This is the refrain of the day. Yes, the two high profile suicides this week are tragic. Just a few blocks from my home, the iconic handbag designer Kate Spade took her life at age 55. This morning, media headlines are filled with references to the death of superstar chef and storyteller Anthony Bourdain who was found dead at age 61 in his Paris hotel room. CNN confirmed that the cause of death was suicide.
But it’s not two suicides this week. It is 15,120 based on conservative estimates from WHO. What do these high profile and anonymous cases tell us?
Different groups, different rates, moving in different directions. Many factors contribute to increased risk for suicide around the world. In the 1990’s for example, China had one of the highest suicide rates. By 2014, overall suicide rates declined dramatically, and among rural women under the age of 35, suicide rates dropped by as much as 90%. In contrast, a report this week from the United States Centers for Disease Control shows that suicide rates have been rising in every state over the past two decades. Half of states have seen an increase of over 30%. Around the globe, suicide rates are increasing, but we need to ask more nuanced questions because the global numbers fail to capture the reality that rates vary depending on more local variables at specific moments in time.
Low probability; high consequence. One million is a big number and one million suicides per year are one million too many. However, we need to keep in mind that there are a number of big numbers. WHO estimates that 450 million people currently suffer from a mental illness or neurological condition, and a total of 55.3 million people die each year. These are both big denominators in relationship to suicide, and despite the serious and troubling absolute numbers of lives lost by suicide, it remains the case that they are low probability, high consequence events that are notoriously difficult to prevent.
Reducing Risk. Strategies for preventing low-probability events include focusing on broad systemic factors (e.g., reducing war and exposure to trauma), proximal intervention efforts (e.g., reducing access to firearms), and individual treatment effort (e.g., providing treatment for someone with depression and substance abuse). The complex interplay of risk variables at each of these levels of analysis are at the heart of the research programs of scholars around the world, including Columbia colleagues Barbara Stanley PhD, John Mann MD, and Madeline Gould PhD, MPH. Addressing the big picture, systemic factors reflect population-based strategies that are key for prevention. They are also long-term investments. Evidence-informed treatment strategies are essential at the acute moment of risk for a given individual. Reducing suicide globally requires that we increase what we know about what works at each level of intervention.
Major risk factors. How can we predict a suicide attempt? Like all wicked problems, there is no single cause. Many factors intersect in just the wrong way to make this lethal outcome of suicide a reality for any given individual. We do know that risk factors include a previous suicide attempt, untreated mental health conditions (particularly depression, bipolar disorder, anxiety, or schizophrenia) and substance-abuse disorders. Precipitating factors include proximal factors like substance misuse, stressful life events (e.g., financial crisis, divorce, life transitions or loss), and more distal factors like history of childhood trauma or abuse. The problem is that the majority of individuals with any one of these health conditions or life experiences will not die by suicide.
Don’t be a tourist. Today at lunch, while discussing another topic completely, someone said to me how important it is that we not live our lives as tourists. Put another way, if not now, when? If not me, who? Individual efforts will never succeed in getting us to zero suicide, but for each of us knowing the common warning signs and having some guidance about what we might do if we are concerned about someone are essential as a starting point. “R U OK?” from Australia, Seize the Awkward from the JED foundation in partnership with the Ad Council and the American Foundation for Suicide Prevention, and #BeThe1 campaigns can move us from being tourists to agents for change on this tragic topic.
Last week I talked about the particular challenges men face in talking about their mental health challenges. In truth, most people don’t find it easy to talk about mental illness. Social connection and hope are key factors that can carry each of us when we are most vulnerable. The scientific data are clear, and I know this to be true personally. My condolences to all of the 15,120 individuals who died by suicide this week, including Kate Spade and Anthony Bourdain.