance abuse disorder, which is a common co-occurrence with depression and anxiety
  • Identify symptoms of PTSD, an additional complicating factor
  • Provide easy-to-read numbered scores and alerts to practitioners so that they can make informed decisions          
  • Evaluate patients while adhering to privacy and HIPPA guidelines

 

These screening tools can also be useful for pain doctors or any practitioner who is prescribing narcotics. Identifying patients with a potential to abuse these medications due to underlying psychiatric symptoms can help reduce morbidity and mortality associated in particular with abuse of opiates or benzodiazepines5.

Suicide in America: Overview

When evaluating why the suicide rate is increasing, several topics come to the forefront. Although not directly caused by the opioid epidemic, both situations indicate that the American population as a whole is struggling with economic and possibly cultural problems, along with untreated medical and mental health conditions.

Increased rates of Major Depressive Disorder, an important risk factor in successful suicides, may be related to changes in the American lifestyle that have significantly increased negative social factors like loneliness and lack of support6. The magnifying factor of social media in the practice of bullying, especially among younger generations, is still being studied but may be a significant risk factor in youth suicides7.    

When reviewing the data, an important question comes up: are rates of mental illness and suicide in the American population getting worse or is awareness and reporting just getting better?

When looking at the long-term information, the per-capita suicide rate in the US was actually decreasing from about 1975 to the late 90s, ostensibly due to better awareness and treatment options for psychiatric disorders8. When this rate started to reverse and climb around 1999, researchers were at some loss to explain the changing trend9.

Unfortunately, the statistical increase is great enough that increases in awareness or reporting are unlikely to account for the increase.   

Suicide Risk Factors

What are the major risk factors for successful suicide attempts? The character of completed suicides is markedly different than that of people who attempt suicide unsuccessfully10.

The former is often characterized by serious stress caused by economic and mental illness factors; the latter is often done as an impulsive or attention-seeking measure by people with conditions like borderline personality disorder. So, which people are actually in the danger zone?

  • Bullied teenagers. Some of the largest increases in suicide in the last 5 years have been among adolescents, with bullying–especially on social media—seeming to be a significant causative factor11.
  • Major mental illness. It goes without saying, but people experiencing Schizophrenia, Major Depressive Disorder, or psychosis of any kind are much more likely to successfully complete suicide, to the point where lifespans among this subset are significantly lower than the general population12.  
  • Trauma and PTSD. Persistent, invasive symptoms stemming from traumatic incidents add a serious risk for suicide.
  • Substance abuse & co-occurring disorders. For a variety of reasons, addicts are at a greater risk of death, whether accidentally or intentionally13.  
  • Access to lethal means. Simply having firearms, large amounts of dangerous medications, and other easily-accessible means can increase suicide risk. These lethal means make it easier for people experiencing distress to impulsively end their lives14.  
  • Career/economic difficulties. Major economic stressors like losing or getting laid off from a job, a perceived lack of opportunity, and long-term poverty can put people at a higher risk for substance abuse and suicide15.
  • Social and cultural stressors. In some cases, minorities, gay and transgender people, and others who are at a perceived social disadvantage may feel rejected or isolated and have higher rates of substance abuse, self-harm, and suicide16.         

 

Signs and Symptoms

Often, people who are at risk of suicide will first display warning signs and symptoms.

These include: sudden, uncharacteristic happiness; giving belongings away; psychosis (bizarre thoughts and actions, hallucinations, and/or detachment from reality). Sometimes, however, there are no overt warning signs.

What is known is that most people have psychiatric symptoms for an extended period of time before suicide is attempted17. Again, digital or automated screening tools administered by front-line professionals have the potential to make a huge difference in cases where people are resistant to discussing their symptoms because of guilt, shame, or fear.

Suicide Prevention: What can be done?

Just like the causes of suicide, prevention is a complex undertaking.

As a society, Americans will need to continue raising awareness and reducing stigma around mental health problems, bullying, and addiction. Increasing medical and mental health infrastructure so that all people can get treatment is also extremely important.

Among more concrete steps, proven interventions can be organized into three categories: short-term, mid-term, and long-term:

Short-term

When someone is a clear danger to themselves or others, it’s time to call 911. All states and the District of Columbia have some form of “72 hour hold,” or a period where a homicidal or suicidal person can legally be hospitalized involuntarily in a safe and supervised environment.

The problem is that each state’s laws vary widely, and some states don’t even require the evaluation of a licensed healthcare professional during the hold18. Ideally, the hold laws in all states should meet a standard—that guarantees medical evaluation and preserves 14th amendment rights—set by an appropriate agency, like the Department of Health and Human Services.     

Mid-term

After being hospitalized or otherwise making contact with the healthcare system, patients who experienced severe suicidal ideation need continuing care that often involves medication management.

In some states, patients can only be discharged from an involuntary hold if follow-up care has been arranged. Sometimes, care options are limited, especially in rural or economically disadvantaged communities.

In these cases, a primary care physician may be the only prescribing authority available if the patient has been placed on medications.

However, patients do best when they have access to a structured PHP (partial hospitalization) or outpatient treatment program19.

These more intensive therapies are suited to the high acuity indicated by suicidal ideation or attempt. In supportive environments with 1-on-1 and peer support, these patients are more likely to return to work, school, and being a productive member of society. Without intensive therapy, patients are more likely to relapse, given the severity of their symptoms20.

Part of mid-term treatment may also involve bringing in family or loved ones to participate in caring for and supporting the suicidal person. Because drug and alcohol use co-occurs in a high percentage of patients with mood disorders, treatment for addiction should also be a component of aftercare if indicated.

Finally, patients being released from an involuntary hospitalization should also always make a “safety plan” with loved ones. This includes the extremely important step of refusing discharge until any lethal means like firearms are removed from the patient’s living situation.

Having a follow-up plan also helps the patient and his/her loved ones anticipate what to do in the case of another crisis, which is a proven way to prevent relapse and suicide attempts21.

Long-term

Long term suicide prevention involves the “bigger picture” of the social and economic conditions in which suicide is most likely to happen. Education in schools, support groups for at-risk students, and outreach for families, coaches, pastors, and other community members are all equally important initiatives.

Among adult populations, particularly older white men, outreach programs could also have an effect on mortality rates. This group is particularly vulnerable due to the high prevalence of a lethal means—firearms—in their households22. Without violating anyone’s amendment rights, a conversation about depression, mental illness, and gun ownership is certainly overdue.    

Because rates of suicide appear to be tied to perception of economic opportunity (or lack thereof)23, programs to put areas like the Rust Belt back to work should also be considered in the context of mental health.

Starting trade schools, infrastructure work, and other projects is certainly a lofty goal, but the myriad benefits mean that long-term investment in this type of work could help generations of Americans avoid addiction, serious mental health problems, and premature death.

It also bears repeating that increasing the mental health resources available to all Americans will also help both the mental health and addiction emergencies that are currently having such a drastic effect on public health. In areas where adding more mental health professionals isn’t immediately possible, helping primary care and other front-line doctors implement mental-health and addiction screening tools is an important step.   

Suicide in America: Conclusion

America’s suicide problem is serious enough that it has now become the leading cause of death in certain subsets of the population. According to the CDC and other Federal health organizations, everyone from children to the elderly is being affected by serious mental health problems, addiction, and suicide.

If 45,000 Americans as young as 1024 were dying every year from war or a communicable disease, the public outcry would be huge. The problem is also economic: it is estimated that suicide costs the economy some $69 billion every year in lost productivity25. Because of a combination of stigma and lack of awareness, however, the problem of suicide is all-too-often swept under the rug.

To fight what has literally become an epidemic, the US will require the public and political will to make some sweeping changes.

Besides improving the way Americans think and talk about mental illness, major changes need to happen to America’s health system to allow comprehensive access to mental healthcare services—and barring that, primary care and other front-line physicians at least should equip themselves with advanced screening tools to help make the most informed decisions possible.

Long-term, boosts to America’s economy in impoverished rural and urban environments alike could have significant positive effect on public health, including a reduction in addiction and suicide alike among vulnerable populations.

These solutions will be difficult and expensive to implement, but the fact that rates of suicide and addiction are so high that they may actually be lowering American’s average lifespans—for the first time in some 30 years—brings an unparalleled urgency to this crisis.

Politicians, community leaders, and policy makers will need to understand that number of lives that could potentially be saved makes all of these sweeping changes worth it.  

Notes

  1. Curtin SC , Warner M , Hedegaard H, “Increase in Suicide in the United States, 1999-2014,” NCHS Data Brief, 241 (01 Apr 2016): pp. 1-8.  
  2. IBID
  3. Joinson, Adam M., “Self-Disclosure in Computer-Mediated Communication: the Role of Self-Awareness and Visual Anonymity,” European Journal of Social Psychology, 31 no. 2 (March 27, 2011): pp. 177-192. DOI: doi.org/10.1002/ejsp.36  
  4. IBID
  5. Cheatle, Martin D., “Prescription Opioid Misuse, Abuse, Morbidity, and Mortality: Balancing Effective Pain Management and Safety,” Pain Medicine, 16, no. 1 (October 2015): pp S3–S8. DOI:doi.org/10.1111/pme.12904
  6. IBID
  7. Ahuja, A., “LGBT adolescents in America: Depression, discrimination and suicide,” European Psychiatry, 33 Supplement, (March 2016): pp. S70. DOI doi.org/10.1016/j.eurpsy.2016.01.981
  8. American Foundation for Suicide Prevention, “Suicide Statistics” (2018),  https://afsp.org/about-suicide/suicide-statistics/
  9. IBID
  10. Brown, Gregory K.,Beck, Aaron T.,Steer, Robert A.,Grisham, Jessica R., “Risk factors for suicide in psychiatric outpatients: A 20-year prospective study,” Journal of Consulting and Clinical Psychology, 68 no. 3, (June 2000): pp. 371-377.
  11. IBID
  12. Baams, Laura,Grossman, Arnold H.,Russell, Stephen T., “Minority stress and mechanisms of risk for depression and suicidal ideation among lesbian, gay, and bisexual youth.” Developmental Psychology, 51 no. 5, (May 2015): pp. 688-696.
  13. Brown, Gregory K.,Beck, Aaron T.,Steer, Robert A.,Grisham, Jessica R., “Risk factors for suicide in psychiatric outpatients: A 20-year prospective study,” Journal of Consulting and Clinical Psychology, 68 no. 3, (June 2000): pp. 371-377.
  14. Sale Elizabeth,Hendricks Michelle,Weil Virginia,Miller Virginia,Perkins Scott, McCudden Suzanne, “Counseling on Access to Lethal Means (CALM): An Evaluation of a Suicide Prevention Means Restriction Training Program for Mental Health Providers”, Community Mental Health, Journal 54 no. 3, (April 2018,):pp 293–301.
  15. Bustamante Madsen, L., Eddleston, M., Schultz Hansen, K., & Konradsen, F., “Quality Assessment of Economic Evaluations of Suicide and Self-Harm Interventions: A Systematic Review”, Crisis: The Journal of Crisis Intervention and Suicide Prevention. (2017). Advance online publication. DOI: dx.doi.org/10.1027/0227-5910/a000476
  16. Ahuja, A., “LGBT adolescents in America: Depression, discrimination and suicide,” European Psychiatry, 33 Supplement, (March 2016): pp. S70. DOI doi.org/10.1016/j.eurpsy.2016.01.981
  17. Trena Anastasia, Humphries‐Wadsworth Terresa, Pepper Carolyn M. , Pearson Timothy M., “Family Centered Brief Intensive Treatment: A Pilot Study of an Outpatient Treatment for Acute Suicidal Ideation.” Journal of the American Association of Suicidology, 45 no. 1 (February 2015)pp: 78-83. DOI: doi.org/10.1111/sltb.12114
  18. Leslie C. Hedman, John Petrila, L.L.M., William H. Fisher, Jeffrey W. Swanson, Deirdre A. Dingman., Scott Burris, “State Laws on Emergency Holds for Mental Health Stabilization” Psychiatric Services, 67 no. 5, (May 01, 2016): pp. 529-535. DOI: doi.org/10.1176/appi.ps.201500205
  19. IBID
  20. Trena Anastasia, Humphries‐Wadsworth Terresa, Pepper Carolyn M. , Pearson Timothy M., “Family Centered Brief Intensive Treatment: A Pilot Study of an Outpatient Treatment for Acute Suicidal Ideation.” Journal of the American Association of Suicidology, 45 no. 1 (February 2015)pp: 78-83. DOI: doi.org/10.1111/sltb.12114
  21. Leslie C. Hedman, John Petrila, L.L.M., William H. Fisher, Jeffrey W. Swanson, Deirdre A. Dingman., Scott Burris, “State Laws on Emergency Holds for Mental Health Stabilization” Psychiatric Services, 67 no. 5, (May 01, 2016): pp. 529-535. DOI: doi.org/10.1176/appi.ps.201500205
  22. Sale Elizabeth,Hendricks Michelle,Weil Virginia,Miller Virginia,Perkins Scott, McCudden Suzanne, “Counseling on Access to Lethal Means (CALM): An Evaluation of a Suicide Prevention Means Restriction Training Program for Mental Health Providers”, Community Mental Health, Journal 54 no. 3, (April 2018,):pp 293–301.
  23. Bustamante Madsen, L., Eddleston, M., Schultz Hansen, K., & Konradsen, F., “Quality Assessment of Economic Evaluations of Suicide and Self-Harm Interventions: A Systematic Review”, Crisis: The Journal of Crisis Intervention and Suicide Prevention. (2017). Advance online publication. DOI: dx.doi.org/10.1027/0227-5910/a000476
  24. American Foundation for Suicide Prevention, “Suicide Statistics” (2018),  https://afsp.org/about-suicide/suicide-statistics/
  25. American Foundation for Suicide Prevention, “Suicide Statistics” (2018),  https://afsp.org/about-suicide/suicide-statistics/

 

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