Suicide is never “gotta set myself free” – a letter to Epic Rap Battles and a discussion on how we talk about suicide

Sunday entry instead of a Monday one, but it’s an important and timely one.

If you are a nerd like me, and you’ve spent any time on YouTube, chances are you have come across Epic Rap Battles of History. They are a YouTube channel which hosts rap battles between historical or celebrity figures. They lampoon everyone, and they are so, so clever and funny. I’ve always loved them and get excited when they publish a new video.

Early this morning, they premiered their latest battle between George Carlin and Richard Pryor. The battle, as usual, was hilarious. This one featured guest appearances be Joan Rivers and Robin Williams. Williams appears last, and it’s his last line which causes the problem:

Again, that last verse:

“I love the prince
but you’ll never have a friend like me
Thanks folks that’s my time
Gotta set myself free”

And Williams disappears into the top of the screen.

That last line is clearly a reference to William’s suicide in August 2014. And that line is a huge problem. Suicide should never, ever be discussed as a freeing option, one which somehow frees people from the bonds of pain and life. Suicide is not an option. Discussing it as a positive thing frames it in a positive way, and that encourages others to look at suicide as if it should be considered.

Some of you may remember that this isn’t the first time that William’s suicide was displayed this exact way, using the same language (which is a reference to both the suicide itself and Genie’s desire to be free in Aladdin). After William’s suicide, The Academy of Motion Picture Arts and Sciences put out this tweet:

The tweet was criticized by suicide prevention activists. It made suicide appear celebratory, a victory over depression and pain, and a viable option for anyone who hurts. This can never, ever be the case.

From the article:

  • Christine Moutier, chief medical officer at the American Foundation for Suicide Prevention: “If it doesn’t cross the line, it comes very, very close to it. Suicide should never be presented as an option. That’s a formula for potential contagion.”
  • Ged Flynn, chief executive of the charity Papyrus: I am particularly concerned that use of the ‘Genie, you’re free’ tweet could be seen as validation for vulnerable young people that suicide is an option.”
  • Jane Powell, director of the support group Calm, “We all want Robin to be in a happier place but it’s not a good message for people feeling suicidal, because we want them to stay with us and not go find some starry night escape with genies,” she said.

This is needed largely because suicide contagions are real: After William’s suicide, suicides increased by 10%. And, as the study I linked to notes, media coverage of suicide can be critical to how the coverage of suicide influences suicidiality in others. There are media recommendations for how to cover suicide (I actually tweeted it yesterday, before this video, in reference to an ongoing situation in my home region which thankfully ended well).

One of the key recommendations is not to glamorize suicide or present it as an option. The media has failed that before: Epic Rap Battles failed it here. Do I think they did this on purpose? No, absolutely not. I think it’s an honest mistake. But I hope it’s one they correct.

Again, here are the facts:

  • In 2017, over 47,000 Americans took their own life. These are the highest rates of suicide since World War 2.
  • Suicide is the 10th leading cause of death in the United States, and the 2nd leading cause of death for 10-24 year-olds.
  • Suicide rates have increased 33% since 1999.

We have an epidemic, or, in the words of Congersswoman Susan Wild (D-PA), a national emergency. National emergencies require being addressed on all fronts. One of those is cultural and communication. No one with a platform over over fourteen million subscribers should make such a casual reference to suicide and describe it as “gotta set myself free.” I’m hoping this was unintentional. And I hope that ERB will consider changing the video.

And to everyone else: Please watch how you discuss suicide. Please take it seriously. And please use person-first language which ensures that we let people know they are loved and cared for, and that we never, ever, ever want them to “set themselves free.”

An in-depth look at America’s suicide numbers

This Bloomberg story came out about two weeks ago and reviewed America’s rising suicide numbers. It’s findings, as you can imagine, are damning. Some of the salient points:

  • In 2017, 47,000 people died by suicide – and 1.4 million made attempts.
  • From 2000-2006, the suicide rate increased by 1% annually. From 2006-2016, that increased to 2%.
  • Life expectancy has fallen for three straight years – the first three consecutive year drop since 1915-1918.
  • Suicide is the 2nd leading cause of death for 10-34 year-olds.
  • Suicides cost U.S. businesses between $80-100 billion annually.
  • A lack of resources is to blame for many of these issues. According to some experts, the United States needs 50 mental health beds for every 100,000 people – but some states have numbers as low as 5 per 100,000.

The article goes on to say something I’ve discussed in the past – part of the intractability of our mental health and suicide crisis is the intertwined nature of the problems. Health care, genetics, finances, social support, culture – they all interact to influence mental health. As the article notes, combine that with a rapidly changing economy, advances in technology and a changing cultural scene, and you have a recipe for the disaster we’re currently experiencing.

Mental Health parity (reimbursing physical and behavioral health care at the same rates) and a lack of doctors play a role as well. As recent court cases have noted, many insurers still aren’t adequately reimbursing for mental health services, or they are resorting to alternative methods (such as steering patients to doctors who are no longer even in their network) in order to keep people out of treatment.

The story also noted that changing the way we gather data could lead to additional insights which may result in better treatment of mental health disorders: In 2010, England started measuring overall life satisfaction and recently created a “Minister of Loneliness.”

So, what’s the conclusion of this article? Besides “holy crap this is bad”?

I think I’m gonna be repeating myself a bit here. But the conclusion is that addressing suicide for real will require a huge investment of resources and an acknowledgement that it’s more than just mental health. We have to address insurance and fiscal policies. Create a culture which is more accepting of mental health challenges. Understand that the challenges of mental health are comprehensive ones which tie a variety of areas together.

And I think we have to be willing to pay. For care. For insurance access. For bed space in the event that there are emergencies.

I hated reading this article because it was painful. But we need to know the truth about mental illnesses. And the truth is that this problem will take a long, long time to fully address.

 

The importance of inclusion – for everyone

I caught this article on Facebook the other day – it’s results caught me by surprise (to an extent) but it has a key finding that I really wanted to go over.

In 2014, the University of British Columbia examined the connection between suicide rates and having a Gay-Straight Alliance at High Schools in Canada. The results showed that students were less likely to feel discrimination, experienced lower suicidal thoughts, and have lower rates of suicide attempts.

Just gay students, right?

Wrong. All students.

This is a pretty striking finding. Not only are GSAs positively related to the mental health of gay students, but if the findings of this study are correct, they can also positively impact the mental health of students whose lives would (theoretically) not be impacted directly by the Gay-Straight Alliance.

This is great for many reasons. First, as I discussed last week, LGBT Americans sadly have significantly higher rates of a slew of negative mental illnesses, including suicide. Clubs like GSAs can provide safe places for LGBT teens to congregate, build vitally necessary social relationships and learn they aren’t alone. All of these are mitigating factors against mental illness and suicide.

Intuitively, this makes sense. But the finding that I think is more worth examining is why GSAs are potentially tied to lower suicide rates in heterosexuals. First, a disclaimer: It is worth noting that this study is correlational, not causational. In other words, while lower suicide rates and GSAs appear to be related, the lower suicide rates may not be a direct result of GSAs. Indeed, it is possible that there are more GSAs because of lower suicide rates, or that a third factor (such ass wealth of a school district, education attainment of parents, etc) is tied to both GSAs and lower suicide rates.

However, the fact that both of these items seem related (regardless of the relationship) begs the question: What is the relationship between a more tolerant society for everyone, not just the directly affected groups?

This is one worth thinking about, because it can help change the frame of how we view ideals like inclusion an tolerance. We often have conversations about how they can positively impact effected groups – how marriage equality leads to better lives for LGBT individuals, how a lack of racism can improve the lives of impacted groups, etc.

But I want to change that perspective for a second.

I certainly think I’m not a racist person, and I can’t imagine what it is like to be that way. Being racist means you walk around which large chunks of anger, bitterness and resentment inside you all the time. Doesn’t that lead to higher levels of depression, of anxiety, and self-destructive behaviors?

That’s what I want to know. And it makes me wonder if more studies like this aren’t available – ones which show that a more tolerant and more inclusive society is better for everyone, not just affected groups.

As always, I’d love to hear your thoughts, your experience and if more research is available which proves or disproves this theory. Please let us know what you think in the comments below!

 

The disproportionally high levels of suicide among (some) minority groups

It’s been written repeatedly, and it’s true: One of the most likely demographic to die by suicide are middle aged, white men. But, as a recent report in USA Today helps illuminate, we shouldn’t confuse this reality with the notion that white men are the most at risk – or that other groups don’t need very real assistance.

USA Today’s story, which was published earlier in the week, came with this stark headline: Suicide Rate for Native American Women is up 139%. Native American and Alaska Natives have a suicide rate 3.5 times higher than the lowest group – an astonishingly high number.

The story highlights a very, very ugly truth: In mental health – just like in health care generally speaking, unfortunately – minority communities have it worse. But, in the case of suicides, not every minority community is this way. For example, suicide rates among African Americans and Pacific Islanders have increased, but remain roughly half the rate of suicides as whites, according to the American Foundation for Suicide Prevention:

suicideRatesByEthnicity.png

Meanwhile, according to the Suicide Prevention Resource Center, rates of suicides among Hispanics also remain far below the United States average, with Hispanics dying by suicide at a rate of slightly more than half of the rest of the United States population.

This is good news, of course, and a very rare bit of good news when it comes to health care for black and Hispanic communities. What drives these rates lower? There are many theories, primarily the idea that strong family and community support provide a degree of resilience not available in other cultures, as well as the idea that self esteem and religiosity rates are higher among African Americans.

All of these factors may tie into why other minority groups have higher rates of suicide. LGBT community members are three times more likely to die by suicide. On average, LGBT members as well as Native Americans, have lower levels of self esteem, community support and family bonds.

In total: The minority suicide rates are not what they would reflexively seem to be. That’s something for all of us to keep in mind as we deal with public policy and suicide.

Yes, people really are this stupid about mental illness and suicide

Sometimes, I find myself falling victim to the availability heuristic, and if you read this blog on a regular basis, I bet you do too.

For those of you unaware, the availability heuristic is defined as: “A mental shortcut that relies on immediate examples that come to a given person’s mind when evaluating a specific topic, concept, method or decision. The availability heuristic operates on the notion that if something can be recalled, it must be important, or at least more important than alternative solutions which are not as readily recalled.”

Why am I mentioning this now? Well, if you read this blog, I’m guessing you have an interest in mental health and mental illness. It’s probably a subject you follow closely and in which you are are well educated. I bet you have more evolved views on the causes and symptoms of mental illness and understand it’s complexities. And, I’d bet that the vast majority of people you interact with feel the same way.

Ahhhh, dear reader, allow me to share portions of an Email I just received. Among it’s gems:

  • “People commit suicide because they lack hope. True hope comes from putting your trust in the Lord Jesus Christ.”
  • “A troubled person who believes in evolution and does not know anything about the Bible, may turn to suicide as an escape.”
  • “If you want to reduce suicide, introduce the Bible back into school and stop teaching the fairy tale of evolution.”

First, a disclaimer, and let me make it crystal clear: The purpose of this entry is not to mock anyone’s faith or sincerely held beliefs. Rather, it’s to point out an absolutely ridiculous example of thinking. Faith absolutely assists some in the fight against depression and hopelessness. That’s wonderful. If that’s something which may work for an individual, I highly, highly encourage them to find a method of counseling which fits their views on religion, God and spirituality.

But the notion that prayer, Jesus or teaching creationism will cure depression and suicide for everyone is absurd.

Mental illness is highly complex. It often requires time, resources and multiple, simultaneous methods of treatment and lifestyle changes in order to fully address and treat. There is no one size fits all bullet. But what absolutely will not help is judgmental statements like the above, or the adherence to a one-sized fits all approach.

I’d also challenge anyone who makes a statement about reducing depression, mental illness and suicide to make sure that their comments are backed up by research. As I’ve noted in previous entries, there is a complex relationship between religion and mental illness, but as best I could find, there is ZERO relationship between teaching evolution and mental illness. Someone correct me if I’m wrong.

We’ve made great strides in the area of mental illness of late, but we still have a long long way to go. And absolute statements like the ones made above will do nothing but drive people further into the shadows.

There are people this uneducated out there, and I hope this is something we can all remember.

Five horrifying statistics about suicide today

As I wrote earlier this week, we’re in a bad way when it comes to suicide as a nation. Suicide rates are rising – badly – and we need to do more to address this ongoing crisis.

We need to have a better understanding about where we are at when it comes to suicide as a country. To that end, here are five things you should know about suicide in America, 2019.

Suicide rates are at near fifty year highs. After hitting lows in the late 1990s, suicide rates began to climb again. They are now at rates which haven’t been seen in fifty years, and have increased 33% since they hit their lowest point in 1999. More than 47,000 Americans died by suicide in 2017, making suicide the 11th leading cause of death in the United States. The number is so high that it has actually begun to drag down the average life expectancy of Americans.

Gun ownership and suicide rates are directly related. This isn’t to say that gun owners are more likely to kill themselves, but it does show a direct relation between the means of suicide and actual suicides. One study revealed that suicide rates are higher in states with high rates of gun ownership, and lower in states with lower rates. Another showed that firearms account for roughly half of all suicide deaths.

For every completed suicide, there are twenty-five attempts.

Women are more likely to attempt suicide, but men are more likely to complete it. This is, in part, due to the method by which each gender typically attempts suicide. Women are more likely to attempt suicide by drug overdoses and other less violent means, giving rescuers a greater opportunity to reverse suicide attempts. Men are more likely to use firearms and asphyxiation related methods, which are typically harder to reverse.

Suicide rates are highest in the Mountain West states, and lowest in the Mid Atlantic. According to the CDC, the states with the highest suicide rates are Montana, Alaska, Wyoming, New Mexico and Idaho. States with the lowest rates are New York, New Jersey, Massachusetts, Maryland and California.

If you are looking for more information about suicide, I highly recommend you visit the American Foundation for Suicide Prevention’s website. After all, the only way to stop a problem is to fully understand it.

Suicide rates are rising in girls – with the highest rise among ages 10-14

I guess I should warn you ahead of time, but this entry has some absolutely brutal statistics. For those who may be disturbed by such content, please note that the following blog entry will review information on suicide, including methods.

A new study which appeared in JAMA examined whether or not the gap between suicide in boys and girls was narrowing. Broadly speaking, while women are more likely to attempt suicide, men are more likely to complete it. This is for a variety of reasons, but the most obvious one is that men typically use more violent means to commit suicide, and are thus less likely to be saved by medical professionals.

The results of the JAMA study were disturbing. It examined 85,051 suicides of children and teenagers, ages 10-19, between 1975 and 2016. The most painful result:

Following a downward trend until 2007, suicide rates for female youth showed the largest significant percentage increase compared with male youth (12.7% vs 7.1% for individuals aged 10-14 years

From the conclusion of the study:

A significant reduction in the historically large gap in youth suicide rates between male and female individuals underscores the importance of interventions that consider unique differences by sex. Future research examining sex-specific factors associated with youth suicide is warranted.

Further examination of the data reveals that the rate at which women were using hanging and suffocation for suicide were approaching the same rates as men. In other words, girls are starting to use more lethal means to kill themselves, a highly disturbing trend, and one that will lead to additional deaths.

A key and tragic consideration to keep in mind when it comes to suicides is that, for every death by suicide, there are an estimated 25 attempts. A rise in use of more lethal means of suicides means that more suicide attempts will result in death.

To put the above statistic another way: If every suicide attempt led to a death, we’d lose approximately 1,175,000 people every year.

Unfortunately, none of this information is all that surprising, though it is deeply disturbing to know that more 10 year olds are killing themselves at accelerating rates. A study which came out last months showed that the number of children going to the emergency room doubled between 2007-2015. Suicide is the 2nd leading cause of death of 15-34 year olds in America, and rates of mental illness are rising among young adults faster than any other age group.

Clearly, our young people are under more pressure than ever before, and clearly, we are failing them if we don’t do a better of job of addressing this crisis.

Back to the study above. One of the things I’d like to focus on – at least when it comes to trying to reduce this gap – is means reduction. If young girls are starting to use more violent means for suicide, we must do a better job of determining why, and what, if anything, we can do about it. There are public policy options when it comes to guns, but I’m not sure what you can do, if anything, when it comes to suffocation or hanging.

We have to do something. The only way to guarantee failure is not try anything.

Report: Netflix’s 13 Reasons Why tied to rise in suicides

13 Reasons Why started as a book and then made it’s way to a Netflix series. From the summary:

Clay Jensen returns home from school to find a strange package with his name on it lying on his porch. Inside he discovers several cassette tapes recorded by Hannah Baker—his classmate and crush—who committed suicide two weeks earlier. Hannah’s voice tells him that there are thirteen reasons why she decided to end her life. Clay is one of them. If he listens, he’ll find out why.

Clay spends the night crisscrossing his town with Hannah as his guide. He becomes a firsthand witness to Hannah’s pain, and as he follows Hannah’s recorded words throughout his town, what he discovers changes his life forever.

The series on Netflix generated no shortage of controversy when it graphically depicted the suicide of Hannah. At the time, there was concern that the depiction of suicide may encourage other vulnerable young adults to do the same.

A new report suggests those fears were well founded.

The brutal findings, courtesy of a study conducted by the Journal of the American Academy of Child and Adolescent Psychiatry:

The Netflix show “13 Reasons Why” was associated with a 28.9% increase in suicide rates among U.S. youth ages 10-17 in the month (April 2017) following the shows release, after accounting for ongoing trends in suicide rates, according to a study published today in Journal of the American Academy of Child and Adolescent Psychiatry…The number of deaths by suicide recorded in April 2017 was greater than the number seen in any single month during the five-year period examined by the researchers.

The study notes that suicide rates spiked during the promotion for 13 Reasons Why and in the aftermath of its immediate release, and spiked particularly among young males. Homicide rates – which are influenced by similar cultural and sociological factors – did not show a spike during the same time.

As this Vox article notes, this increase is likely tied to the concept of suicide contagion – the idea that one suicide will encourage more. At least one suicide expert advised Netflix not to release the show:

His fears sprang from the problem of suicide contagion, which is what it’s called when media attention focused on one prominent suicide leads other people who are struggling with suicidal ideation to try to kill themselves. It’s a danger that young people are especially vulnerable to.

To be fair, there are certain concerns with the conclusion of this study. This includes the it’s design (which makes it impossible to rule out other sources) and the fact that boys drove the rise in suicide (girls would have been more expected, given the fact that the lead character is a girl).

This tragic result reiterates an important point: The media and entertainment industries have a moral obligation to be careful with how they discuss and depict suicide.  ReportingOnSuicde.org gives some helpful advice. These include:

  • Avoid glamorizing the death, sensational headlines and showing pictures of grieving and weeping families.
  • Describing the suicide as sudden or “without warning.”
  • Treating suicide as any other crime.
  • Showing or describing the method of death in graphic detail.
  • Using appropriate language, including “died by suicide,” “completed” or “killed himself” INSTEAD of “successful/unsuccessful.”

I never watched 13 Reasons Why, but from what I have read, the show’s depiction of Hannah’s suicide violates all of these rules.

Between the research already done and the study which came out last week, it’s clear that 13 Reasons Why is contributing to an ongoing massive spike in suicide rates – and one that is particularly acute among young adults.

The show should be pulled off the air.

Religion and suicide

About two weeks ago, I was able to participate in a Jewish Federation event on mental health and stigma. The participants included myself, a psychologist, the head of our local NAMI Chapter and a Rabbi. Much of the information I heard during this presentation was things that I had heard before, but the newest perspective actually came from the Rabbi, who discussed what happens with Jews who do die by suicide.

Apparently, in Judaism (like many other religions), a strict interpretation of suicide views the action as a major sin, and those Jews should not be buried in a Jewish cemetery. Thankfully, this Rabbi believes (like many others) that those who do die by suicide are clearly ill at the time of their death; thus, they should not be “punished” for that action and should be allowed to be buried in a Jewish cemetery.

This entire conversation had me thinking about suicide and religion. Are there differences in suicide rates by religion? What about those with no religion – do they have higher or lower suicide rates? How can religion help or hurt someone’s mental health?

The relationship, as best I can tell, is complicated. According to a 2016 study on the subject:

We found that past suicide attempts were more common among depressed patients with a religious affiliation (OR 2.25, p=.007). Suicide ideation was greater among depressed patients who considered religion more important (Coeff. 1.18, p=.026), and those who attended services more frequently (Coeff. 1.99, p=.001). We conclude that the relationship between religion and suicide risk factors is complex, and can vary among different patient populations.

This study would obviously suggest that religion and suicide are positively correlated. But, as a 2017 article from the American Sociological Association notes, the real relationship is more complicated – and that largely depends on where in the world you are discussing:

A Michigan State University sociologist reports in The Journal of Health and Social Behavior that religious participation affects suicide rates differently around the world, and in Latin America particularly, high religious involvement is associated with low suicide rates.

In contrast, in East Asia, where residents are reportedly more secular, higher levels of religious involvement are connected to higher suicide rates. A one percent increase in religious participation is associated with a one percent increase in suicide rates in East Asia.

Statistics for the United States generally follow with the statistics for Latin America, although the link between religious participation and low suicide rates is not as pronounced in the United States.

An interesting 2017 article from the Huffington Post makes a similar argument but from a reverse perspective: That it is atheists, not religiously affiliated people, who have a “suicide problem.”

When I started this entry, I was curious to see what religions have higher or lower rates of suicide. I now see that it’s not that simple. Religion and suicide are related, and that makes sense, of course. On one hand, religion can give people additional joy, purpose and value. Fear of divine punishment can also serve as a powerful motivator to keep people from killing themselves. However, religion can also alter perspectives and force negative value judgments.

My conclusion: The relationship between religion and suicide is complicated and depends on a variety of factors.

As always, let us know what you have to say in the comments below!

No, you cannot “implant” the idea of suicide

One of the great myths of suicide is that you shouldn’t talk about it with someone (particularly younger people) because doing so may somehow “implant” the idea of killing oneself into someone’s head. That’s categorically, unquestionably not true, and I wanted to take a moment to discuss the idea.

The idea that we can unintentionally encourage suicide by discussing it is a frightening prospect because it leaves us powerless. One of the things that many mental health advocates say (and this certainly includes me!) is that we must discuss suicide and mental health. However, there is a persistent fear that discussing suicide may cause someone to consider attempting the act.

There’s good news though: It’s just not true.

There is ample evidence to back up the notion that discussion of suicide doesn’t increase suicidal ideation or attempts; indeed, thankfully, the opposite is true. According to a 2014 review on just this subject:

None [of the studies reviewed] found a statistically significant increase in suicidal ideation among participants asked about suicidal thoughts. Our findings suggest acknowledging and talking about suicide may in fact reduce, rather than increase suicidal ideation, and may lead to improvements in mental health in treatment-seeking populations. Recurring ethical concerns about asking about suicidality could be relaxed to encourage and improve research into suicidal ideation and related behaviours without negatively affecting the well-being of participants.

This is great news, particularly for anti-suicide and mental health programs, as it means that you can talk about suicide without supposedly putting the idea of suicide into someone’s head.

That doesn’t mean, of course, that suicide and mental health can just be discussed in a willy-nilly sort of way; there must be specific guidelines to these conversations.

According to this article from Psychology Today, these conversations can range from casual to serious. Addressing the issue is important, but it doesn’t have to be done in an ultra-serious way. Asking your child about high-profile suicides in the news, asking their thoughts, inquiring about their feelings and state of mind – these are all positive ways of addressing the subject.

The article also does a good job of explaining what to do if someone you know or love says that they have had thoughts of suicide. It notes that many of us have had those thoughts at some point, and that isn’t inherently dangerous. What is dangerous is if these thoughts are persistent, overwhelming or come with specific plans. That’s when more action may be needed.

So, the summary is this: Talk about suicide with your children or others you care about. Do so in a way that is factual and avoids glamourizing the issue, but in a caring and supportive way. This will not encourage the idea of suicide – indeed, it will help prevent it.

It’s important that we have these conversations with people we love, and do so without fear of “implanting” the idea of suicide. This goes for schools, parents – really, all of us.