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Suicide. Ugh.

I’ve wanted to write a post about suicide for a while but I wasn’t really sure what I wanted to say. Do I write about statistics? Do I write about psychology of depression? Do I write about prevention? What do people want to read or hear about? The answer is: probably none of it… and maybe all of it.

I’ve been fortunate enough to not have had anyone really close to me die by suicide. Because of the nature of my work though, I have been intimately involved in the turmoil surrounding suicide– whether it is the contemplation of suicide, the attempts at suicide, the aftermath of suicide. Remember, I am not a “mental health professional” per se. I am your average, friendly neighborhood family medicine doc but darn it if I don’t talk about my fair share of suicide. In a fifteen minute appointment, in the middle of a busy Monday morning, between a diabetic patient and an irritated patient with a sore throat who is late for work — that makes for a very tough conversation to have with someone.

Recently, a longtime patient of mine and her husband lost their adult daughter to suicide. She was in her mid 40s living a few states away. I had never met her but my patient and her husband had always talked so proudly of her. She had a prestigious university degree, a successful career, and was in a longtime relationship with a man that they both adored. As happens in many of these stories, her death was an utter and total shock to everyone. Why, with that resume, would anyone want to die? Sometimes there is a “suicide letter” which is an explanation of sorts. In this case, there wasn’t. So, my patient, her husband, friends, family, coworkers were left guessing and formulating theories and answers to questions they had. I spoke to my patient about a week after she learned of the news. As you can imagine, it was just so sad. There isn’t a lot that I can say… there isn’t a lot that anyone can say to make anyone feel any comfort. She said to me that she didn’t know how to feel because if her daughter had been murdered, she would feel grief for her daughter and anger for the murderer. But because her daughter had taken her own life, the victim and the murderer were the same person— so she felt grief and anger for own daughter. Hmmm. Interesting. Right? Wrong? Neither? Worse though is that she felt as if she didn’t know her daughter as well as she thought she did. Did she miss glaringly obvious signs of depression? Did she miss subtle cries for help? Were there any? Could this have been prevented? Could she have helped? Did her daughter even want help? As I sat listening to her questions, mostly rhetorical, I thought to myself, “why couldn’t that be me sitting there, or someone close to me sitting in front of me with the same questions in a year or two or ten or thirty?”. More questions. Fewer reassuring answers.

The WHO (World Health Organization) estimates that someone dies by suicide every 40 SECONDS somewhere in the world and they predict that by 2020 that rate may increase to one every 20 seconds. According to the CDC, in 2017 suicide was the second leading cause of death in the age group 10-34 in the US, second only to accidents…as young as TEN years old. How bleak. How heartbreaking. I saw a talk given recently by a pediatric physician, Dr. Uchenna Umeh, on YOUTH suicide. YOUTH suicide. I can’t. But it’s happening and you KNOW it’s happening. Don’t ignore it. Don’t stop reading this post because it makes you uncomfortable, or sad, or gives you that awful ache deep in your stomach that makes you want to bury your head in a pillow and turn off the lights. We have a responsibility as parents, as medical providers, as neighbors, as teachers, as adults, as humans to recognize that these statistics are real and that they will not get better without acknowledgement and education.

So what should you know? At a minimum?

Know the Risk Factors

These characteristics alone can’t cause or even predict a suicide attempt but they are characteristics that make it more likely that someone will consider, attempt, or die by suicide. Please be aware of them.

  1. A history of mental disorders, particularly mood disorders such as schizophrenia, anxiety disorders, depressive disorders

  2. Alcohol and other substance use disorders

  3. Hopelessness

  4. Impulsive and/or aggressive tendencies

  5. History of trauma or abuse

  6. Major physical illnesses

  7. Previous suicide attempts

  8. Family history of suicide

  9. Job or financial loss

  10. Loss of relationship(s)

  11. Easy access to lethal means

  12. Local clusters of suicide

  13. Lack of social support and sense of isolation

  14. Lack of healthcare, especially mental health and substance abuse treatment

Those above are widely accepted and listed on sites such as CDC.gov and NIH.gov. I would also consider adding to that list

  1. History of being bullied

  2. Identifying as LGBTQ

What are the signs?

  1. Talking about wanting to die or kill themselves

  2. Talking about death often

  3. Talking about guilt or shame

  4. Looking for a way to die by suicide like searching online or buying a gun

  5. Talking about feeling hopeless or having no reason to live

  6. Talking about feeling trapped or in unbearable pain

  7. Talking about being a burden to others

  8. Increasing use of alcohol or drugs

  9. Abrupt mood changes; acting anxious or agitated; behaving recklessly

  10. Sleeping too little or too much

  11. Withdrawing or isolating themselves

  12. Showing rage or talking about seeking revenge

  13. Extreme mood swings

  14. Saying goodbye to friends and family

  15. Giving away important possessions

What do you do?

  1. ASK. Ask directly. “Are you thinking about killing yourself? “Are you thinking about suicide? DO NOT BE AFRAID TO ASK DIRECTLY. Asking someone if they are thinking about suicide does not given them permission to do it anymore than handing someone a condom gives them permission to have sex. So ask, “are you thinking about killing yourself?” I ask this question in clinic more times than I’d like to but you won’t know the answer until you ask. It is so much easier for someone in crisis to answer “YES” than to ask you for help. So many people want to be asked directly. So few want to ask for help. ASK. And then be prepared for the answer.

  2. KEEP THAT PERSON SAFE. The immediate priority is safety. If there is an immediate risk, safety is always first. Ask where that person is in their suicide plan. Do they already have a plan? Do they already have the means? Are they already in the process? Depending on the answer, you may need to call authorities, or separate the person from the means. Reduce the access to the plan.

  3. BE THERE. Be supportive. Listen carefully and actively. Acknowledge and talk about what that person is saying. Do not ignore it. Do not dismiss it. Do not diminish it.

  4. HELP THAT PERSON CONNECT WITH RESOURCES. Save the National Suicide Prevention Lifeline number in your phone or have it accessible (1-800-273-TALK 8255). Anyone can call this telephone number anonymously and have 24/7 access to a skilled, trained crisis worker. That person can also text TALK to 741741 which is another way to contact the Crisis Line. You can also try and help make a connection between that person and a trusted friend, a trusted family member, a physician, a spiritual advisor, a mental health professional.

  5. STAY CONNECTED. Stay in touch with that person after a crisis. This can make all the difference. It shows that you care. Studies have shown the number of suicide deaths decrease when someone follows up with the at-risk person after a crisis.

There isn’t anything in this post that I was excited to write. It’s a rough topic to discuss and I would love to ignore it as much as anyone else would but we can’t. When suicide is the 2nd leading cause of death in our country for anyone aged 10-34…. how can you ignore that? To quote Dr. Uchenna Umeh in her talk, she said, “we cannot be the first generation to outlive our children.”. We CANNOT be. It takes a village to raise a child. We all have a responsibility to each other to NOT ignore this. To know the basics of this. To know the risk factors. To know the warning signs. To know what to do next. To know that it won’t get better if we just don’t talk about it. To know that “not my kid” doesn’t apply to any of us.

I am attaching the Facebook link to Dr. Umeh’s talk on Youth suicide. She has given permission to share it. It was given as a grand rounds to a group of physicians but I think that it is appropriate for any adult audience. Feel free to listen/watch if you would like to listen to more. Trust me. It’s fascinating and amazing and awful and eye-opening all at the same time.

Under the sea, acrylic, seems so quiet doesn’t it?

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