Suicides are rising, but we can fight back
Suicide among young people is once again at the forefront of our national consciousness with the news two weeks ago that the Washington State quarterback Tyler Hilinski was found dead of a self-inflicted gunshot wound. Halfway across the country, in Perry Township, Ohio, a 15-year-old became the sixth teen in the school district there to kill themselves in the last six months, three occurring just in January. And the swimming legend Michael Phelps said recently that his ongoing bouts of depression, which began when he was a teenage phenomenon, led him to “contemplate suicide … I didn't want to be in the sport anymore ... I didn't want to be alive anymore."
Suicide is a growing public health crisis. The Centers for Disease Control reported recently that suicide rates for teenage girls in the United States have hit a 40-year high. The suicide rates doubled among girls and rose by more than 30% among teen boys and young men between 2007 and 2015, according to the CDC report. Today suicide is the number one killer of teenage girls worldwide and the second leading cause of death in teenagers in the U.S. (only accidents cause more deaths).
Nine out of 10 youth who die by suicide have a mental health condition, while four out of five give clear warning signs. Nearly 3 in 100 high school students report having made such a serious attempt to take their own life during the past year that they required medical treatment. Twice as many report an attempt at suicide that didn't require treatment.
These statistics should serve both as a shock to our collective being and an urgent call for national action. We simply cannot offer heartfelt condolences and then go about our normal daily activities anymore. Just as the opioid crisis has spurred a call to action at the local, state and national levels, the suicide crisis requires an immediate and comprehensive response.
The very good news is that we know how to do away with this preventable and tragic loss of life. The first step is to change and expand the way we talk about suicide. We know that more than half of all people who die by suicide visit their primary care doctor within a month of their deaths.
For the most part, however, a discussion of suicide is not part of the average examination. Nor is depression, which is the psychiatric diagnosis most commonly associated with suicide and is projected to be the second leading component of the global disease burden by 2020. We must start asking about suicide (i.e., screening) like we monitor for blood pressure. If not, we will not find the people who are suffering in silence.
In my work with communities across the globe, I have seen first-hand the great need for and benefits of asking a few questions to identify those at risk for suicide.
I once travelled to a Hindu temple in upstate New York that served a disadvantaged population with a high suicide rate. I trained the entire community on a brief suicide screening we developed — the Columbia Suicide Severity Rating Scale (CSSRS) — which incorporates a few simple questions that can be asked in a consistent way. The questions help determine whether a person is experiencing suicidal thoughts (“Have you actually had any thoughts of killing yourself?”), and if so, whether the thoughts include method (“Have you been thinking about how you might do this?”) and intent (“Have you had these thoughts and some intention of acting on them?”).
A history of suicide attempts is the number one risk factor for suicide. Therefore, asking about a person’s attempt history and other serious suicidal behaviors (e.g., “Have you taken any steps towards making a suicide attempt or preparing to kill yourself, such as collecting pills, getting a gun, giving valuables away, or writing a suicide note?”) is essential to identifying his or her level of risk.
Two weeks after my visit to the Hindu temple, there was an article in the local newspaper. A grandmother who had been at the training had noticed that her grandson wasn’t looking so good, asked him the questions, and said that doing so probably saved his life. Whether you are a doctor, teacher, parent, coworker, friend, relative or anyone else — the first step is asking.
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Using such a screen process works. The most evidence-based tool of its kind is being used in 45 countries on six continents with significant success. And anyone can use this life-saving tool. We have worked with every type of organization — the military; veterans; schools, colleges and universities; health care institutions; first responders; and many government agencies and have witnessed the dramatic impact on suicide rates where talking openly about suicide has been embraced and these helpful simple questions are put in everyone’s hands.
A “total force” roll out in the Marines of the screening program, putting it in the hands of all support workers including legal assistants, financial aid counselors, clergy, etc., helped lead to a 3.5% reduction in suicide in the three years since it's use started in 2014. The Defense Suicide Prevention Office is now rolling the effort out to non-medical personnel in the other Armed Forces branches.
These individuals are often the first to encounter at-risk servicemen and women and are now able to provide lifesaving screening. The power of asking was again illustrated when Utah reported that using the questions and putting them in everyone’s hands helped the state reverse their suicide rate for the first time in years.
And since its implementation, screening efforts helped reduce suicide rate from 3.1 suicides per 10,000 people to 1.1 in 20 months in the Tennessee programs of Centerstone, one of the nation’s largest not-for-profit providers of outpatient community behavioral healthcare.
I recently helped Princeton University put it in the hands of all the athletic coaches so they can hopefully identify athletes like Tyler before it is too late. Thanks to the simplicity of screening, numerous school systems have done the same.
But we still have a long way to go. One of the biggest problems is that most people who need treatment do not get it — 50% to 75% of those in need receive inadequate treatment or no treatment at all. This is partly due to stigma and access-to-care barriers, but, in the end, few avert the problem of under-treatment: Nearly 80% of college students who die by suicide receive no consistent treatment prior to their deaths.
Suicide can be prevented — which sets it apart from other sources of pain and suffering in the world. We need to get to a place where everybody, everywhere asks the questions that help identify at-risk individuals and get them the help that they need. Together, we can prevent these unnecessary tragedies.
Kelly Posner is a clinical professor in the department of Child and Adolescent Psychiatry, Vagelos College of Physicians and Surgeons at Columbia University and the founder and director of the Columbia Lighthouse Project.