How Suicide Quietly Morphed Into a Public Health Crisis

https://www.nytimes.com/2018/06/08/health/suicide-spade-bordain-cdc.html

Version 0 of 1.

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.”