The Choice to “End it All.”

Suicide Definition Graphic

Written by Steven Barto, B.S., Psy.

IT WAS FOUR IN the afternoon. I was driving along the river in my home town. It was the fourth decade of my struggle with active addiction. Overwhelmed with thoughts of utter failure, rabid hypocrisy and complete hopelessness, I started ruminating about the idea of suicide. Why not? It made sense. I was in bondage to drugs and had grown tired of living a life so out of touch with my Christian upbringing. Seems I could not stop lying, cheating, stealing. Doing whatever it took to keep getting high. Duplicity was the word that most described my existence. I’d grown weary of living on the down-low. I was defeated, exhausted and tired of failing.

I turned into an area boat launch and stopped about fifty yards from the edge of the water. I closed my eyes and took my foot off the brake. I’d barely touched the accelerator when I heard an audible voice. It filled the cabin of my car: Don’t. I jammed the brake pedal to the floor and gripped the steering wheel in a panic. I must be losing my mind! There was no one else in the car. The radio was off. Yet, somehow, I heard a voice that seemed to fill the interior of my car. I could feel the voice, insistent but not loud. No sense of anger or disappointment. It was simply an audible, gentle, compassionate insistence.

Don’t end your life!

It’s been said that suicide is a permanent solution to a temporary problem. Perhaps if some in-between state existed—some alternative to death—many suicidal people would take it. One question every surviving family member has asked without exception, that they ache to have answered more than any other, is simple: Why? Why did their friend, child, parent, spouse, or sibling take their own life? Even when a note is left behind, it still never makes sense. Yes, they felt enough despair to want to take their own life, but Why did they feel that way? Alex Lickerman, MD said, “People who’ve survived suicide attempts have reported wanting not so much to die as to stop living, a strange dichotomy, but a valid one nevertheless” (1).

A friend of mine took his own life in 1996. We met a few years earlier as co-workers at a Philadelphia law firm. We were both on staff as litigation  paralegals. He had recently started a new career trading stocks. Apparently, he was under investigation by the SEC for insider trading. His wife kicked him out and filed for divorce. He moved in with his parents and had become quite depressed and withdrawn. He stayed home from work on a Tuesday. After his parents left the house, he took his father’s .357 handgun and drove to his wife’s place. When she answered his knock, he shot himself on the stoop in front of her. I always knew him to be outgoing, hilarious, and always up for a good time. His death made no sense to me.

Unfortunately, suicide without warning is common. Patrick J. Skerrett quoted Dr. Michael Miller, a psychiatrist at Harvard Medical School, in a recent article on suicide: “Many people who commit suicide do so without letting on they are thinking about it or planning it” (2). Currently, suicide is the tenth overall cause of death in the United States. In 2018 there were 48,334 suicide deaths in America. Had I not heard God’s voice that afternoon in 2018, the total would have been 48,335. There were an estimated 1.4 million suicide attempts in the U.S. in 2018. The rate of suicide is highest in middle-age white men in particular. It was the second leading cause of death among individuals between the ages of 10 and 34. On average, there are 132 suicides per day. In 2018, firearms accounted for 50.57% of all suicide deaths in America (3).

America’s suicide rate has increased for 13 years in a row.—The Economist

According to the National Vital Statistics Report, suicide was the second leading cause of death for age groups 10 to 24, or 19.2% of deaths, and 25 to 44, or 10.9%. This report presents final 2017 data on leading causes of death in the United States by age, sex, race, and Hispanic origin. These data accompany the release of final national mortality statistics for 2017 (4). In 2017, the 10 leading causes of death were, in rank order: heart disease; malignant neoplasms; accidents (unintentional injuries); chronic lower respiratory diseases; cerebrovascular diseases; Alzheimer disease; diabetes mellitus; influenza and pneumonia; nephritis, nephrotic syndrome and nephrosis; and intentional self-harm (suicide).

Suicidal Ideation and Social Media

Various social media platforms offer an unprecedented volume, velocity, and variety of social data to researchers. Among these, the most consistently studied is Twitter, a microblogging platform in which participants broadcast 140-character posts directly to one another or to the Twitter community simultaneously. Twitter’s sociological and psychological relevance for researchers and treatment providers is elevated due to ease of accessibility to data, the fact that most data collection activities can be undertaken at no cost to the researcher, and the ease of data management. For example, because Twitter limits individual posts to 140 characters, the information is more easily stored and reviewed than longer Facebook posts.

Facebook Suicide Prevention webpage can be found at www.facebook.com/help/594991777257121/ [use the search term “suicide” or “suicide prevention”].

As with a variety of social media platforms, Twitter has been a boon to suicide researchers, who can observe the behavior of individuals in a non-invasive manner, collecting “live” (time-sensitive) information that might not otherwise be shared because of the stigma of mental illness and suicide. One researcher was able to analyze 125 users who publicly announced they had attempted suicide. Analysis of these individuals’ posting history revealed distinct signals in previous posts that could have been used to predict their upcoming attempts and initiate an intervention (5). This is a relatively large sample that otherwise might have been overlooked.

Strong correlations have been discovered between suicidal expressions on Twitter and state-specified age-adjusted suicide rates. It is believed that posting suicide-related content on social media specifically identifies at-risk individuals. In fact, unique posting patterns have been posthumously discovered for Twitter members who died by suicide when compared to those who died of other causes (6). Such results demonstrate the value of verbal content people post on social media sites—providing unique insight into suicidal behavior.

Twitter’s Best Practices in Dealing With Self-Harm and Suicide at https://support.twitter.com [use the search term “suicide,” “self-harm,” or “suicide prevention”].

Psychologists and sociologists have begun to analyze social media data—correlating the content of social media posts regarding the topic of suicide with eventual suicides or attempts. Analysis has proven most useful in this regard. It must be determined whether suicidal behavior can be correlated to online comments among peers beyond one degree of social separation. Also, it must be determined whether that correlation persists after excluding innocuous commentary regarding mood and attitude. In other words, if mood is held to a constant in the analysis, will the observed association in suicide-related behavior still be higher than chance? Recent research has determined that comments on social media relative to suicidal expressions can be studied and correlated  up to three degrees of separation between peers, but no further. 

N.A. Christakis and J.H. Fowler (7) noted that correlation held between suicidal remarks and suicidal actions even when accounting for the distribution of mood among participants in the social media network. They used the bootstrapping method (employing computer-intensive analysis of  variability within their data samples) to study real-time posting activity on Twitter. Their samples were comprised of two non-consecutive 28-day periods. Mechanical Turk (MTurk; Amazon, 2016) raters have compiled suicide-relatedness ratings for each of the 10,222 most common words in contemporary English for use in evaluating social media posts for occurrence of “suicidal conversation.” These words are correlated with a preexisting list of “sad” words (as they relate to the sad/happy continuum) used to infer the general mood of social media users. Collection and analysis was conducted via double-blind method for accuracy and to allow for detecting statistical variation and spurious correlation.

Some variants of “sad/happy” word expressions that may or may not be associated with suicidal ideation include “I’m so sad! I’m gonna kill myself!” “I’m the worst! LOL!” “My final day on earth…” “Just got in a fight…” “It’s a sad day.” “I love my life!” Analysis included placing “sad,” “happy,” and “suicidal” words into columns on a graph and quantifying the number of uses of such words or phrases. Also, degrees of separation (direct friend versus once, twice, thrice removed) were determined at one through six degrees: friend, friend of friend, friend of friend of friend, and so on. The Sad Column, Happy Column and statistically relevant variables were each plotted along the graph comparing “mood” and “suicide-relatedness” comments. Amazingly, this study may be the first of its kind, and involved collection and analysis of over 64 million post from over 17 million unique social media users in two nonconsecutive 28-day periods. Analysis of this real-time data helped predict (by an algorithm) the information collected, which typically has infinite possibilities of correlative meaning.

You might ask, But why is this important? What does it mean? How can it be utilized? Suppose a counselor is concerned with the suicide risk of students in a high school where a fellow student recently took her own life. To get the best data in the shortest amount of time, the counselor would do the following:

  1. Ask a teacher for a list of the decedent’s closest friends and screen them;
  2. Ask any friends on that list to name their closest friends and screen those friends;
  3. Ask any friends from the new group to name closest friend and screen them, and so on; and
  4. Once there are no more positives in a friend group, screen students at random until a positive is found and begin the procedure again until the resources run out (i.e., there are no more students in the population).

Although the above process will provide an  initial “hint” of an assortativity-informed treatment approach, additional research would be necessary before beginning any efficacious intervention. Researchers warn that no offline behavior was included in their study, and therefore was not available for comparison.

Co-occurring Issues and Suicide

Suicide is a major public health problem and a leading cause of death in the United States. Everyone who chooses to attempt suicide has an underlying reason for wanting to do so. Suicide does not discriminate—people of all genders, ages, religious faiths, and ethnic groups can be at risk. Most people at risk will not follow through. Still, assessing the risk for suicidal behavior is complicated. Researchers tell us that people who attempt suicide may do so in reaction to a particular event, thought, or emotion. These individuals make decisions differently than those who do not attempt suicide. Such factors for increased risk are depression, anxiety, personality disorders, psychosis, severe bullying, rape or trauma, and substance abuse. 

Suicidal acts may be connected to recent events or current conditions in a person’s life. Although such factors may not be the primary motivation for the suicide, they can precipitate it as underlying or co-morbid triggers. A major underlying cause of suicide has been combat stress and other related PTSD issues. People in this at-risk category do not necessarily have to experience the horrors of a war zone. Other types of immediate stress include natural disasters, terrorism at home, or catastrophic loss from such events as a structure fire or a serious motor vehicle accident.

People suffering from chronic pain, severe disability, or a major illness may attempt suicide, believing their suffering is too great or that their death is inevitable. Victims of an abusive or repressive environment from which they have little or no hope of escape sometimes commit suicide. Situations that fit this category may include torture, confinement, sexual assault, or persistent physical abuse. Also, occupational stress has been indicated in some suicides due to extreme tension, anxiety, disillusion or “burnout,” and job-related financial pressures.

Cyberbullying, Substance Use Disorder

In addition to the above precipitating factors, many suicide attempts are preceded by a severe change in mood that do not correlate to an underlying psychiatric diagnosis. Mood changes most likely to lead to suicide often include extreme sadness, unresolved anxiety, frustration, anger, or shame. Unfortunately, the number of teens and young adults who take their own lives has increased due to bullying at school or on social media sites. Nearly 1 in 5 students (21%) report being bullied during the school year, impacting over 5 million youth annually. See National Center for Education Statistics [NCES], 2018. 

There has been a spike in cyberbullying over the last couple of years. This is willful and repeated bullying behavior that takes place using electronic technology, including texting, comments during gaming, Internet sites, social media, emails, blogs, cell phones, and so on. Unlike traditional bullying it can happen anywhere at all hours of the day. Approximately 34% of students report experiencing cyberbullying during their lifetime. See Hinduja & Patchin, 2015. Students who experienced bullying are nearly 2 times more likely to attempt suicide. See Hinduja & Patchin, 2018.

Worldwide, more than 1 million people die by suicide every year. Self-harm deaths have been on the rise in nearly every state in America. In the U.S., suicide deaths (47,173) were almost equivalent to the number of deaths from opioid overdoses (47,600) in 2017. It is essential that suicide prevention practices be implemented and expanded wherever possible (8). Opioid Use Disorder (OUD) has a distinctly strong relationship with suicide as compared with other substance use disorders (9). Pain causes alterations in brain circuitry in the brain’s reward center (involving the ventral tegmental area, nucleus accumbens, and the amygdala), resulting in vulnerability to suicide and a higher risk of opioid addiction. This is supported by epidemiological data that have shown chronic-pain diagnoses are linked to suicide. These associations are only partially explained by co-occurring mental health conditions, which tend to further complicate morbidity.

Tolerance to THC can build quickly in cannabis users. Teens who seek help for cannabis-use problems often report withdrawal symptoms such as anxiety, insomnia, appetite disturbance and depression (Budney & Hughes, 2006). These symptoms are of sufficient severity to impair everyday functioning (Allsop et al., 2012) and they are markedly attenuated by doses of an oral cannabis extract (Sativex) that contains THC (Allsop et al., 2014). Bagge and Borges (2015) conducted a case-crossover study of 363 persons who had recently attempted suicide and were treated in a trauma hospital for a suicide attempt within the previous 24 hours in Mississippi. The researchers compared rates of cannabis use in the 24-hour period leading up to the individual’s suicide (case period) to individuals who used cannabis during the same time period but did not commit suicide (control period). They found that 10.2% of those who attempted suicide had used cannabis within 24 hours of their suicide.

Cannabis was involved in an estimated 6.5% of drug-related suicide attempts, and in 46% of attempts the person had also used alcohol. In the 23% of drug-related suicide attempts with toxicology reports, 16.8% tested positive for cannabis, although this cannabis use could have occurred days or even up to one week earlier. In general, 9.5% of all toxicology reports for deaths by suicide (Borges, Bagge & Orozco, 2016) show the presence of cannabis. There is preliminary evidence of higher detection of cannabis among suicide decedents that do not involve overdose (CDC, 2006) and higher detection among male suicide decedents using non-overdose methods than among females (Darke, Duflou & Torok, 2009; Shields et al., 2006).

So Now What?

The Centers for Disease Control and Prevention (CDC) released data on the ten leading causes of death in the United States recently. Tragically, suicide—too often a consequence of untreated mental illness and substance use disorders, and as such a preventable condition—remains on that list as the 10th leading cause of death for adults and the second-leading cause of death in our youth. Suicide rates increased from 29,199 deaths in 1996 to 47,173 deaths in 2017. Click here for more information.

What are the contributing factors to a state of mind that ends in a person taking his or her life? What can be done to intervene? How can we turn the numbers around? The increased number of suicides year after year say something about the conditions under which people live and die, and about our society at large. Our teens and young adults are deciding in record numbers that killing themselves is the best solution to what is usually a temporary situation. Citizens at the lower end of the socioeconomic scale are significantly more vulnerable due to negative views about life and an increased amount of psychological and social difficulties. Many of these conditions are not diagnosed in time or go untreated. Many are turning to substance abuse to cope, which often increases the risk of self-harm behavior. This speaks to an environment that can promote depression, anxiety, and elevation in substance use disorder. Some sociologists have referred to these suicides as “deaths of despair.”

There are a number of interventions we can apply to these dire circumstances:

  • Safety Planning. Personalized safety planning has been shown to help reduce suicidal thoughts and actions. Patients work with a caregiver to develop a plan that describes ways to limit access to lethal means such as firearms, pills, or poisons. The plan lists coping strategies and people and resources that can help in a crisis.
  • Follow-up phone calls. Research has shown that when at-risk individuals receive proper screening, implementation of a Safety Plan, and a series of supportive phone  calls, their risk of suicide goes down.
  • Cognitive Behavioral Therapy (CBT) can help people learn new ways of dealing with stressful experiences through training. CBT helps individuals recognize their thought pattersn and consider alternative actions when thoughts of suicide arise.
  • Dialectical Behavior Therapy (DBT) has been shown to reduce suicidal behavior in adolescents. DBT has also been effective in reducing the rate of suicide in adults with Borderline Personality Disorder or related personality disorders. These mental illnesses are typically characterized by an ongoing pattern of varying moods, self-image, harmful or risky behavior, and impulsive actions. A therapist trained in DBT helps a person recognize when his or her feelings or actions are disruptive or unhealthy, and teaches the skills needed to deal better with upsetting situations.

If you are struggling with thoughts of suicide, please reach out to someone before the fog of desperation clouds your mind. If you have a friend or loved one who has expressed an intent to take their own life, do not dismiss it as a cry for attention—instead, it is a cry for help. If you are interested in becoming a volunteer or mental health professional and want to be a part of the solution for this national epidemic, please talk to a teacher, professor, mental health professional, pastor, or mentor to find out how to get started.

NATIONAL SUICIDE PREVENTION HOTLINE
1(800) 273-8255

Footnotes

(1) Alex Lickerman, M.D. (April 29, 2010). “The Six Reasons People Attempt Suicide.” Psychology Today. https://www.psychologytoday.com/us/blog/happiness-in-world/201004/the-six-reasons-people-attempt-suicide

(2) Patrick J. Skerrett (Sept. 24, 2012). “Suicide Often Not Preceded by Warnings.” Harvard Health Publishing.

(3) “Suicide Statistics.” American Foundation for Suicide Prevention. https://afsp.org/about-suicide/suicide-statistics/

(4) Melonie Heron, Ph.D., (June 24, 2018). “Deaths: Leading Causes for 2017.” National Vital Statistics Reports, Vol. 68, No. 6. https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_06-508.pdf

(5) Wood, A., Shiffman, J., Leary, R., and Coppersmith, G. (2016). “Language Signals Preceding Suicide Attempts.” CHI 2016 Computing and Mental Health, San Jose, CA.

(6) Bryan, C.J., Butner, J.E., Sinclair, S., et al. (2018). “Predictors of  Emerging Suicide Death Among Military Personnel on Social Media Networks.” Suicide and Life-Threatening Behavior, 48, 413-430. http://dx.doi.org/10.1111/sltb.12370

(7) Christakis, N.A., and Fowler, J.H. (2013). “Social Contagion Theory: Examining Dynamic Social Networks and Human Behavior.” Statistics in Medicine, 32, 556-577. http://dx.doi.org/10.1002/sim.5408

(8) https://doi.org/10.1016/j.jcjq.2019.10.001

(9) Bohnert KM, Ilgen MA, Louzon S, McCarthy JF, Katz IR. Substance use disorders and the risk of suicide mortality among men and women in the U.S. Veterans Health Administration. Addiction 2017; 112:11931201.

 

 

For Jimmy, Who Bruised By Ribs and Busted My Nose

I had a bully who pursued me nearly every day during middle school until one day I’d had enough. I round-house punched him in the face, bloodied his crisp white t-shirt. His dad came to the house and threatened to beat up my dad because I beat up his son. “See, this is why I hate fighting,” I said to my dad. The following poem by Brian Fanelli is dedicated to anyone who has ever had a bully.

In our neighborhood, Fat Jimmy descended the mountain,
his chest heaving like a bull,
ready to maul a matador.

He cracked his scarred knuckles, hunted scrawny prey,
curb stomped our basketballs
like heads he wanted to bash,

or ghost rode our bikes
down the garbage trail dump,
until one day I gripped my handlebars

like a soldier clinging to a rifle,
refusing defeat as Jimmy knocked me to my back,
clocked me in the chin.

Numbed, I laughed as he pounded and pounded,
until my nose gushed, my ribs throbbed,
my skin swelled faster than his heated cheeks.

This poem is for the bully who never cried,
who hid belt lashes from us, who ran from the sound
of his father’s battered Ford tracking him down,

the son whose hands tightened to fists like his father’s,
who uncurled his fingers to study my blood,
and then extended a hand to lift me up.