The deaths of the
designer Kate Spade and the
chef Anthony Bourdain, both of whom committed suicide this week,
were not simply pop culture tragedies. They were the latest markers of an
intractable public health crisis that has been unfolding in slow motion for
a generation.
Treatment for chronic depression and anxiety — often the
precursors to suicide — has never been more available and more widespread. Yet
the Centers for Disease Control and Prevention this week reported a
steady, stubborn rise in the national suicide rate, up 25 percent
since 1999.
The rates have been climbing each year across most age and
ethnic groups. Suicide is now the 10th leading cause of death in the United
States. Nearly 45,000 Americans killed themselves in 2016, twice the number who
died by homicide.
After decades of research, effective prevention strategies are
lacking. It remains difficult, perhaps impossible, to predict who will commit
suicide, and the phenomenon is extremely difficult for researchers to study.
One of the few proven interventions is unpalatable to wide
swaths of the American public: reduced access to guns. The C.D.C. report found
that the states where rates rose most sharply were those, like Montana and
Oklahoma, where gun ownership is more common.
It is predominantly men who use guns to commit suicide, and men
are much less likely to seek help than women.
The escalating suicide rate is a profound indictment of the
country’s mental health system. Most people who kill themselves have
identifiable psychiatric symptoms, even if they never get an official
diagnosis.
The rise in suicide rates has coincided over the past two
decades with a vast increase in the number of Americans given a diagnosis of
depression or anxiety, and treated with medication.
The number of people taking an open-ended prescription for an
antidepressant is at a historic high. More than 15 million Americans have
been on the drugs for more than five years, a rate that has more
than tripled since 2000.
But if
treatment is so helpful, why hasn’t its expansion halted or reversed suicide
trends?
“This is the question I’ve been wrestling with: Are we somehow
causing increased morbidity and mortality with our interventions?” said Dr.
Thomas Insel, former director of the National Institute of Mental Health and
now president of Mindstrong Health, which makes technology to monitor people
with mental health problems.
“I don’t think so,” Dr. Insel continued. “I think the increase
in demand for the services is so huge that the expansion of treatment thus far
is simply insufficient to make a dent in what is a huge social change.”
Drug trials and other randomized studies are virtually useless
for capturing measurable effects on suicide. Most drug trials explicitly
exclude subjects deemed a suicide risk; even when they don’t, the studies don’t
last long enough to say anything definitive about who commits suicide.
But one recent study, by Danish researchers, supported the benefits of
therapeutic intervention.
Using detailed medical records, the investigators studied more
than 5,500 people who had been treated for deliberate self-harm, including
cutting and clear suicide attempts.
Over decades, the portion of those people who got psychotherapy
at suicide clinics were about 30 percent less likely to die or commit further
self-harm than those who did not.
“I personally think that it’s the quality of care that matters,
not the quantity,” Dr. Insel said. “We need more access, better measures and
better quality of care.”
But
in this country, many of those who commit suicide have received little or no
professional help. Indeed, they rarely tell anyone beforehand of their plan —
when there is one. Often the act is impulsive.
According to Matthew Nock, a professor of psychology at Harvard,
the wide majority of people who die by suicide “explicitly deny suicidal
thoughts or intentions in their last communications before dying.”
Andrew Spade, Ms. Spade’s husband, said she had seemed fine when
he’d talked to her just before her suicide. Mr. Bourdain was filming one of his
clever, humorous shows in Strasbourg, France, when his body was discovered.
The rise of suicide turns a dark mirror on modern American
society: its racing, fractured culture; its flimsy mental health system; and
the desperation of so many individual souls, hidden behind the waves of smiling
social media photos and cute emoticons.
Some experts fear that suicide is simply becoming more
acceptable. “It’s a hard idea to test, but it’s possible that a cultural script
may be developing among some segments of our population,” said Julie Phillips,
a sociologist at Rutgers.
Prohibitions are apparently loosening in some quarters, she
said. Particularly among younger people, Dr. Phillips said, “We are seeing
somewhat more tolerant attitudes toward suicide.”
In surveys, younger respondents are more likely than older ones
“to believe we have the right to die under certain circumstances, like incurable
disease, bankruptcy, or being tired of living,” she said.
The cultural currents that deepen despair and increase the
chances of suicide have long been staples of sociological debate.
The social scientists Christopher Lasch and Robert Putnam
identified postwar influences that have corroded the fabric of local everyday
life — the block parties, church meetings, family barbecues and civic groups
that once bound people against solitude and abandonment.
More recently, the economists Anne Case and Angus Deaton of
Princeton have argued that the hollowing out of the economy and loss of middle
and working class supports, like unions, have contributed to a broad increase in
self-reported pain in those groups, both mental and physical.
The aggressive marketing of opioids by Purdue Pharma and others
eased some of that pain — and helped create a generation of addicts, tens of
thousands of whom die each year. Opioids are the third most common drugs found
in the systems of suicides, after alcohol and anti-anxiety medications like
Xanax, the C.D.C. reported.
A decline in marriage rates has likely played a role, as well.
In her research, Dr. Phillips has found that in 2005 single middle-aged women
were as much as 2.8 times more likely to kill themselves than married women,
and their single male peers 3.5 times more likely than married men to do the
same.
“In contrast to homicide and traffic safety and other public
health issues, there’s no one accountable, no one whose job it is to prevent
these deaths — no one who gets fired if these numbers go from 45,000 to
50,000,” Dr. Insel said.
“It’s shameful. We would never tolerate that in other areas of
public health and medicine.”
If you are having thoughts of suicide, call the National Suicide
Prevention Lifeline at 1-800-273-8255 (TALK) or go to SpeakingOfSuicide.com/resources for
a list of additional resources.
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