“People, they go back and forth between ‘I don’t know if I’m going to do this today; maybe next week.’ But sometimes they’re reassured that they have a solution, even though most of us rationally would say that’s not a good solution,” Jane Pearson, head of Adult Preventive Intervention and chair of the Suicide Research Consortium at the National Institute of Mental Health (NIMH), says to me. She was kind and helpful and followed up our phone conversation with a long email full of resources to check out and additional people to bug. She focuses on the catching-you-before-you-fall field of medicine: she studies how to stop suicides before they happen, whether from the emergency department or the community. “If you’re collaborating and really trying to help somebody, you have to acknowledge that this is a solution they’ve come up with. And you can always say, ‘I don’t agree with that, but you got it….In the meantime, let’s see if we can generate other ideas. And help you find a life worth living.’”1
For fuck’s sake, put it off. Postpone till tomorrow the self-obliteration you long for today.
It’s excruciating to have someone you adore, someone whose suffering you loathe yourself for increasing, ask you to promise never to do the thing you spend 80 percent of your waking life thinking about. You say, “Promise me you’ll never try again,” and I, no matter how much I love you and want you to be happy and fulfilled and pain-free, think, “But what if I have to?”
The impulse to live and keep on living is one of the most basic of any organism. Self-extermination requires a force of will strong enough to override everything your body has evolved to do: survive. Vomiting, gag reflexes, pain thresholds, the need to keep breathing, a fear of heights or a thundering oncoming train—these all kick in involuntarily, bits of your nervous system at war with each other. There are also cultural and legal taboos that keep people from killing themselves. Most religions aren’t cool with doing yourself in and sometimes hell can be an effective—albeit crappy, if you’re suffering from self-blame already—deterrent. Attempting suicide was a crime in the UK until 1961;2 in Canada, until 1972.3 As recently as 2014, trying to kill yourself in India could’ve put you behind bars for a year, although like most penal sentences that doesn’t appear to have been much of a deterrent: India’s suicide rate grew from 10.9 per 100,000 in 2009 to 11.4 in 2013—an additional seven thousand people a year.4
What drives a person to that point?
There are countless factors at play but few are as esoteric as Hamlet’s existential “To be or not to be.” (Hamlet didn’t off himself: Ophelia did.) The vast majority of suicides have one common element, and it isn’t a detached intellectual conclusion as to the nature of being. Mental illness features prominently in 90 percent of cases for which coroners, medical examiners or forensic psychologists can determine a motive.5 Regardless who you are or how you do it, if you kill yourself—or make an earnest effort to that effect—chances are compassionate, evidence-based care would have alleviated the awfulness you’re dying to escape.
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DEPRESSION’S THE MOST common mental illness giving rise to suicidal ideation but it’s hardly the only one. There is a compelling argument for classifying suicidality as a distinct pathology—a disorder in its own right, rather than a symptom of something else. Maria Oquendo, past president of the American Psychiatric Association and the chair of psychiatry at the University of Pennsylvania’s Perelman School of Medicine, has been lobbying for suicidality to have a section of its own in the next iteration of that thornily authoritative conferrer of legitimacy, the Diagnostic and Statistical Manual.
“Not everybody who is suicidal is depressed. And not everybody who is depressed is suicidal. But they’re frequently comorbid pathologies.” They’re illnesses that go hand in hand, she tells me over the phone.6 (I certainly see both in my own predicament.) Separating suicidality into its own category would, ideally, encourage the use of suicide-specific interventions or at least make it harder to ignore in the hope that by treating the mood disorder the desire to die will evaporate.
So if someone talks about feeling persistently down, for example, but mentions as they’re leaving the doctor’s office that they’re thinking of killing themselves, having a separate diagnostic code for such suicidal ideation can remind the doctor to tackle it on its own. That would also make suicidal ideation in a patient or in the population easier to track: it would show up in the emergency department, for example, or in the coroner’s office; it would make it easier for researchers to study the desire to die, to get a sense of how prevalent it is, where and among what populations.
Physicians and epidemiologists have been trying to uncover suicide risk factors: characteristics outside existing disorders that make people more likely to try to kill themselves. Hopelessness; an “over-general” memory that skips over specific details; hyper-perfectionism; trouble solving problems; and a tendency toward black-and-white or all-or-nothing thinking are among them. Hopelessness certainly resonates for me: beyond sadness, self-loathing or any other negative emotional state, an absence of hope can be the most decisive thing propelling me to seek death. The shittier things get, the more the claustrophobic horizons of your world close in. There’s no room for hope because there’s no room for anything. So I confess it was news to me that not everyone with depression feels hopeless.
“Depressed people who still have hope tend not to become suicidal,” says Tom Ellis, who when I spoke with him was the senior staff psychologist at the Houston-based Menninger Clinic and has been researching the differences between suicidal and non-suicidal mentally disordered people. “They come in and say, ‘I’m going through a terrible patch. I’m hopeful, if I get treatment, I’ll get better.’…I would say the mere act of getting treatment means you have some hope.” 7 (I agree and I disagree here. It’s possible for me to have enough hope to take my meds but not enough not to try to kill myself.) A degree of psychological flexibility—the ability to notice your thoughts and feelings with a degree of circumspection, so they’re of you but they’re not you—can also be a protective factor against suicide. “So if I have a thought like, ‘I’m no good,’ I’m able to step back and say, ‘That was just a thought that came up. It’s not necessarily a fact…nor is it necessarily going to be helpful, nor should I base my decisions, such as life or death, on the basis of a thought that comes up.”
If eight hundred thousand people around the world kill themselves every year,8 that means about twenty-two hundred a day, or three every two minutes. Statistically, two dozen people killed themselves in the time it took you to get out of bed, showered and caffeinated. Maybe forty-five during your commute to work; another ninety in the time you spent making dinner. Unless you, like me, take an eternity to do any of those things, if they happen at all. In which case, think of it this way: every time you mull killing yourself and manage to talk yourself down because you have more to do and more to ask of life, a handful of people have lost that internal wrenching wrestling match and ended it.
In Canada, where eleven people kill themselves daily,9 you’re almost ten times more likely to kill yourself than you are to be killed by someone else.10 About 120 Americans kill themselves every day. Victims of America’s gun epidemic are overwhelmingly suicides: Americans are more than twice as likely to die by their own hands as someone else’s and almost twice as likely to shoot themselves to death than be shot to death by someone else.11 If you die young, suicide’s much more likely to be the cause: in 2016 it was the second-leading cause of death for Americans between ten and thirty-four years old.12
The vast majority of people who kill themselves are men—not because they’re more likely to be depressed or suicidal but because they’re more likely to choose lethal methods like guns. (Studies have found women actually make up the majority of people seen in emerg following suicide attempts.) Many, many more people try to kill themselves than actually do it—about half a million Americans are brought to emergency rooms every year after having tried to e
nd their lives.13
Epidemiologists are leery of putting too much weight on sharp changes over short periods but America’s spike in suicide appears too big to be a blip. The rate of people killing themselves in one of the most prosperous countries in the world jumped 33 percent in eighteen years, from 10.5 to 14 per 100,000.14 It rose more for women than for men, which narrows the gap between the two but still leaves men four times more likely to kill themselves. The suicide rate among adolescent girls jumped the most, tripling—tripling—during that time period. (But keep in mind, the huge rate of change is influenced by a small denominator: 1.5 per 100,000 up from 0.5.)15
“When [the Centers for Disease Control] released their statistics of this increase between 1999 and 2014, people went, ‘What?’” NIMH’s Jane Pearson recalls. She just wishes there were more of that, more of a sustained palpable jolt in the public consciousness. “There was some recognition that this is a problem. But compared to other health problems, we don’t have a Susan Komen foundation [one of the best-funded breast cancer organizations in the US], a big organization advocating for this.”16
Her colleague Sarah Lisanby at NIMH—the head of translational medicine, in charge of morphing research into health interventions—doesn’t know what’s driving America’s spike in suicides but she hopes the sharp jump will be a call to arms for the research and clinical communities. “We’re making progress in terms of our neuroscientific understanding. We can translate that into public health impacts,” she tells me, pointing to research into biomarkers and neurocircuitry that can mean new or better-informed treatments. “And we need to accelerate that pace of translation because people are dying.”17
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EVEN AS RATES rise, reality is likely worse: evidence indicates we’re undercounting suicides by a significant amount—by as much as two-thirds, depending how you guesstimate. For one thing, despite the supposed decrease in shame in having a family member kill themselves, our persistent societal freak-out regarding suicide can make both relatives and authorities hesitant to classify deaths as such. There’s a very high burden of proof required for coroners (usually in Canada) and medical examiners (in the United States) to classify a death as a suicide. There’s rarely incontrovertible evidence: most people don’t leave suicide notes and not everyone talks about killing themselves before killing themselves. Even if they had at some point in the past, how do you know this specific incident was a suicide? If someone is depressed, even suicidal, but also misuses drugs, how do you know for sure whether an overdose is purposeful? How do you know for sure whether a single-vehicle crash was careless driving or driven by a need for death? How can you be certain whether someone slipped or jumped?
You’re more likely to find suicides when you look for them. And, much of the time, we don’t. “The under-reporting of suicide is a recognized concern in Canada and internationally,” reads a 2016 study by the Public Health Agency of Canada.18 Suicide deaths are also examined a lot less closely, on average: about 55 percent of US suicide deaths get autopsied, compared to 92 percent of homicides.19
The more autopsies a county does, the more suicides it identifies, West Virginia University researcher Ian Rockett has found: if you spend more time investigating a death you’re more likely to deem it intentional on the part of the deceased. I reached him by phone after reading some of his papers: he and his colleagues studied the rate of suicide classifications by county and found that the more detailed death certificates are, the more time coroners or medical examiners spend on them, the better-resourced they are to be able to do so, the greater that county’s rate of deaths classified as suicides.20 Another study, this one in Austria, found that the higher the autopsy rate, the higher the suicide rate: the more deaths you examine closely, the more of them you’ll find to have been the result of tragic intentional self-harm, not tragic accident.
But we’re doing fewer autopsies in Canada and the States, not more: the percent of deaths subject to autopsy in Canada dropped almost in half between 2000 and 2011—from 9.9 percent to 4.8, “further subjecting suicides to misclassification,” 21 the Canadian public health paper reads. In the US, autopsies dropped by more than 50 percent between 1972 and 2007.22
This has been a known issue for a while. The consequences of under-reporting extend beyond public health nerds who get off on accuracy. It suggests something is less of a problem than it is and therefore less deserving of our attention and our dollars. Which is convenient, given how icky it makes us feel in the first place. Finding fewer suicides can make it seem like suicide is less of an issue.23
“If you think about it, society hasn’t been that invested in suicide prevention,” Rockett points out. “If you more accurately portray the self-injury deaths and say, ‘This is mental health,’ there’s potential for rather more resources to be directed toward the problem.” 24 Take poisoning, where intent can be particularly tricky to divine: poisoning deaths classified as suicides dropped even as poisoning deaths classified as “undetermined intent” rose. Studies in both Canada25 and the US26 have found evidence suggesting it isn’t just that people are making more unintentionally reckless decisions regarding what they smoke, snort, swallow, inject—we’re actually misclassifying suicides as accidents. We know substance use increases your risk of suicide. But if you die thanks to a lethal amount of the substance you’re misusing, your death is less likely to be classified as a suicide.27
Canada’s Public Health Agency came to similar conclusions: overall suicide rates dropped. Suicide poisoning rates dropped. Accidental poisoning deaths rose. Poisoning deaths of undetermined intent jumped by even more—almost 42 percent. The study estimated as much as 60 percent of suicides in 2011 were mistakenly labelled deaths of undetermined intent by self-poisoning. (The low end of that estimate is 15 percent, so take it with a bunch of salt. But it’s still a double-digit underestimation.)28
Botched suicide attempts also go under-reported: many people who try to kill themselves either don’t seek medical help or lie about why they are seeking it. I’ve done both those things. I’d do them again. As I’ve said, telling anyone you’ve tried to kill yourself, let alone someone you don’t know, let alone someone who could suspend your right to freedom of movement, gives one enormous pause. (Not that telling someone you love is any easier.)
But take time to talk to people in hospital for near-fatal poisonings and it can be telling.
Infuriatingly but perhaps unsurprisingly, undercounting suicides, and therefore minimizing the self-destructive death toll and its magnitude as a public-health issue, is worse for marginalized populations.
The suicide rate for white Americans in 2016 was almost three times that of Black Americans.29 “It didn’t make a lot of sense to me,” Rockett says. “I couldn’t think of any other major cause of death where Blacks would have had an advantage.” Fact is that non-white North Americans are less likely than white people to get any kind of care for their depression, much less care that meets evidence-based standards. Far fewer Black people who’ve killed themselves or may have killed themselves took antidepressants in the year before their death than their white counterparts which, given what we know about the role mental illness plays in the vast majority of suicides, suggests Black people are less likely than white people to get the psych treatment they need.30
And then the same marginalization that makes you less likely to get treatment also makes it less likely your death will be classified accurately, because lack of documented depression treatment leading up to your death makes coroners more likely to classify your death as being due to an “injury of undetermined intent.”31 Which means we’re underestimating the toll this public health crisis takes on your community—and, therefore, the degree of need for prevention and interventions that could be directed toward it. Cascades of compounded marginalization. We probably aren’t underestimating Black suicides by a factor of three, but maybe enough to be significant.
So what do you do with that?
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br /> Resources would help. More thorough—or at least more frequent—autopsies would help. Talking to people in ICUs would help. Lessening the need for absolute certainty in determining intent might also make classification both easier and more inclusive, albeit with somewhat broader definitions.
Ian Rockett would like to see a tweak in classification: instead of probing the recesses of someone’s psyche at the moment of their death for a very specific kind of purpose—Was this overdose accidental or purposely suicidal or a combination of suicidality, self-destructive fatalism and a substance disorder?—medical examiners and epidemiologists could instead focus on the fact that the individual in question died by their own hand.32 He says his preferred term is “drug self-intoxication.” It combines what’s now disaggregated into either “accidents,” or “suicides,” or “undetermined,” excises intent and focuses on the fact that the dead person did this. In his ideal world, medical examiners would differentiate between licit and illicit drugs, tap into prescription drug monitoring systems to get a better sense of how the individual obtained the drugs that killed them.
He isn’t suggesting eliminating entirely the category of accidental deaths. But he’d like to reverse the starting hypothesis, so that in order to rule something an accident you have to find evidence indicating an accident, rather than simply a lack of evidence indicating specific intent. Of course “there are deaths that are unintentional: a three-year-old gets into a cabinet and finds a pesticide.” But “from an epidemiological standpoint, we want to approach things differently.”
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