Tag: suicide

05/18/21

Support and Defend Against Suicide

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There has been an alarming increase in the number of veterans who commit suicide each year. The latest statistics in the 2020 National Veteran Suicide Prevention Annual Report indicated that the number of veteran suicide deaths per year in 2018 was 6,435, an increase 379 per year since 2005. Age- and sex-adjusted suicide rates for the U.S. adult population was 18.3 per 100,000 in 2018. For veterans, their age- and sex-adjusted rates were 27.5 per 100,000 in 2018. “Over the period 2005-2018, age- and sex-adjusted suicide rates rose faster among Veterans than among non-Veteran U.S. adults.”

Veterans between the ages of 18 and 34 had the highest suicide rate in 2018, 45.9 per 100,000, while veterans 75 and older had the lowest suicide rate in 2018, 27.4 per 100,000. The absolute number of suicides was highest among veterans 55-74 years old, accounting for 40% of all veteran deaths by suicide in 2018. There were clear sex differences with Veterans, where the age-adjusted suicide rate among women was 15.9 per 100,000 and 39.6 per 100,000 among men. Suicide rates rose faster among men than among women both for veteran and non-veteran populations. See the following graphs from the 2020 National Veteran Suicide Prevention Annual Report.

Compared to the steep rise of suicides among U.S. adults, these increases may not seem so alarming. The suicide rate for U.S. adults has increased 47.1% since 2005. The number of American adults who died by suicide in 2018 was 46,510, and 31,610 in 2005. This compares with a 6.3% increase among veterans during the same time period. The number of suicide deaths among veterans in 2018 was 6,435; and in 2005 the number of veteran suicides was 6,056. See the following graph.

Yet an analysis of the data from the 2019 National Veteran Suicide Prevention Annual Report by Robert Whitaker suggested a somwhat disturbing factor hiding in the statistics. In “Screening + Drug Treatment = Increase in Veteran Suicides,” Whitaker noted the increase in suicide among Veterans was at least partly driven by the VA’s suicide prevention efforts. The VA’s screening protocols resulted in a greater number of veterans coming into psychiatric care, where treatment with psychiatric drugs is regularly prescribed. “Suicide rates have increased in lockstep with the increased exposure among veterans to such medications.”

Suicide prevention efforts began in the U.S. in the late 1980s, when The American Foundation for Suicide Prevention and other organizations like the American Psychiatric Association and the National Alliance on Mental Illness drew attention to suicide as an “unrecognized public health” problem. Individuals with mood disorders who were “untreated” were said to be at particularly high risk of suicide. “The Foundation pushed screening programs as a way to get more people into treatment. Its advisory board and presidents touted antidepressants as ’anti-suicide’ pills.”

The American Psychiatric Association, the National Alliance on Mental Illness, and the pharmaceutical companies that sold antidepressants all helped promote this message to the public. In 1997, their efforts prompted both houses of Congress to declare suicide a “national problem.” Two years later, U.S. Surgeon General David Satcher issued a “Call to Action to Prevent Suicide,” and the U.S. Department of Health and Human Services formed a task force, composed of individuals and organizations from the private and public sectors, to develop a “National Strategy for Suicide Prevention.” The task force published its recommendations in 2001, which doubled-down on the “public health” approach that had been promoted by the American Foundation for Suicide Prevention.

Government agencies launched suicide prevention efforts. Crisis call centers were created; depression screening programs were introduced. Checklists like the CDC Depression checklist and the Patient Health Questionnaire (PHQ-9) were developed. Medical professionals were trained to recognize the “warning signs” for suicide. “The goal was to get more people struggling with mood disorders into treatment, with antidepressants recommended as a first-line therapy.”

The prescribing rates for antidepressants have steadily increased since 2000. And the age-adjusted suicide rate has also increased from 10.4 per 100,000 in 2000 to 14.0 per 100,000 in 2017. The CDC reported past month use of antidepressants increased from 7.7% in 1999-2002, to 12.7% in 2011-2014. The age-adjusted suicide rate for Americans rose from 10.4 per 100,000 in 2000 to 14.0 per 100,000 in 2017. Whitaker’s data on suicide rates was only age-adjusted, not age- and sex-adjusted suicide rates, so his statistics will not be an exact match with those reported above in the National Veteran Suicide Prevention Annual Reports. See the following graph from the Whitaker article.

The failure of this approach to suicide prevention, which emphasizes getting people into treatment, is not a uniquely American phenomenon. In the 1990s, the World Health Organization urged countries around the world to develop national mental health policies and to improve their mental health services, which included providing their citizens with better access to psychiatric medications. The belief was that this would lead to better mental health outcomes, which would become visible in the form of reduced suicide rates.

Researchers from the UK, Denmark and Australia have now conducted three studies of whether such efforts have affected suicide rates, and all came to the same conclusion: improved access to psychiatric services and psychiatric drugs was associated with an increase in national suicide rates.

Soon after Prozac came to market in the late 1980s a significant number of patients taking Prozac began having suicidal thought (See “Antidepressant Fall from Grace, Part 1”). There were numerous case reports of people taking the drug who committed suicide. At this point, there is clear evidence that SSRI and SNRI antidepressants can prompt suicidal impulses and acts in some users. In 2003, David Healy and a team of researchers conducted a metanalysis of all random controlled trials (RCTs) of SSRIs and found that suicide attempts were 2.28 times more likely with an SSRI than a placebo.

Like the federal government, the VA sees suicide as a “public health” issue. In 2006 it appointed a National Suicide Prevention Coordinator. The next year it established a toll-free Veterans Crisis line. It has steadily increased resources devoted to this issue, even spending almost $20 million for Make the Connection to market the VHA’s services to veterans. The VA introduced mandatory screening for all veterans. This screening is a regular feature of VHA care, with screening of some sort as part of every patient appointment.

The VA’s clinical guidelines for treating depression and PTSD, the two most commonly diagnosed psychiatric disorders, recommend SSRI and SNRI antidepressants as first-line therapies. A 2015 report by the General Accounting Office (GAO) said 94% of all VHA patients diagnosed with depression from 2009 to 2013 were prescribed an antidepressant. “Studies of VHA patients with PTSD have reported that about 80% are prescribed a psychiatric medication, with antidepressants the drug class of choice.” Polypharmacy, taking multiple medications, is common with 35% of those diagnosed with depression taking two classes of psychiatric drugs and 15% taking three classes of drugs. Those diagnosed with PTSD had an even more pronounced polypharmacy, with 36% taking two classes of psychiatric drugs and 25% taking three or more classes.

In the 2016 report, Suicide Among Veterans and Other Americans, the VA divided patients into four subgroups: 1) undiagnosed and untreated (for a mental health or substance use disorder); 2) undiagnosed and treated (with either a psychiatric drug or non-pharmacologic treatment); 3) diagnosed and untreated; and 4) diagnosed and treated. Given the regular screening for mental health disorders, undiagnosed patients apparently did not show symptoms of depression, PTSD or any other psychiatric disorder that would have generated a diagnosis during the screening process. These patients should be at low risk of suicide and theoretically, any treatment should further reduce this risk.

The “diagnosed” patients should be at a higher risk of suicide. Suicide prevention efforts focus on getting these patients into treatment, with antidepressants seen as a first-line therapy than can lower the risk of suicide. Thus, if suicide prevention efforts are helpful, the suicide rate for the diagnosed patients who are treated should be lower than for diagnosed patients who, for whatever reason, shun treatment. The 2019 GAO report found that 18% of diagnosed patients did not get treatment.

The results were as follows. Those without a diagnosis who received MH treatment were more likely to die by suicide than those without a diagnosis who did not receive treatment. “In 2014, those who got treatment died at twice the rate of the ‘untreated’ group.”

Those with a mental health or substance use diagnosis who received mental health treatment were also about twice as likely to die by suicide than those who were diagnosed but did not receive mental health treatment. “The difference in suicide rates for the treated and untreated groups is consistent over time, year after year.” The suicide rates for those diagnosed with a mental health or substance use diagnosis have remained stable since 2005. They have hovered around 70 per 100,000 population. “The reason that the suicide rates for VHA patients have been rising is that the VA’s suicide prevention efforts—the outreach campaigns and the mandatory screening—have led to a steady increase in the number of veterans diagnosed and treated for those disorders.”

The data for the four subgroups suggested an increased the risk of suicide with the diagnosed and treated group having the greatest risk:

  • Undiagnosed/untreated: 24.8 per 100,000
  • Diagnosed/untreated:  34.4 per 100,000
  • Undiagnosed/treated: 47.6 per 100,000
  • Diagnosed/treated: 68.2 per 100,000

This finding runs directly counter to the variable suicide rates that would be expected if the “treatment” were effective. Yet it is consistent with RCT data showing antidepressants double the risk of suicide compared to placebo. Since the VA launched its suicide prevention efforts in 2006, there have been more than 70,000 suicides. “That is a number greater than the total of all combat deaths since 9/11.”

When you join the military, you take an oath to “support and defend” the Constitution against all enemies, foreign or domestic. Fulfilling that oath means you risk being killed in combat. But it doesn’t mean you have to be willing to risk committing suicide from taking psychiatric medications.

12/13/16

The Vicious Spiral of Suicidality

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A study published in the November 2016 issue of JAMA Psychiatry suggested that patients were at an increased risk of suicide during the three months immediately following their discharge. They were fifteen times more likely to commit suicide than similarly matched patients who were treated for non-mental health issues. Individuals without any outpatient care in the months before their hospitalization were at an even higher risk. Individuals diagnosed with depressive disorders were at the highest risk, followed by those with bipolar disorder and then schizophrenia.

The lead author of the study, Mark Olfson, was interviewed on the JAMA network about the study. He said one of the limitations of the study was it didn’t have the level of detail to get at why depression and depressive disorders were the highest short-term risk of suicide. However, he speculated that since one of the symptoms (diagnostic criteria) for depression was related to suicide, and many individuals are hospitalized because of suicide attempts or suicide risk, this is “probably what conveys their short-term risk of suicide following hospitalization discharge.” He added that effective approaches to suicide risk reduction should involve strengthening a patient’s connectedness, reducing social isolation, and engaging them in outpatient care. In his review of the study for Mad in America, Justin Karter quoted the study authors as saying:

These patterns suggest that complex psychopathologic diagnoses with prominent depressive features, especially among adults who are not strongly tied into a system of care, may pose a particularly high risk. As with many studies of completed suicide, however, the low absolute risk for suicide limits the predictive power of models based on clinical variables. These constraints highlight the critical challenge of predicting suicide among recently discharged inpatients based on readily discernible clinical characteristics.

The association of suicide risk and hospitalization has been evident in previous studies. For example, a 2005 study reported in the Archives of General Psychiatry, found there were two sharp peaks of suicide risk around psychiatric hospitalization. There were during the first week after admission and in the first week after discharge. The length of hospitalization was also a factor, with individuals receiving less than the median length of stay having a significantly higher risk. The study also confirmed previous reports that prior admission to a psychiatric hospital is also associated with a higher risk of suicide.

This study, to our knowledge, is the first to explore how suicide risk differs by diagnosis across the phase of psychiatric hospitalization. We find that affective disorders increased the risk for suicide the strongest across all phases of time since hospitalization compared with other diagnostic groups. We also find that affective and schizophrenia spectrum disorders tend to have a more intensive effect on the risk of suicide, whereas substance abuse disorders have a more prolonged effect on the risk of suicide.

In an article for the website, Speaking of Suicide, Stacey Freedenthal cited the recommendation by David Rudd, a nationally known suicide expert, who recommended initially seeing an individual at least twice in the week after discharge. The elevated risk of suicide after hospitalization was not necessarily related to a premature discharge. Referencing David Rudd, she said:

Instead, suicidal intent is fluid, impossible to predict from one moment to the next, let alone day-to-day. Of course, whatever led to hospitalization in the first place, whether a suicide attempt, mental illness, or some other crisis, places a person at higher risk than normal for suicide.

However, there was a 2014 study reported in Social Psychiatry and Psychiatric Epidemiology that found psychiatric admission in the previous year was highly associated with completed suicide. “Furthermore, even individuals who have been in contact with psychiatric treatment but who have not been admitted are at highly increased risk of suicide.” The authors said the relationship was one of association, rather than causation. “People with increasing levels of psychiatric contact are also more severely at risk of dying from suicide.”

An editorial in the same issue by Large and Ryan said that compared to those who had no psychiatric treatment in the previous year, those who received medication were 5.8 times the risk of suicide; those with at most outpatient psychiatric treatment had 8.2 times the risk; patients with emergency department contact without an admission had 27.9 times the risk; and admitted patients had 44.3 times the risk of suicide. These ratios were after controlling for other risk factors.

The strongest risk factors for suicide after discharge were: prior suicide attempts and depressive symptoms. Additional risk factors include: hopelessness, worthlessness, guilt and a family history of suicide. Large and Ryan said they believed it was likely that a proportion of individuals who suicide during or after an admission to hospital do so because of factors inherent in the hospitalization. They argued that such suicides should be considered as “nonsocomial”—acquired in a hospital.

There was a significant positive correlation between a PTSD diagnosis and suicidality in a study by Panagioti, Gooding, and Tarrier. Comorbid major depression was a compounding risk factor. The association of suicidality and PTSD persisted across “studies using different measures of suicidality, current and lifetime PTSD, psychiatric and nonpsychiatric samples, and PTSD populations exposed to different traumas.”  Another study of national suicide rates in 25 European countries concluded that stigma towards persons with mental health problems could influence suicide rates within a country. The authors hypothesized that possible mechanisms could include stigma as a stressor, or social isolation as a result of stigma. Large and Ryan said:

There is now little doubt that suicide is associated with both stigma and trauma in the general community. It is therefore entirely plausible that the stigma and trauma inherent in (particularly involuntary) psychiatric treatment might, in already vulnerable individuals, contribute to some suicides.

So it seems there is a vicious spiral with suicidality. Together, depression and suicidality may lead to hospitalization, which itself is a risk factor for suicide. Hospitalization, particularly when it is involuntary, can lead to stigma and trauma, which exacerbates feelings of worthlessness and hopelessness—-themselves further risk factors in suicide.

How then do we help the chronically depressed and suicidal person? Perhaps the place to start is by not harming them any further. We need to recognize and minimize the potential for stigma and trauma from hospitalization. We need to address feelings of helplessness and worthlessness from very beginning of any contact with a depressed and suicidal person. In Cruel Compassion, as he reflected on how to avoid further harm with chronic mental patients, Thomas Szasz gave the following quote of C.S. Lewis that I think is helpful here.

Of all the tyrannies a tyranny sincerely exercised for the good of its victim may be the most oppressive. . . . To be “cured” against one’s will and cured of states which we may not regard as disease is to be put on a level with those who have not yet reached the age of reason or those who never will; to be classed with infants, imbeciles, and domestic animals. . . . For if crime and disease are to be regarded as the same thing, it follows that any state of mind which our masters choose to call “disease” can be treated as a crime and compulsorily cured. . . .Even if the treatment is painful, even if it is life-long, even if it is fatal, that will be only a regrettable accident; the intention was purely therapeutic.

Szasz went on to add:

To help the unwanted Other, we must therefore first relinquish the quest to classify, cure and control him. Having done so, we can try to help him the same way we would try to help any person we respect—asking what he wants and, if his request is acceptable, helping him to attain his goal or accept some compromise.

08/20/14

Suicide is NOT Painless

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Recently we all heard of the successful suicide of Robin Williams. The media aftermath has stirred up a shit-storm of debate and controversy. I asked someone who lost a loved one to a completed suicide how they reacted to the news. The person’s hope was that since Robin Williams was a celebrity, that a constructive dialogue would occur and help someone else decide not to try suicide. So I want to introduce you to some suicide statistics that relate directly to the tragic loss of Robin Williams. And perhaps start us thinking about how we can help prevent other people from trying to end their life.

The Center for Disease Control and Prevention (CDC) maintains a wealth of statistics on suicide at “National Suicide Statistics at a Glance.”  Among the trends in suicide rates for males between the age of 45 and 64, suicide by firearms were most common, 15.52 per 100,000 in 2009. Suicide by suffocation was second. “Suffocation suicide rates among males aged 45 to 64 years have increased 103.5% since 2001 from 2.91 to 5.92 suicides per 100,000 in 2009.”

“From 1991 to 2009 the suicide rates were consistently higher among males 65 years and older compared to the younger age groups.” But they were decreasing, from 40.12 per 100,00 in 1991 to 29.09 in 2009. HOWEVER, the rates of males between 25 and 64 increased from 21.27 per 100,000 in 2000, to 25.37 per 100,000 in 2009.

I then looked at the latest census figures available on the US census website for males between the ages of 25 and 64 to estimate the number of males these suicide statistics would reflect. Roughly 2,000 men like Robin Williams between the ages of 25 and 64 successfully completed suicide—480 who did so by suffocation—in 2009, the last year statistics were available. So there were 479 other families who suffered the pain of a completed suicide, as does the family of Robin Williams.

What can you do to help prevent more suicides? Look at the website for the National Strategy for Suicide Prevention  (NSSP) for information. The NSSP has a number of goals and objectives to facilitate suicide prevention:

  • Foster positive public dialogue; counter shame, prejudice, and silence; and build public support for suicide prevention;
  • Address the needs of vulnerable groups, be tailored to the cultural and situational contexts in which they are offered, and seek to eliminate disparities;
  • Be coordinated and integrated with existing efforts addressing health and behavioral health and ensure continuity of care;
  • Promote changes in systems, policies, and environments that will support and facilitate the prevention of suicide and related problems;
  • Bring together public health and behavioral health;
  • Promote efforts to reduce access to lethal means among individuals with identified suicide risks;
  • Apply the most up-to-date knowledge base for suicide prevention.

From the revised NSSP, the Action Alliance selected four priorities in suicide prevention that, if accomplished, they hope will help the group reach its goal of saving 20,000 lives in the next five years. These priorities are:

  1. Integrate suicide prevention into health care reform and encourage the adoption of similar measures in the private sector.
  2. Transform health care systems to significantly reduce suicide.
  3. Change the public conversation around suicide and suicide prevention.
  4. Increase the quality, timeliness, and usefulness of surveillance data regarding suicidal behaviors.

One agency I worked for required counselors to complete the background paperwork and have the necessary forms signed during the initial session with a new client NO MATTER WHAT. In a way that was understandable, because if the person never returned and you didn’t have the right forms signed, the agency wouldn’t get paid for the time you spent with the individual. But it made it difficult for the counselor if someone was in crisis, or needed some encouragement. One time I broke that rule and inadvertently helped prevent a suicide.

The more information and forms I completed, the greater was my impression that the woman was discouraged and hopeless. So I stopped the paper pushing and really talked with her about her problems. She had struggled off and on with drug use for over twenty years and didn’t have much hope at that moment that she could stop and get her life together. Her last relapse had led to the breakup of a long-term relationship. We talked and I was able to help her see she could re-establish abstinence; maybe even reconcile the relationship. There was some hope.

When she returned for the second appointment we completed the required paperwork that I didn’t do during the first session. And then she told me she had decided before our first counseling session that if she felt as hopeless after the session as she did before it, she had intended to kill herself. People will sometimes say that they intended to kill themselves, but not really have more than the idea of suicide. But she has a prior history of attempts; and she had a plan that would have been successful if she attempted it.

We have a responsibility to be with one another, to make space for one another, to be kind to one another… and hopefully through doing so, we make life that much more bearable. We do our best suicide prevention by letting go of the goal of suicide prevention, and, instead, creating alternatives.

I think this quote’s essay is headed in the right direction for suicide prevention. Maybe the best technique is to simply be committed to letting people know that you care enough about them to enter their darkness and help them move out into some light.