Join in wearing yellow on World Suicide Prevention Day, September 10
He stared at the loaded gun for what seemed like an hour. My patient couldn’t believe that the world had come to this — the pandemic was proof to him that the world was ending. He remembered the horror of serving in Iraq right after 9/11, and he remembered the pain of coming home and not being able to find a job. He breathed in, picked up the gun, and put it to his right temple, leaving it there for a few minutes. Memories flooded his mind, thoughts bouncing every which way.
He didn’t know why he eventually put the gun down, and neither did I, exactly. But I knew he then picked up his phone and called my office. My nurse came to me, and I went to her phone and talked to him, asking him to come to my office right away — no appointment needed, just come in.
Every doctor will encounter suicidal people in their practice. Psychiatrists and the CDC tell us that the current suicide rate is the highest since World War II at 14.3 suicides per 100,000 individuals. For comparison, the highest suicide rate in the past 100 years was during the Great Depression at 21.9 suicides per 100,000. There is concern that we are heading toward that level.
On September 10, World Suicide Prevention Day is honored around the globe. The National Institutes of Health urges wearing the color yellow on that day; the Yellow Ribbon has been a symbol for suicide prevention since the 1990s. More sobering to consider is the fact that September 17 is National Physician Suicide Awareness Day.
Suicide can happen without warning, but there are often subtle signs that can alert us. These include talking about wanting to die or expressing great guilt or shame and a sense of being a burden to others, according to the National Institutes of Health. Behavior that ranges from extremely sad to more anxious and agitated and even rage should trigger concern. NIH also cites behavioral changes as researching ways to die; saying goodbye to friends, giving away important items and making a will, and taking dangerous risks such as driving extremely fast or using drugs and alcohol more often as red flags.
But patients, friends and colleagues don’t always offer a clue that they are in such distress. “Mental pain is less dramatic than physical pain, but it is more common and also more hard to hear,” C.S. Lewis wrote in The Problem of Pain: “The frequent attempt to conceal mental pain increases the burden… In the whole realm of medicine there is nothing so terrible to contemplate as a [person] with chronic melancholia.”
Grief after suicide can be particularly devastating. The sudden, mysterious, and often violent nature of suicide can confound loved ones and health care providers. In medical school, one of my classmates and close friends died by suicide; it was an utter shock, and speaking at the funeral was just so painful. We didn’t think it could happen to one of us in the medical field; I thought we were immune to this, but I was wrong. The emotional pain from losing someone to suicide can last decades because the normal and expected grieving processes of “closure” are not there. Questions such as “Did I do enough?” or “Could I see this coming?” abound.
Stigma makes it challenging to talk about suicide. What can we say to the parents of a teenager who died by suicide or the spouse of a physician or surgeon, or veteran? There is no evidence that bringing up the topic of suicide in conversation with someone will induce them to die by suicide; actually, it is the contrary. Evidence shows that asking someone directly and providing a safe space to talk about their thoughts can help decrease the risk of suicide. Speaking about suicide is not something to shy away from.
Why does suicide happen? The reasons are varied but identifiable. Family history of suicide and adverse childhood events unfortunately can increase risk early in life. Severe mental illness, including substance use problems, can significantly increase the risk for suicide. Many social and economic factors can also play a role, such as the recent pandemic. In America, men complete suicide more than women, but in China, the reverse is true.
In 2021, one in five high school students seriously considered suicide, and one in 10 actually attempted. Suicide is the tenth leading cause of death in North America and the leading cause of death worldwide for those 15 to 24 years of age.
The good news is that suicide can be prevented. Here are some ways that can help if you suspect someone might be considering taking their own life and steps that can be taken to reduce suicides as a whole.
Ask your patient clearly and directly if they are suicidal. Many people who eventually die by suicide would have seen a health care provider in the months leading to the suicide if they had been urged to do so. Similar to CPR, the evidence-based intervention for suicide is QPR, meaning Question, Persuade, Refer. Don’t dance around the topic, be direct.
Connect quickly. Research shows that suicide acts can happen within one hour after someone has a serious suicidal ideation. Risk of suicide is also very high after discharge from a psychiatric hospital. Connecting with family in a supportive environment and seeing a health care provider as soon as possible after discharge can help decrease the risk.
Urge them to call 988, the national suicide hotline. This service provided by the federal government is the equivalent to 911 and is specifically for mental health. Improved and fine-tuned in the last two years, it has been fully funded and staffed to help those who are suicidal.
Restrict lethal means. Decades of data shows that access to lethal means increases the risk of suicide significantly. According to Stanford University, researchers found that people who owned handguns had rates of suicide that were nearly four times higher than people living in the same neighborhood who did not own handguns. Suicide is often an impulsive act and men who own handguns are eight times more likely to die of gun suicides than men who don’t own handguns. Women who own handguns are 35 times more likely than women who don’t.
Treat mental illness. In the United States, 80-90% of those who die by suicide have a diagnosed mental disorder. Medications, including antidepressants and lithium, have been shown to decrease suicides.
Embody hope. Hopelessness is a known acute risk factor for suicide. A professional can help channel that despair into a realization that there is plenty to live for. Many schools have also created Hope Squads that promote self-worth and have been recognized as an effective vehicle in secondary schools for conveying suicide prevention messages. Its peer-to-peer approach and education about mental illness has opened doors and saved lives.
Have a national plan of action. When Finland in the 1980s had a very high rate of suicide, it started a national plan to address suicide and since then it has cut its suicide rate by half. The current plan includes 36 proposals including raising awareness, influencing access to common means of suicide, and early intervention. The Biden administration has been working hard to create a national plan, something that the World Health Organization suggests all nations should do.
When my patient was considering suicide, he thankfully came to my office and we had a good session — he was really struggling. We also got him to see one of our therapists and I brought him back in a few days. I adjusted his medications, and he eventually allowed his family to hold on to his guns. He later got a job at the local railyard and eventually was engaged to be married.
Many of our colleagues have had the experience I had of losing a fellow medical student or colleague to suicide and experiencing the grief and confusion that follows. On average, more than one physician takes his or her own life every day, according to the American College of Emergency Physicians. In the U.S., ACEP notes, suicide deaths are 250-400% higher among female physicians than females in other professions.
On September 10, join in the effort to raise awareness that suicide can be prevented and support our colleagues, friends, and family by wearing a yellow ribbon. More importantly, pay close attention and watch for the signs that others around you are struggling and intervene if you suspect that person could be having suicidal thoughts. And if you are the one that is depressed or have even fleeting thoughts of suicide, please, please reach out to a professional for help or call 988 right away.
Email David Hsu, MD
