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Monday, November 19, 2018

The Preventable Tragedies of Suicide


The pattern of highly accomplished and successful people committing suicide is transfixing. It assures the rest of us that a life of accolades is not all that it’s cracked up to be and that achieving more will not make us happier. 
At the same time, it reveals the fact that no one is safe from suicide, that whatever defenses we think we have are likely to be inadequate. 
Kate Spade’s handbags were playful and fun. Her quirky look was unmistakable and bespoke exuberance. 
Anthony Bourdain was almost inconceivably high-functioning, and won so many awards that he seemed ready to give an award to his favorite award. 
High-profile suicides such as these cause copycat suicides; there was a nearly ten-per-cent spike in suicides following Robin Williams’s death. 
There is always an upswing following such high-profile events. You who are reading this are at statistically increased risk of suicide right now. 
Who knows if Bourdain had read of Kate Spade’s suicide as he prepared to do the same thing? 
We are all statistically more likely to kill ourselves than we were ten years ago. That increased vulnerability is itself depressing, and that depressing information interacts with our own unguarded selves. If life wasn’t worth living for people such as Bourdain and Spade, how can our more ordinary lives hold up? 
Those of us who have clinical depression can feel the tug toward suicide amped up by this kind of news. The gap between public triumph and private despair is treacherous, with the outer shell obscuring the real person even to those with whom he or she had professed intimacy.
There has long been an assertion popular in mental-health circles that suicide is a symptom of depression and that, if we would only treat depression adequately, suicide would be a thing largely of the past. 
We learn of Kate Spade’s possible marital woes as though marital woes rationalized a suicide. It is true that, in someone with a significant tendency to suicide, external factors may trigger the act itself, but difficult circumstances do not usually fully explain someone’s choice to terminate his or her own life. People must have an intrinsic vulnerability; for every person who kills himself when he is left by his wife, there are hundreds who don’t kill themselves under like circumstances.


A new Centers for Disease Control and Prevention report shows a vast increase in American suicides over the past decade, and asserts that fifty-four per cent of the suicides reviewed didn’t have a previously known mental-health issue. “Instead, these folks were suffering from other issues, such as relationship problems, substance misuse, physical health problems, job or financial problems, and recent crises or things that were coming up in their lives that they were anticipating,” Deborah Stone, a behavioral scientist at the C.D.C. and the lead author of the new study, told NPR.
But that finding mostly calls into question the definition of mental-health issues. For someone without a mental disorder or illness, would suicide seem like the permanent answer to temporary woes? Suicide is a result of despair, hopelessness, the feeling of being a burden on others. It can be fed by mental illness or by life circumstances, but is almost always the result of both. “The highest rates are white men in their fifties or sixties,” Victor Schwartz, the chief medical officer of the jed Foundation, a suicide-prevention group, told me. “Divorce, losing your family, feeling like there isn’t a runway ahead of you. That’s a very desperate place to be. Throw in alcohol and a gun, and it’s lethal.”
Suicide is on the rise nationwide. It claims more American lives each year than do automobile accidents. It has gone up twenty-five per cent in the past two decades, with increases in almost every state. There were close to forty-five thousand deaths from suicide in the United States in 2016 alone. It is now one of the top ten causes of death in the country, one of the top three for adolescents. What explanation can there be for this catastrophic escalation? The answers swirl around like a dust cloud. Opioid dependency drives self-annihilation, and many of the drugs to which people become addicted are easy to take in fatal doses, especially opioids in combination with benzodiazepines. A third of Americans are sleep-deprived, and sleep deprivation has a devastating effect on mental health. The mental-health system has deteriorated; according to Schwartz, there is less access to good care in most parts of the country than there was fifteen or twenty years ago. Rates of teen depression have risen since 2011, and students are carrying more debt and face more uncertainty about their lives. Despite a growing economy, people who are employed today do not feel confident that they will be employed tomorrow; with automation, many jobs feel terribly precarious. And the social safety net is being reeled in at every opportunity.
The proximity of a means to suicide swells suicide numbers; when you reduce access to means of suicide, you reduce suicide. When barriers went up at the Golden Gate Bridge, the suicide rate in San Francisco diminished. Australia has shown a decrease in suicide since the establishment of better gun restrictions there. Fifty per cent of American suicides involve a firearm. And gun control would be the quickest path to reducing American suicides. Whereas only about ten percent of those who attempt an overdose with pills succeed, according to Schwartz, some ninety per cent of those who attempt with a firearm are successful in ending their own lives. Suicide is often impulsive, and, if the means do not spring to hand, the impulse passes and people go on to good lives.
John MacPhee, the executive director of the jed Foundation, told me, “If you look at C.D.C. data, there appears to be a relationship to being in a rural area; rates are escalating most in the same demographics where opioid dependency and gun ownership coincide with economic trouble. Meanwhile, young people everywhere perceive that the stakes are higher, and also that they are binary: you’ll win in life or you’ll lose. Kids are putting more pressure and stress on themselves and have a lot more anxiety. There’s social norming: the appearance of suicide in the media in ways that have a tragic impact for some number of people.” Schwartz observes that school shootings undermine a sense of safety; young people who are already anxious have their anxiety validated by the news from Parkland or Santa Fe. But those shootings also affect adults; if schools have become unsafe, then what real safety do any of us have?
Modernity is alienating, and it has been alienating for a great while; look at an Edward Hopper painting if you think this post-industrial misery has come about only since the Internet was invented. Isolation is another significant suicide risk. People who believe that no one will miss them have little to stand between them and the final act. As someone who has written and spoken about depression, I receive frequent letters from people grappling with the condition, and what is most striking to me is how alone many of them are. I hear from people who wake up, eat breakfast, go to a job at which they interact with a machine all day, pick up food on the way home, eat in front of a television, and then go to bed. These people are so alone that they are effectively invisible to the rest of us; we don’t get to interact with them enough to see their misery. Many of them describe suicidal feelings.
There are no perfect solutions; there is no vaccine against suicide on the way. “We need to beef up our mental-health system: we are not training enough clinicians, not getting enough clinics built across the country,” Schwartz says. “Many clinicians are untrained in suicide prevention. We need preventive public-health initiatives on managing depression and anxiety in the pre-crisis stage. Every school should have an approach—but so should every employer and every small town.” We also need an insurance structure that gives more people with mental-health challenges ready access to care. Veterans make up about eighteen per cent of adult suicides, and we need to support those who have served the country.
Dr. Kelly Posner, who helped develop the Columbia-Suicide Severity Rating Scale (C.-S.S.R.S.), pointed out that more policemen die of suicide than die on the job; more soldiers die of suicide than die in combat; more firefighters die of suicide than die in fires. “And it’s one preventable cause of death,” she said. The C.-S.S.R.S. is used in the military and elsewhere to identify people with suicidal leanings and give them help; suicide in the Marines is down twenty per cent since the tool was introduced. Posner proposes that it, or something like it, should be used at every G.P. visit. “Fifty per cent of suicides saw their G.P. in the months before they killed themselves,” Posner said. “If we don’t ask and monitor, we have a lost opportunity for prevention. There’s a dangerous myth that, if you ask people about suicidal feelings, it causes people to become suicidal; in fact they are relieved. Aggressive screening could be transformative.” On the one hand, ghoulish media reports increase suicide’s contagion; on the other, silence is deadly. Dr. Jeffrey Borenstein, the C.E.O. of the Brain & Behavior Research Foundation, has said, “If you are concerned about a loved one, you should express your concern. Some people have the misconception that asking a person about suicide will increase the risk, but in reality asking does not increase the risk of suicide, but can save a life.”
But it won’t answer the question entirely. In a compelling installment of Head Talk, a series of online mental-health videos, titled “When Not Killing Yourself Becomes the Goal,” the psychotherapist Maggie Robbins, who herself has bipolar disorder, says, “There was a point where I realized that, if I died of old age, I would win, because so many people with bipolar disorder kill themselves that simply not to kill myself would be a big goal. And I thought, ‘That’s really a low bar.’ And then I said, ‘No, it’s not a low bar, because it can be that hard.’ ” It’s hard for people who have never been suicidal to understand how seductive it can seem. Though their acts may have been impulsive, the likelihood is that both Kate Spade and Anthony Bourdain had struggled with demons for many years.
There is another factor that should not be underestimated. On a national stage, we’ve seen an embrace of prejudice and intolerance, and that affects the mood of all citizens. My psychoanalyst said that he had never before had every one of his patients discuss national politics repeatedly, in session after session. Now there is a continuous strain of anxiety and fear from one side, and brutality from the other. Hatred is depressing—it is of course depressing to be hated, but it is also depressing to hate. The erosion of the social safety net means that more and more people are at a sudden breaking point, and there are few messages of authentic comfort to offer them in these pitiless times. One is done in by disease, by isolation and despair, and by life crisis. At the moment, many people’s vulnerability is exacerbated by the unkindness manifest in each day’s headlines. We feel both our own anguish and the world’s. There is a dearth of empathy, even of kindness, in the national conversation, and those deficits turn ordinary neurosis into actionable despair.

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