Suicide Prevention

Every year, approximately 40,000 people die from suicide in the United States. Nearly twice the number of people killed annually by homicide, one American commits suicide every thirteen minutes. Even more shocking, for every suicide death there are roughly 25 attempts; meaning that one million people in the United States attempt suicide each year. Most suicides occur mid-life, between the ages of 45 and 54. A lower number of teenagers and young adults die by suicide, but a higher number of young people make attempts, and suicide, as the second leading cause of death for people ages 15-34, makes up a higher ratio of young fatalities.

In the face of such overwhelming statistics, it is important to remember that suicide is a preventable public health issue. There are many overlapping and interacting causes of suicide, which can make prevention seem confusing or difficult. But in reality, a solid understanding of the environmental and health-based implications of suicide can help to make suicide prevention more approachable.

The nation's first suicide prevention center was opened in Los Angeles in 1958, but suicide didn't become a central political issue until the mid-1990s. Suicide research and prevention efforts of the 1990s culminated in the first National Suicide Prevention Conference, held in Reno, Nevada in 1998. The 81 recommendations developed over the course of the Reno Conference are considered the bedrock of modern suicide prevention. Twenty years later, most suicide prevention legislation and programming is still informed by key points from the Reno Conference:

(1) Suicide prevention must recognize and affirm the value, dignity, and importance of each person. (2) Suicide is not solely the result of illness or inner conditions. The feelings of hopelessness that contribute to suicide can stem from societal conditions and attitudes. Therefore, everyone concerned with suicide prevention shares a responsibility to help change attitudes and eliminate the conditions of oppression, racism, homophobia, discrimination, and prejudice. (3) Some groups are disproportionately affected by these societal conditions, and some are at greater risk for suicide. (4) Individuals, communities, organizations, and leaders at all levels should collaborate to promote suicide prevention. (5) The success of this strategy ultimately rests with individuals and communities across the United States.

Unfortunately, such heavy reliance on the Reno Conference means the most prevalent suicide prevention materials look like relics from the 1990s. Many online resources visualize "suicide" using the same stock photos of people with slumped shoulders and downcast gazes. Not only can these images make sufferers feel like a cliché, they can be grossly misleading. While depression is often cited as a leading cause, suicide doesn't result from one factor alone. Even though 98% of people who die by suicide have diagnosable mood disorders, mental illness, among other suicide risk factors, is not as easily recognizable as the stock photos make it seem.

In a 2014 study, neuropsychologists discovered that suicide survivors tend to have lesser memory capacities and shorter attention spans than people with depression who have not attempted suicide. Serotonin, a neurotransmitter which facilitates learning and memory, is often present at lower levels in people who suffer from depression, even though depression cannot be explained by serotonin levels alone. Many people with depression struggle to break free of negative thought patterns, and those who suffer from this symptom may be more likely to exhibit suicidal behavior.

Robust resources analyze suicide risk factors through correlations, rather than attempting to pin down the definite causes of suicide. Depression is just one variable with a high correlation, most other variables are environmental or social, such as economic recessions, gun prevalence, daylight patterns, divorce laws, media coverage, and substance abuse. Even if a suicide prevention resource abides by the Reno Conference's key points, recognizing that suicide often results from a combination of internal and external conditions, its recommendations for intervention are likely vague or flimsy. Common suicide prevention measures include: increasing help-seeking, responding effectively to people in crisis, ensuring effective treatment, enhancing life skills, and facilitating social connectedness; but what does that look like? What could a concerned loved one do to accomplish these goals? The online literature is largely devoid of straightforward steps to action. Instead there are descriptions of "high risk behavior" - increasing alcohol or drug use, acting anxious, behaving recklessly, withdrawing, sleeping too little or too much, and displaying extreme mood swings - signs and symptoms that are unhelpfully similar to typical teenage behavior.

Navigating the oftentimes fine line between depression and suicidal thoughts can be difficult. Chris Gethard, a comedian who openly struggles with depression and has survived suicidal thoughts and attempts, discusses the dynamic between himself and his loved ones in an episode of his podcast Beautiful/Anonymous. Now that Chris experiences depressive episodes without having suicidal thoughts, his wife shows her support by "riding the storm" without trying to solve anything. He goes on to distinguish, if he were to express suicidal thoughts, he would need an entirely different kind of support:

If suicidal thoughts are being expressed, that's a whole different ball of wax and you have to make hard decisions as a loved one and just do what you have to do to protect your people. There are times in my life when I was heading down that road and expressing it to people, and I look back and realize they were well within their rights to call an ambulance or a cop car. In the moment I was like "oh thank God they didn't," but long-term I can look back as an adult now and go "oh man, that probably would've been the best for me if somebody did."

At the end of the day, suicide is a health concern, and the most sure-fire way to keep someone healthy is to call an ambulance. What might be costly or embarrassing in the short-term could save a life, or open up treatment opportunities and a productive dialogue at the very least. Any expression of suicide, whether talking about a desire to die or looking for a way to kill oneself, should prompt an immediate call for help to the National Suicide Prevention Lifeline, a mental health professional, or 911. The rest of this article discusses broader methods of systemic suicide prevention, contextualized in culture, age, gender, and environment.

Suicide prevention materials rarely make a distinction between different types of suicide, but tend to address premeditated suicides exclusively. Classic symptoms such as feeling burdensome or sleeping irregularly are more likely to fit a premeditated suicide, one that was planned over a longer period of time or used a method requiring careful calculation. Researchers, however, have come to recognize premeditation as just one-half of the suicide dichotomy. Most suicide deaths result from so-called passionate suicides, ones that take place after an immediate crisis with little forethought. Victims of passionate suicide show few of the classic warning signs. Instead, they tend to display a high degree of impulsivity and are drawn to methods of self-harm, such as jumping or firearms, that offer ease, speed, and the certainty of death.

Passionate suicides may be more unpredictable than premeditated suicides, but they are often easier to prevent. In a report entitled "Where Are They Now," researcher and psychologist Richard Seiden followed up with all 515 of the people who were thwarted from jumping off the Golden Gate Bridge between 1937 and 1971. Even after accounting for suicides that may have been mislabeled as accidents, only ten percent of those people went on to kill themselves. Ten percent is still much higher than the general population, but a 90 percent post-intervention survival rate is significant. Seiden explains this high rate of recovery as a result of in-the-moment fixation, followed by a permanent change in outlook after the attempt. In a suicidal moment, people aren't thinking clearly. They may have a Plan A, but they typically don't have a Plan B. One man was apprehended on the Golden Gate after observers noticed him pacing and looking increasingly forlorn. He had been planning on jumping from a spot on the other side of the bridge, but he was afraid of getting hit by a car on the way there. It may seem ironic, but it is important to understand that suicidal thoughts are not logical.

Particularly with passionate suicides, removing the means of action is an effective form of prevention. Because impulsivity is a common symptom of mood disorders, it can be argued that mental health-based methods of prevention would logically be the most effective; however, treating the symptom of impulsivity, rather than the underlying cause, has had some impressive results. Common suicide methods that require forethought or a great amount of effort, such as overdosing or cutting, also happen to be the least fatal. But shooting, jumping, and other methods of passionate suicide are often the most deadly. It may be hard to stop someone who, after multiple attempts, is still determined to commit suicide, but with the proper preventative tools, there's a good chance of saving the people who would have died due to the lethal method of their first attempt.

A famous example of coincidental means-based prevention took place in Britain during the mid-20^th Century, when most people heated their homes with coal gas. In its unburned form, coal gas releases high levels of carbon monoxide, and a leak in a closed space could cause asphyxiation in just a few minutes. By the late 1950s, suicide by coal-gas accounted for 2,500 deaths, or half of Britain's total number of suicides. It became so common, the phrase "sticking one's head in the oven" was used as a colloquial expression of frustration. Over the next two decades coal gas was replaced with the cleaner, and coincidentally less toxic, natural gas. By 1970 there was virtually no carbon monoxide running through domestic gas lines, and Britain's total suicide rate dropped by nearly a third.

Where the means of suicide are more difficult to get ahold of, rates of suicide are much lower. Guns, for example, are the most common method of suicide in the United States. Shootings are extremely fatal, even if they only account for less than one percent of all American suicide attempts. A 2007 study found that higher rates of gun ownership translates to higher rates of suicide. Accordingly, both the rate of gun ownership and the rate of gun suicides are exactly 3.5 times higher in Vermont than in New Jersey. In a 1985 study of self-inflicted gun violence, only half of the participants reported having suicidal thoughts for more than 24-hours, and none of them had written a suicide note.

The key to preventing impulsive suicides is to inject as much time as possible between the initial suicidal thought and the suicidal action. A slower process offers more opportunities for dark moments to pass. Bridges with high railings or suicide barriers have been proven to decrease suicide rates. Gun owners are advised to keep their firearms locked in a safe, and store their ammunition separately. Method-based prevention is especially effective for teenagers, who have a tendency toward impulsivity. In a 2001 study, an astonishing 24 percent of suicide survivors between the ages of 13 and 34 contemplated suicide for less than five minutes before they acted. Even a few extra seconds, the time it takes to locate the key to a gun safe or climb a high railing, could make the crucial difference between action and reconsideration.

While adults tend to attempt suicide after major life stressors, kids and teens are more susceptible to less significant events. Younger people have less experience getting through tough times, and risk factors can "line up like lights on a street." According to Richard Lieberman, mental health consultant for the Los Angeles County Office of Education, "for a kid to go from thinking about suicide to attempting suicide, all these lights have to turn green." Multiple stressors, maybe a breakup followed by a failed exam and a poor performance at the championship game, can compound until the pressure becomes too great. One stressor could be the suicide of a friend, family member, or even a celebrity.

Because teen suicides often result from longer lists of smaller stresses, teenagers are particularly prone to "contagious suicides." Using statistical formulas normally used for tracking disease outbreaks, researchers have confirmed that suicide is contagious, able to be transmitted between people. Suicide clusters, accounting for 1-5 percent of all teenage suicides, are most often comprised of victims who were connected through social networks. People who knew a suicide victim are nearly twice as likely to have suicidal thoughts. Teenagers, people with preexisting mental illness, and those with an especially close relationships to the victim are at greater risk. Mood disorders are not communicable diseases, but exposure to a suicide can be the final factor to flip the switch from depression to suicidal thoughts.

Teen suicides are especially likely to develop into a suicide cluster because of the way they are handled by families and communities. There seems to be a higher shame factor for teenage suicides; parents often omit any mention of suicide from obituaries, and ask the medical examiner to cite a cause of death other than suicide. Friends of the victim may feel guilty too. Teenagers, hesitant to involve adults in what might seem like a personal issue, are less likely to report suicidal signs even though they are more likely to notice them. Because there is a greater hush surrounding teen suicides, people who have been deeply affected by a teenager's suicidal death are less likely to seek the help they need.

Classifying suicide as a contagious disease can make it seem more mysterious and less preventable, but in reality, the many years of research and progress in treating diseases can now be applied to suicide prevention. The public has long accepted that the three leading causes of death in America, heart disease, cancer, and stroke, can be assuaged through behavioral modifications. Public health professionals believe the behaviors underlying suicide can be approached the in same way. The Suicide Prevention Resource Center recommends a "postvention" for communities touched by suicide, focusing on supporting people who have been affected by the suicidal death and reducing risk for those most vulnerable to copycat behavior.

In the months following Marilyn Monroe's probable suicide, there was extensive news coverage, widespread grief, and the United States suicide rate increased by twelve percent. A number of studies have confirmed that there are a greater number of suicides after media reports of suicide. Any media that emphasize, glamorize, or make suicide seem like an inevitable solution can have a negative impact on at-risk individuals. In response to such media crises, the World Health Organization published a set of guidelines for safe reporting. Ever since the guidelines have been in place, suicide risk drops when reporters adhere to recommended methods for coverage. For example, after Kurt Cobain reportedly committed suicide in 1994, suicide prevention hotlines in the Seattle area surged, and suicide rates actually decreased.

Much of the research about suicide and the media, however, is outdated and doesn't take social media into consideration. In the 1970s, a suicide was estimated to profoundly impact the lives of six people. Now, in the age of social media, a suicide affects 135 people on average, with one-third of them experiencing a dramatic life disruption. Social media memorial sites can attract hundreds of comments and thousands of followers. Messages often flatter the victim, and can seem as though they're romanticizing death. All media coverage of suicide, including memorial pages, should include links to suicide prevention resources, and moderators should be assigned to ensure that comments adhere to safe reporting guidelines.

Social media has taken a lot of the blame for inspiring copycats, but reports of copycat suicides far predate the emergence of social media. In 1974, suicide researcher David Phillips coined the term "The Werther Effect" to describe a series of copycat suicides that had occurred two centuries earlier, after the publication of Johann Wolfgang von Goethe's novel, The Sorrows of Young Werther. It is widely believed that Werther's fictional suicide inspired a wave of young men across Europe to kill themselves, wearing similar clothes to Werther, using similar pistols, and oftentimes having copies of the novel beside their bodies. Shakespeare's Romeo and Juliet has also been accused of romanticizing suicide, along with more modern works of fiction such as 13 Reasons Why. While some fiction copycats certainly do happen, most commonly with people of the same gender as the character, researchers have determined that the public in general are able to distinguish between fact and fiction. Though fictional portrayals of suicide often lead to spikes in internet searches, the actual suicide rate is not affected.

According to the Center for Disease Control, men make up 78 percent of U.S. suicides even though women attempt suicide more often. This disparity is caused by gendered differences in method. Men are more likely to use the more lethal methods of firearms or hanging, while women typically overdose. Gender is also a major predictor for environmental suicide risk. Studies of the correlation between economic recessions and suicide have shown that rates of suicide for men rise notably after a financial crisis, whereas the rise for women is markedly less. Seasonal variations and divorce laws, however, impact women more substantially than men. Particularly in high-latitude countries, suicides are concentrated in the summer months, with 48 percent of suicides in North Greenland occurring during the period of constant light. In nations with unilateral divorce laws, suicide rates for women between the ages of 25 and 65 are greatly reduced. Unilateral divorce allows one spouse to end their marriage with or without consent from the other spouse, making divorce quicker and easier, especially for people trying to escape from abusive relationships. Although men and women are equally prone to mental illness, the gendered differences in symptom expression or cultural expectations seem to have a substantial impact on suicide risk.

As a loved one or a bystander, it's not your job to talk someone out of suicide. It is your responsibility to engage victims of suicidal thoughts with professional help. Calling 911 is always a solid and easily memorable option for reporting a potential suicide, but there are also a variety of suicide-specific resources available:

• The National Suicide Prevention Lifeline (1-800-273-8255) fields calls 24/7, and also has an online chat option. Text CONNECT to 741741 and a trained crisis counselor will respond.
• The Maryland Crisis Hotline (1-800-422-0009) provides support, guidance, and assistance 24/7 for people struggling with substance abuse or their mental health.
• The Trevor Project (866-488-7386) specializes in talking to LGBTQ+ youth. They also have an online chat services, a social network called TrevorSpace, and you can text "Trevor" to 202-304-1200 Monday-Friday between 3 p.m. and 10 p.m. Eastern Time, or noon-7 p.m. Pacific Time.
• The Society for the Prevention of Teen Suicide is an online resource for parents who are concerned that their child might be at risk. Parents may also call the National Suicide Prevention Lifeline to find local help.
• Suicide Prevention Services of America (630-482-9696) provides a hotline focused on helping people cope with depression, but it is not the ideal resource for people who are in immediate danger of suicide.