Suicide - A Reflection on our Changing American Society
BY: Elinore F. McCantz-Katz, MD PhD, Assistant Secretary for Mental Health and Substance Abuse
February 3, 2019
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.1 Suicide rates increased from 29,199 deaths in 1996 to 47,173 deaths in 2017.
What are the contributors to the state of mind that ends in a person taking their own life? What can government do about this? What responsibility do we have to each other to take actions that will alter this course? These are questions of great importance, because rising deaths by suicide say something about the conditions under which our people live and die and about our society at large.
One of the questions that many have asked is why these figures are so staggering. A recently published data analysis from two waves of the Midlife in the United States (MIDUS) study in 1995-1996 and 2011-2014 comparing measures of psychological distress and well-being in adults illuminates trends that should give us all pause. This study shows that Americans at the lower end of the socioeconomic status distribution in our nation express significantly more negative views about life satisfaction and psychological and social well-being and those negative views have significantly increased in recent years. This speaks to an environment that can promote the development of depression, anxiety, and, in many cases, addiction. Some have referred to “deaths of despair” that result from the struggle for survival with no relief to be had.
A person with mental health issues will often be vulnerable to suicide, in part because they lack access to care or will not have a positive response to the care received. This can lead to hopelessness that is the harbinger of suicide. While there are multiple methods used, a gun is the most frequent means of suicide. It is also likely that suicide by drug overdose is more common than we realize. This means suicide death numbers may be even higher, and those higher but hidden numbers are some of the deaths that result from drug overdoses. The majority of overdose deaths involve opioids—increasingly a result of heroin or illicit opioid pills contaminated by fentanyl. Further, most of these deaths involve multiple substances—opioids, benzodiazepines, alcohol, medications used to treat mental disorders, and other medications.
When drug overdose deaths occur, it is usually not possible to know if the death is accidental or a suicide. However, we do know several circumstances likely to contribute to these overdose deaths. This can include people with chronic pain who have not responded to opioid medications as well as people whose clinicians are no longer willing to prescribe and leave a person to the abyss of opioid withdrawal—itself a painful condition that would only worsen the underlying pain and other physical and mental health challenges such people face. People who have become addicted to opioids too often are not able to access effective and safe treatment in their communities, nor are they able to get into recovery because they lack community supports essential to stabilizing their lives and moving away from drug abuse. Many of these people, now counted as unintentional “drug overdose deaths,” may suffer what I refer to as the “silent suicides.”
There is certainly a great need for and role of the government in addressing these issues. The federal government invests significant resources into suicide prevention activities. From collection of the statistics on suicide and public outreach by the Centers for Disease Control and Prevention (CDC), to the resources made available for research into suicide etiology, prevention and intervention by the National Institute on Mental Health (NIMH), to the state- and community-based funding for services provided by the Substance Abuse and Mental Health Services Administration (SAMHSA), ), the federal government, through HHS and collaboration amongst other federal departments, works diligently to address this major health issue.
I will take it one step further to say that the research funded by NIMH has substantially contributed to the approaches SAMHSA has taken to put its suicide prevention funding to best use. For example, NIMH-funded research on a program known as “Zero Suicide” showed that one place to focus resources was on the training of health care practitioners in clinical settings.5We learned from that research that the majority of those who will die by suicide are seen by a health care practitioner in the 3 months prior to those events. The majority (83%) of individuals who die by suicide have accessed health services in the year prior to death, and half made a medical visit within 4 weeks.
In addition, SAMHSA funds the National Suicide Prevention Lifeline (800-273-8255) and has several programs to address suicide prevention in youth that are given to communities nationwide. States receive mental health block grant dollars that can be used to address suicide prevention and treatment of underlying mental disorders. SAMHSA has also invested in a nationwide program of training and technical assistance to expand access to evidence-based treatment at a local level and to address major mental health issues facing Americans, including suicide.
Government resources alone, however, will not address America’s epidemic of suicide. Changes in our society contribute to the isolation and desperation that too many endure. The immersion of Americans from an early age into the cyber universe—for example, online activities and social media with nonstop access in the form of cell phone use—can contribute to the increasing loss of social connectedness, support from family and friends, and community at large in favor of a 24/7 barrage of information and communication (some wanted and some not). Therefore, social media can provide an adverse platform for unfortunate interactions with others, especially for our young people. The anonymity conveyed by social media permits a person to communicate messages with no thought to the harm it may do to another emotionally.
This medium decreases personal interaction, impedes learning of acceptable social norms, and inflicts outright harm on some, such as young people subjected to cyber-bullying. In recent surveys, 34 percent of youth reported being cyberbullied in their lifetime, and bullying has been cited as a contributing factor in cases of retaliation. Additionally, new research describes cell phone addiction and reports that college students spend up to 9 hours daily on their cell phones. This can have major consequences for our youth, including academic failure. Social media obsession may impair learning activities in school and infringe on the ability of people to attain career goals. It is not a leap of logic to posit that such failures contribute to mental illness and the development of substance use disorders. It is also possible that those most vulnerable to such addiction have pre-existing mental illness that might be detected were regular screening to occur. Unfortunately, preoccupation with social media has become a new “norm” in our society, with a clear detrimental effect for many.
Government can’t stop these activities or the potential consequences of those choices. This must be addressed by Americans at large—individuals, families, schools, communities. What really makes sense in terms of repairing our social fabric? In fact, these same digital methods of communication will be part of the solution to some of the ills imparted by them. Research to develop new approaches to therapeutic interactions navigated through text messaging and online activities will likely yield methods that will be more widely accepted by Americans than are the typical interpersonal interactions of traditional psychotherapeutic interventions.
The bottom line is that addressing issues of suicide and societal problems must be a partnership. Government resources are there to help, but all Americans have an important role to play in addressing the difficult issues facing our society. In doing so, we can all make a real contribution to reducing suicide in our country.