Suicide awareness campaigns encourage people to talk about suicide, look for warning signs and call a suicide prevention hotline when in crisis. But can suicide really be prevented? For some people, these campaigns may help. But for others–particularly those with serious brain illnesses like bipolar, schizophrenia and major depressive disorder–it’s not nearly enough.
When I was a junior in college, one of my professors began acting strangely. After weeks of teaching us economic theory, his lectures abruptly veered into his personal life. In embarrassing detail, he regaled us with stories about an intense emotional connection he shared with a woman, his experience with psychedelics and his disdain for the academic system.
The next week, he announced that our final grades would be based not on homework and tests, but instead randomly generated–an A, B, C or D based on the luck of the draw. Someone must have complained to the school, because after that class, I never saw him again. A few weeks later, I learned that he had stepped in front of a train, taking his own life.
Could his suicide have been prevented? I don’t know. But I do know that preventing suicide is much more complicated than suicide awareness campaigns would have us believe.
These campaigns tell us that identifying early warning signs and connecting people to crisis hotlines can prevent suicide. While well-intentioned, they imply that if only families had recognized the telltale warning signs, their loved one could have been saved. This message seems not only cruel to the surviving family members but also misleading. If only preventing suicide was that simple.
While it is commonly reported that people show sudden signs such as hopelessness, withdrawal and giving away possessions, many suicides happen without warning. In other cases, suicides happen after years-long struggles with psychiatric illness. Rather than new behaviors emerging, these feelings of hopelessness, mood swings and thoughts of suicide may have long been part of a person’s daily existence. How could their families possibly predict when suicide was imminent?
Unfortunately, suicidal thoughts are a common symptom of serious mental illness, and an estimated 90 percent of people who die by suicide have a mental disorder. People with bipolar disorder have a 20 to 30 times higher risk of suicide than the general population, and up to half of people with schizophrenia or bipolar disorder attempt suicide at some point in their lives. Major depressive disorder also has a higher risk of suicide.
It is difficult to understand the mindset of someone who is suicidal. This journal excerpt, written by a woman with severe depression who later succumbed to suicide, eloquently describes the depths of such despair:
“The pain is all-consuming, overwhelming… I live in hell, day in and day out. Every day, I break down a little more. I am eroding, bit by bit, cell by cell, pearl by pearl. I am not getting any better. ‘Better’ is alien to me, I cannot get there… I am a hopeless case. I have lost my angel. I have lost my mind. The days are too long, too heavy; my bones are crushing under the weight of these days.” (Published in Kay Redfield Jamison’s book “Night Falls Fast”).
A person in this state is not likely to call a crisis hotline, and hearing that their life matters and is worth living wouldn’t make the slightest difference. Overcoming this intense emotional pain and despair requires more than a caring voice on the phone. It requires a regimen of long-term intensive treatment, medication and support that is often elusive, and even that may not be enough.
When we focus on suicide awareness campaigns, money that could be spent on care and treatment is diverted to ad campaigns and outreach. While well-intentioned, more awareness and crisis hotlines are not what we need.
So what can help?
Removing guns– Getting guns out of the hands of people with serious mental is just common sense, especially given that many suicides are impulsive. One study found that, in most cases, the decision to die and the act itself happen the same day, and in nearly a quarter of the cases, they contemplated suicide for no more than 5 minutes. If you take away the means in that moment, you could save a life. In some states, Red Flag laws allow firearms to be temporarily removed when a person is a danger to themselves or others. However, not all states have this law, and not everyone knows of its existence.
Removing barriers to mental health treatment — It is incredibly difficult to find a psychiatrist accepting new patients, let alone a psychiatrist who accepts your insurance without a weeks-long wait. We have mental health parity laws in place, but we are far from reaching that ideal. There is also a shortage of inpatient beds. The lack of beds is due to a discriminatory federal rule known as the IMD Exclusion, which prohibits Medicaid from reimbursing states for psychiatric care in facilities with more than 16 beds. The result is that care is simply not available for people who need it.
Implementing a continuum of care— In a typical scenario, a person hospitalized for psychiatric illness may be discharged 5 to 7 days later, regardless of whether they have stabilized, with a list of medications, resources, and in many cases, little to no follow-up care. Instead, we need a full continuum of care from inpatient to intensive outpatient care to long-term oversight and support, with physicians at all stages communicating with each other and to the families of the patient. We do it for other illnesses. To exclude mental illness from this standard of care is nothing short of discrimination.