There is ample data from the Centers for Disease Control and Prevention (CDC) to suggest suicide rates have risen since 1999. More difficult to ascertain is how much one can attribute that to improved precision in reporting versus a rise in actual numbers.
Regardless, we are all aware of the destructive nature of suicide and its rippling effect on those it touches.
One need only recall the high-profile suicides of Robin Williams, Kate Spade and Anthony Bourdain, among others, to recognize the impact on communities and society at large. We are a more interconnected world than ever in history. While suicide has always been a part of the human experience, there is a renewed urgency to identify those at risk and intervene to the extent possible.
For the past eight years, I’ve been the medical director of a high acuity psychiatric unit specializing in the treatment of suicidality. To begin, let’s differentiate between suicide attempts and nonsuicidal self-injury. The latter, most identified with borderline personality disorder, is problematic for the outpatient or emergency department provider. Often the intent of the self-injurer is to relieve stress or inflict pain (but not to die), though a problem arises when the behavior, used to elicit sympathy from others, inevitably fails and causes an upping of the ante to produce the needed attention.
Those for whom suicide attempts are expressions of a desire for death the treatment is different. Depression is near universal in this population. The road to suicidality is populated with a combination of genetic predisposition, temperament, environment, luck and resiliency. Overcome by a major depressive episode, hopelessness predominates and suicide is viewed as the only way through. The individual comes to believe that “others will be better without me” and that delusion proves hard to dispel.
Some reasons behind the rate increase
Suicides could be occurring at a greater rate as we retreat to worlds that, ironic given our interconnectivity, are increasingly isolated. People are spending high amounts of time interfacing with their phones rather than interacting with others. Teens are having less sex, it is thought, for this very reason. Near constant engagement with social media can itself be toxic—seeing the lives of others so grandly displayed by selfies in exciting places leads one to feel wanting by comparison. Obsessively counting the “likes” of others cannot bode well for self-esteem.
Our knowledge of suicides has increased, as well. No longer are we placated by obituaries that speak of sudden death in a 20-something-year-old without mentioning suicide. The rapid spread of information leads to both copycat incidents (such as the Momo phenomenon—a new "suicide challenge" children are taking through a popular messaging app) and a reinforcing of a depressed individual’s notion that all is lost. Add in the opioid epidemic, the flirting with suicide by experimenting with escalating doses of narcotics (adulterated with fentanyl and carfentanil) gives us an idea of the issues at hand that might be raising the suicide rate.
Treatment can help
On a positive note, is the reduction of the stigma associated with depression and suicidality and the fact people are more open to treatment. Resources are available to help those in need, ranging from national organizations (such as the National Alliance on Mental Illness and the American Foundation for Suicide Prevention) to community mental health centers and hospitals.
Doctors can start by asking patients a standard question to screen for depression. That can lead to further screening using tools such as the Patient Health Questionnaire or PHQ-9, a nine question scale to screen for the severity of depression, which can direct care, either for a sub-acute referral or to an emergency room for more detailed assessment. Some patients will require hospitalization—generally the option of last resort, but one doctors should consider when a person’s safety cannot be guaranteed. Most ascribe appropriately to erring on the side of caution. Inpatient stays are relatively brief, the goal being to begin medication treatment with anti-depressants and to link the individual with appropriate aftercare, usually a partial hospital program or intensive outpatient program.
Today’s primary care physician is overwhelmed with patient volume and has a dearth of time. Addressing a patient’s mental health can be time consuming but given the integral nature of mental issues on general physical health it is vital to long term care. Larger practices can consider embedding a mental health clinician, whether a social worker or nurse practitioner, for more thorough on-site evaluations of patients.
Doctors need to know there is treatment for their patients who are suicidal. There are medications (in severe cases lithium and the anti-psychotic drug clozapine) and therapies, such as cognitive behavioral therapy and dialectical behavioral therapy, depending on the patient’s diagnosis. Therapy can occur in both individual and group settings and offer both support and improved coping strategies.
Time will tell if the current suicide trend persists, but our current focus is on the ready identification of those in need and bringing resources to bear. A suicide has lasting impact on those in its vicinity; our best efforts to intervene are necessary to prevent further tragedies.
Joseph H. Baskin is a staff psychiatrist at the Cleveland Clinic where he serves as medical director of a high acuity unit that specializes in the treatment of suicidality. He is an assistant professor at the Cleveland Clinic/Case Lerner School of Medicine. He is also a novelist, weaving his expertise in psychiatry into psychological thrillers. His latest, Exit Strategy, was published in June. For more information, please visit www.suicidefrontlines.com, where he writes about a variety of topics pertaining to suicide and connect with him on Twitter @BaskinJoseph.