REBROADCAST / American Diagnosis / Why do people die by suicide?

Hi everyone, Dr. Celine Gounder here. We're back with brand new episodes of Epidemics starting this Friday. Today we have one final rebroadcast from our sister podcast American Diagnosis, formerly known as In Sickness and in Health. The pandemic has pushed a lot of people to the limit. Social distancing has many feeling lonely and disconnected. Skyrocketing unemployment has people worried about losing their homes and how they're going to put food on the table. And of course, there's the anxiety about catching a bad case of COVID Mental health experts are worried that these stressors and more have led to an increase in suicide in America. And alongside all this, Gun sales have gone way, way up. Americans bought nearly 2 million guns in March alone. That's the second busiest month for gun sales on record. In this episode of American Diagnosis, we looked at why people die by suicide and how having a gun in the home increases the risk.

Had I known what I know now, I would have been very worried.

You focus on the most lethal and common method for suicide and you make it less deadly or less available for an attempt. So in the U.S., that's guns.

We lose close to 50,000 of our fellow Americans every year to this very preventable form of death. It's just a shame.

Welcome back to In Sickness and in Health, a podcast about health and social justice. I'm Dr. Celine Gounder. This season, we're looking at gun violence in America. We've spent the last several episodes talking about urban gun violence, specifically the killing of young Black men. But homicide isn't even half the picture when it comes to gun violence in America. 60% of gun violence deaths in the U.S. are suicides. And it's getting worse. The suicide rate in the U.S. has been going up so much that it's actually reduced the nation's life expectancy. This is especially true for middle-aged white men without a college degree, the same group most likely to own a gun. But despite the increasing number of Americans impacted by suicide, it remains widely misunderstood. There are a lot of questions. How can we prevent someone from taking their own life?

If they're less able to act on it, that doesn't solve their misery, but it keeps them alive so we have a chance to help them.

Is suicide impulsive?

To believe that requires an understanding of human nature that is just so flawed.

And who is most at risk?

Gun ownership is this really strong predictor of death by suicide. Mental illness, not so much.

The fear and stigma around suicide makes it a hard issue to tackle in public health, but it's not impossible.

We kind of need to grow up and face fears, and this is killing our loved ones. Killing fellow Americans, killing people around the world, and we need to grow up and do something about it.

Today on In Sickness and in Health, suicide and guns. There's a lot of misconceptions and clichés about suicide, so I want to start off with some basics.

Hello?

Uh, yeah, hi, is this Thomas?

It is.

Hi, Thomas, it's Celine Gounder calling.

Is this still a good time to talk?

So I called Thomas Joiner.

My name is Thomas Joiner. I'm a psychologist, a clinical psychologist. I'm the Robert O. Lawton Professor of Psychology at Florida State University. I study suicidal behavior.

Thomas told me he'd always been fascinated with human nature. That's part of what got him interested in psychology. —that and the opportunity to help people.

The reduction of misery is something that appeals to me. There's a lot of unanswered questions with regard to suicidal behavior.

And that was something Thomas had firsthand experience with.

I've lost loved ones, very close loved ones, to suicide. My dad, for instance. I really had no idea. I was very green at the time. I was a graduate student in clinical psychology, but woefully inexperienced, and I mean, I would have seen something like this coming now with what I know now, but no, I didn't see it then.

His father's suicide wasn't the only reason why Thomas decided to study suicide, but it showed him that the way people tend to think about suicide didn't match his dad's story.

The clichés or sort of things that people just mindlessly say about suicidal people Those things tended not to apply to my dad at all. Things like suicide's a cowardly thing to do. My dad was far from cowardly, on the contrary. And there are other examples too of, you know, suicide's weak. Now, he wasn't weak. Suicide's selfish. He wasn't selfish. And so that was very eye-opening to see all that.

Thomas went on to develop something called the interpersonal theory of suicide.

The theory is, you can boil it down to 3 variables. The idea is that when these 3 things happen simultaneously in one person, well then that person is at risk for death by suicide. So what are those 3 things? The first one we've named perceived burdensomeness. That's kind of a mouthful, it's also pretty obvious what that's about. It's the idea that you're a burden on others. At least you feel that way. That line of thinking leads people to think things like, "Everybody would be better off, I would be better off, my family would be better off if I were gone." The second one is called thwarted belongingness. That's a kind of a long way of just saying you feel really lonely, isolated, Alienated.

The third one is called capacity or capability.

It has to do with the idea that death by suicide is intrinsically hard to do. It's scary, it's highly unusual, it's often painful. And when you think about things like that, to do something like that, you have to have a certain capacity to face fear, face pain. And not everybody has that capacity. So when those three things come together in the same person, that's when they're in that danger zone of very high risk. And many of those people who are in that zone either attempt or tragically die. That's the theory in a nutshell.

Thomas's theory didn't rely on old clichés. He also feels it better reflects what was going on with his father.

Well, his fearlessness, let's start there, was pronounced. He was a Marine. He was a stoic person, not emotionally, but when it came to physicality. There are countless examples of him and me out in a boat in the middle of the Gulf of Mexico, for example, fishing for huge fish, fish that were bigger than that I was at the time. And, you know, when you do stuff like that, physical hardships happen. Things like cuts to the hand and, you know, things like that. And, and that would happen, of course, and he would just be completely unfazed by that. So his physical tolerance, his physical fearlessness was already— that was just a fact about him and had been for decades before his death. In the days and weeks before his death, his social isolation and social withdrawal were marked. And had I known what I know now, I would have been very worried about that. The sense that— this is an interesting thing because the sense of burdensomeness of those three factors in the interpersonal theory, the three being burdensomeness, low belonging, and capacity for suicidal behavior— burdensomeness That can be the hardest to detect. When you withdraw socially, people can see that. When you're physically a fearless person, people can often see that. But when you're feeling like you're a burden, that can be a very interior experience. And I think that was the case with my dad.

Thomas says that he had no idea his father was thinking about suicide. It seemed like it came out of nowhere. But that's not how it is for the person thinking about suicide?

I think there's just rampant misunderstanding. The misunderstanding goes along the lines— the usual narrative is somebody all of a sudden, on a whim, out of the blue, decides on this and does it. My view is that these rarely, if ever, come out of the blue. Opportunity can happen quickly, opportunities to act on a plan or or act using a certain method, those can arise quickly, but that's a different matter than it being impulsive. That's opportunistic.

Thomas says that suicide is simply too scary, too difficult to do on a whim. It takes years of experiences that prepare someone to be able to go through with something, with something so final.

It's rarely, if ever, in the moment. Rather, it's years and decades before in which impulsive individuals are having experiences that teach them physical hardship.

This is why suicide gets talked about sometimes as a, quote, "death of despair." This is a phrase we also hear used to describe alcoholism or opioid overdoses. This phenomenon is hitting middle-aged white people especially hard. Thomas says alcohol and drug use and suicide are interconnected, just not in the way you might think. Take the idea that alcohol makes people impulsive. Someone gets drunk and then suddenly decides to end their life.

That narrative seems very intuitive to the lay public and actually to some mental health professionals. I think it's badly mistaken.

For Thomas, it's more about how alcohol or drug use increase someone's capability for suicide.

If you commit to a lifestyle of something like severe alcohol misuse, or, you know, the same would apply to opioid use, when you reflect on that lifestyle, what it means is hardship, a lot of physical hardship. You get in accidents, you get arrested, you get sick. It also means alienating others around you— loved ones, friends, coworkers. It also means job loss, which in turn has relevance for whether you're contributing, whether you feel like you're a burden on others, things like that.

In fact, Thomas did a study that found that 7 out of 10 people who died by suicide, including some alcoholics, had very little or no alcohol in their systems when they died.

The role of alcohol misuse and other drugs is that they affect lifestyle patterns. They affect people's jobs, they affect people's tolerance for physical hardship decades and years before the suicidal incident. And what's going on at the time in terms of whether they're high or drunk is actually missing the point.

All this isn't to say that just alcoholics and drug users are at risk for suicide. Someone's profession can just as easily engender suicidal capability.

Some of the groups that we've seen that have higher capability is within the military.

This is Mike Anestis. He's a professor at the University of Southern Mississippi. We first spoke with Mike in Episode 14 on the instrumentality of guns.

So ER docs, I think, have a similar situation to the military in that on the one hand, you have a self-selection bias, right? So folks opt into that career knowing that they're going to experience and see certain things. Think about what ER vets are doing to people's bodies and what they're seeing all day long. Think about how often they see death. And then think about how that might impact what they could do to their own bodies.

So people's experiences, from drug use to professions, build up a tolerance to hardship and pain—things that contribute to someone's capability to end their life. But what about mental illness? What role does depression play? Play when it comes to suicide risk.

One of the ways that we've tripped up a bit in the suicide prevention field is that we, we talk about suicide risk broadly rather than looking at the difference between risk for thinking about suicide and risk for attempting or dying by suicide. And so mental illness, for instance, tells us a lot about thoughts of suicide, but almost nothing about suicidal behavior.

One of the reasons why mental illness isn't as good an indicator as some people might think is the stigma around seeking help. A CDC report on suicide found that many people who ended their life did not have a mental illness at the time of their death, or at least they hadn't been diagnosed with one.

And it doesn't mean they didn't have a mental illness. It means they haven't been diagnosed with one. And that tells us that people are not often engaging with the mental health care system or telling us about their thoughts of suicide and thus being identified as at risk.

So if people aren't seeking help for depression or other issues that can contribute to thoughts of suicide—things like isolation, feeling worthless—that means a diagnosis of mental illness isn't as good an indicator for who's at risk for suicide as it may seem.

We're not all that good at knowing that desire is present until someone has died. We are no better now at predicting suicide risk prospectively than we were in the 1950s. It's just about chance.

But there is something else out there, something much more reliable when it comes to predicting who's at risk for dying by suicide: gun ownership.

What I do feel confident saying is firearm ownership and increasing rates of firearm ownership have played a unique and important role in the suicide rate in the United States.

Mike and his co-author Claire Houseman looked at suicide data from the CDC. Then they looked at a bunch of variables to see if there was a correlation with suicide.

We looked at CDC suicide rate data at the state level. We looked at gun ownership levels at the state level, and we considered every single possible confounder we could think of. We entered into the same equation what's the median age, what's the percentage of the population under the poverty line, college degree, military veteran, mean elevation of the state above sea level. It's a strangely robust relationship. How many people in each state had depression, suicidal thoughts, substance use in the past year. All of those things were important too, but firearm ownership gun ownership was still significantly associated with the suicide rate at the state level.

All those variables that Mike and Claire put into their equation, they predicted 95% of the difference in suicide rates between states. They weren't missing much.

One of the misperceptions when I talk about that is people think I'm saying, well, mental illness doesn't matter and it's just about the guns, which I'm not saying at all. Mental illness absolutely matters. That tells us a lot about who's thinking about suicide, and it's vital that we focus on that too. But what it tells us is that mental illness does not explain away the gun association. For regular listeners, this is nothing new.

Just having a gun in the house, even if it's supposed to be for self-protection, puts you at risk to die. This is part of the reason why Mike is arguing to shift the conversation about suicide prevention toward reducing the ability to easily harm yourself.

And so we argue that we should find treatment or prevention approaches that focus on capability And the most obvious one that exists right now is means safety.

Means safety boils down to making a common method of suicide more difficult to access, or at least less deadly.

The reality is owning a firearm dramatically increases the risk of death by suicide. Individuals in gun-owning homes have at least 5 times greater risk of death by suicide. That risk goes up higher when the guns are stored unsafely. These are not debatable points. This is reality. Our country needs to publicly and very clearly articulate the reality of the data, and then promote approaches that are not a threat to the Second Amendment right now, because you're not going to solve firearm suicide without firearm owners, and you're not going to have firearm owners with you if the whole conversation is a debate about the Second Amendment. The most effective thing we can do would be, on a national scale, insisting on safe storage of firearms and temporary removal in times of distress.

Thomas Joiner again.

If that method, whatever it may be, can be made, you know, more safe, if it can be removed from the person's presence, even by a little bit, even by an inch or a foot or a yard, those small differences can maybe translate into the difference between a lethal suicide versus not. Huge difference.

And that small act of prevention could save someone from ever attempting suicide again. Because suicide isn't inevitable. Thomas points to people who went to the Golden Gate Bridge with every intention of jumping to their death, but were stopped.

If that's true, then most of them, nearly all of them, should be dead. The actual truth is that very, very few of them are dead, way less than 10% have died, far less. So in other words, the ones who are alive years and sometimes decades later completely flatly contradicts this idea of inevitability. Means safety works, it's life-saving, and then the effects are lasting. A very important public health message that has a lot of promise to save a lot of lives. We need to get this right or else we're gonna bark up the wrong tree in terms of intervention and prevention. This work is not about my dad anymore. This is about tomorrow people are gonna die and I'd like to stop that.

Rates of suicide in the U.S. are on the rise. A lot of researchers are puzzling over why this might be. But meanwhile, tragically, too many Americans are dying by suicide. Half of those suicides involve a gun. Yes, mental illness is a factor. It's people who are socially isolated and who think they're a burden on others. But it's not just that. Lots of people feel that way, at least at some point or another. They don't all die by suicide. It's the people who have the fearlessness, the know-how, the practice, and the access to lethal means who die by suicide. In this country, guns are by far and away the most readily available and deadly tools out there. Next time, we're going to take a look at a very specific group of suicidal persons: mass shooters. Understanding that mass shooters are suicidal and what sets them apart from others who take their own lives will help us prevent the tragedies that are dominating the news of late. That's next time on In Sickness and in Health.

If someone you know is in crisis or thinking of hurting themself, do not leave them alone. Remove any firearms, alcohol, drugs, or sharp objects that could be used in a suicide attempt. Take them to an emergency room or seek help from a medical or mental health professional. Call the U.S. National Suicide Prevention Lifeline at 800-273-TALK. That's 800-273-8255. Or text the Crisis Text Line at 741741. Another resource for LGBTQ youth is The Trevor Project's Lifeline at 866-825-8255. 888-7386.

Today's episode of In Sickness and in Health was produced by Zack Dyer and me. Our theme music is by Alan Vest. Additional music by the Blue Dot Sessions. If you enjoy the show, please tell a friend about it today. And if you haven't done so already, leave us a review on Apple Podcasts. It helps more people find out about the show. You can learn more about this podcast and how to engage with us on social media at insicknessandinhealthpodcast.com. That's insicknessandinhealthpodcast.com. I'm Dr. Celine Gounder. This is In Sickness and in Health.