Suicide: Unseen Public Health Crisis


Suicide: Unseen Public Health Crisis
Dr. Ricardo Cáceda is researching the biology of suicide as an assistant professor at the University of Arkansas for Medical Sciences. (Karen E. Segrave)

(A clarification has been made to this article. See end for details.)

Longtime political consultant Ron Oliver divides his life into before Aug. 31, 2013, and after.

That’s the morning he discovered that his wife of 31 years, Floy, had hanged herself in the garage of their North Little Rock home.

“Since this happened to me, I wonder now when I read obituaries how many of them might have been suicides,” Oliver said last week. “Before, I never thought about it.”

Some of them undoubtedly are. Suicide is the 10th most common cause of death in the United States, and Arkansas’ rate of suicide, 17.4 per 100,000 residents in 2014, is 30 percent higher than the national average of 13.4.

In Arkansas, suicide is as common as traffic fatalities and three times as common as homicide. But both of those causes of death are reported routinely, while self-harm is not, making suicide seem far more rare than it really is.

According to the American Association of Suicidology, every suicide impacts 147 other people, 18 of them intimately. The impact, then, spreads far beyond the individual or household and into the workplace, where employers need to be prepared for work disruption.

Families rarely reveal suicide in paid obituaries — Oliver didn’t — and news organizations are selective in when and how they report suicides. The Associated Press, whose reporting policies are widely adopted by member newspapers, “does not cover suicides or suicide attempts, unless the person involved is a well-known figure or the circumstances are particularly unusual or publicly disruptive.”

The death on Feb. 25 of Dr. Charles Henry, a Little Rock ophthalmologist, is a recent case in point. A paid obituary that did not include the cause of death was published in the Arkansas Democrat-Gazette, but more than a week passed before Deputy Editor Frank Fellone acknowledged in an op-ed column that Henry had killed himself by leaping from a parking deck in downtown Little Rock.

The Democrat-Gazette, Fellone wrote, has a longstanding policy of reporting suicide as news only if it involves a prominent person or happens in a public place. Fellone said Henry’s suicide should have been reported since it fit both criteria, but no news article was published because of “a misunderstanding, or miscommunication, in the newsroom,” and not because of any effort to suppress the news.

Reluctance to report most suicides is not just a gesture of sensitivity toward suddenly bereaved families, although recommended reporting guidelines certainly call for compassion and consideration. News organizations must balance the need to inform their audiences about a persistent public health issue with the documented phenomenon of copycat acts — what researchers like Dr. Ricardo Cáceda call a “contagion.”

Cáceda, pronounced kuh-SAY-duh, is an assistant professor in the Psychiatric Research Institute at the University of Arkansas for Medical Sciences in Little Rock, which each month treats 20 to 30 individuals who have tried to kill themselves and 60 to 80 more who are having suicidal thoughts. And the PRI, with 13 in-patient beds, is just one of more than a dozen treatment facilities in the area that are similarly busy.

And Little Rock is urban. Social isolation and lack of access to mental health treatment are both risk factors, Cáceda said. As a result, suicide is twice as common, per capita, in rural areas as in urban areas.

Arkansas, he said, has a severe shortage of mental health providers, and new patients can wait six months or more for an appointment.

The suicide rate in New York, which has more mental health professionals per capita than any other state, is less than half that of Arkansas, he pointed out. Meanwhile, the highest rates — more than 20 per 100,000 residents — tend to be in sparsely populated states like Montana, Alaska and Wyoming.

“But this is just the tip of the iceberg,” Cáceda said. “The statistics show that there are 20 people who have attempted to kill themselves for each person who successfully ends their life.”

Between 1 and 5 percent of the general population have considered suicide at some point, he said.

Wrong Way

Nationwide, the statistics have been going in the wrong direction.

“There’s overall increasing suicide rates since the ‘90s, and it’s been particularly persistent,” Cáceda said in an interview last week.

The reasons for the discouraging trend are not fully understood, Cáceda said, and predicting suicidal behavior remains very difficult. His own research is focusing on the biology that makes someone decide to end his life. He has been comparing MRI scans of the brains of people who have attempted suicide with scans of people who have only had suicidal thoughts that they haven’t acted on.

Suicide is highly impulsive, Cáceda said. In most cases, only about 10 minutes pass between the thought of suicide and the attempt, so making access to deadly methods more difficult — by regulating pesticides or packaging medications in blister cards rather than pill bottles — can reduce the number of suicides by frustrating the impulsive behavior.

Although their obituaries raise fewer questions, suicide is more common in older people, and especially among older white males, even those who seem to have all the outward signs of success. (This has been called the “Richard Cory” phenomenon, after the well-known poem published in 1897 by Edwin Arlington Robinson.)

Breadwinners and “high achievers” who retire, by choice or not, can be at higher risk of losing a “sense of purpose,” Cáceda said. Seniors who have more ailments that may cause physical and psychological pain that leads to suicidal thoughts and behaviors are also at risk.

Substance abuse is a very common risk factor. Told that Arkansas Business was also working on a story about assistance plans for impaired employees, Cáceda said, “Those two stories, I think they are related, because at the end of the spectrum of those nonfunctioning employees there are some that are going to end up taking their lives or thinking about or trying to.”

Of approximately 100 suicidal patients the PRI sees each month, about half are using opioids, he said. Tragically, the highest risk for suicide is within one to four weeks after being discharged from a hospital, according to Cáceda.

Why?

When researchers ask why people choose suicide, they are looking for trends and predictors. For family members left behind, like Ron Oliver and North Little Rock District Judge Randy Morley, the why question is much more specific.

“When you undergo this, part of the hell you live with is trying to figure out why and what happened,” said Morley, whose daughter Amy killed herself at age 19.

(Like Floy Oliver, Amy Morley hanged herself, but suicide by firearm is by far the most common method. In 2014, according to the American Association of Suicidology, 49.9 percent of suicides were by firearms. In 2014, there were 21,334 suicides by firearm compared with 15,809 homicides by any means.)

Morley’s life, too, is divided into before and after, but his dividing line is June 26, 2007. Amy would have turned 28 last week.

Depression or some other form of mental illness is almost universal in suicide, Cáceda said, but suicide is certainly not universal among depression patients.

Oliver’s wife was 65 and had been diagnosed with rheumatoid arthritis for 16 years. But depression was something recent and situational — her daughter died of an accidental drug overdose at their house just 10 weeks before — and it never occurred to Oliver that his wife might be suicidal.

“I knew she was depressed, but a lot of people get depressed, and it was not a lifelong thing. She was always just the opposite,” he said.

On the Saturday morning that she died, Floy Oliver got up at a normal time, brushed her teeth and dressed, and seemed “a little upbeat for a change,” Ron Oliver said. He decided to sleep in, a simple decision that has haunted him.

Similarly, Morley knew that Amy — an accomplished business student at the University of Arkansas — was experiencing one of the depressive periods that had plagued her since she entered puberty, but both of them thought it too would be temporary.

“There were signs there, and I talked with her about it. I told her, ‘There are things that can make you feel better.’ And she said, ‘Daddy, you know I always come out of this.’”

It was the last conversation they had about her mental health.

Amy consumed alcohol on the night before she died, and her father believes that the letdown that comes when the blood alcohol level drops may have triggered the impulse to kill herself.

Impact

Even though they may be irrational, feelings of guilt are common in the families of suicide victims. Oliver, who is now retired, said his guilt over the past two and a half years has come in two stages:

“Long-term — I should have done this or tried that or taken her to a hospital. And the immediate thing — why didn’t I get up earlier? For the first year, that was on my mind every day: Why didn’t I just get out of bed that morning?

“I had a therapist tell me that if it didn’t happen that morning, it would have happened another time. But you don’t know that. Maybe if I could have gotten her through that morning, maybe this wouldn’t have happened.”

Judge Morley is still grieving for his daughter but finally starting to look outward, which is one of the reasons he agreed to an interview.

“I’m nine years out, and I’m just now at a point where I feel like I could actually do something about prevention,” he said. “It messes you up that bad.”

Like Oliver, Morley has had grief counseling. His counselor encouraged him to set aside time for grieving every day, which helped keep him from breaking down in public.

But Morley, who also credited a supportive work staff with helping him continue to function, worries that many of the hundreds of thousands of people who are bereaved by suicide each year do not have access to counseling.

“Because it is undercover, because it is veiled in our society, we don’t understand the huge impact these suicides have on our society,” Morley said. “And the ability of suicide to destroy people is immeasurable.

“I wouldn’t wish it on my worst enemy, but it has allowed me to listen to people who have gone through this after me and not try to fix them.”

(Clarification, April 4, 2016: American Association of Suicidology statistics on the number of people impacted by each suicide were unclear in the original version of this story and have been clarified.)