Suicide: Myths, Media, and Difficult Discussions

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Q&A

Christine Moutier, MD, Chief Medical Officer for the American Foundation for Suicide Prevention, shared recent survey data and the latest suicide prevention techniques with Psychiatric Times^TM.

Psychiatric Times: Youth suicide has been getting a lot of media attention lately. As the Chief Medical Officer for the American Foundation for Suicide Prevention, would you say youth suicide is increasing? Why or why not?

Christine Moutier, MD: According to mortality data from the Centers for Disease Control and Prevention (CDC), youth suicide rates had been rising from 2007 through 2018. In 2019, we saw the first decreases in rates in over a decade, when youth rates decreased by 5.2% from 2018 to 2019. And then for 2020, during the pandemic, although we do not yet have finalized 2020 suicide data from the CDC, preliminary numbers on the total US suicides (across all age groups) show a further decrease by 5.6% when compared to 2019. However, certain populations (ie, youth and young adults, as well as historically marginalized communities) may be disproportionately impacted by the pandemic and may be experiencing different suicide-related trends than the general population. We need more data to identify trends among youth suicide mortality during the pandemic. It is also worth noting there are fluctuations in suicide rates of all age groups over time.

PT: According to reports, the proportion of mental health–related emergency department (ED) visits among adolescents aged 12 to 17 years increased 31% in 2020 compared with that during 2019. Do you expect to see another rise in the coming years?

Moutier: The CDC report looked at trends in emergency department visits for suspected suicide attempts by age group and sex during 3 time periods during the COVID-19 pandemic. Key findings included:

- During February and March 2021, when compared to the same time period in 2019, there was a 39% increase in ED visits for suspected suicide related concerns among youth aged 12 to 17 years.

- The increase for females aged 12 to 17 years was 51%.

- The increase for males aged 12 to 17 years was 4%.

- Young individuals (aged 18 to 24 years) did not see a similar increase as adolescents.

It is important to note these are not mortality data, but rather ED presentations for “suspected suicide attempts,” meaning likely self-harm (some of which is nonsuicidal), suicidal ideation, and suicide attempts. In general, many suicide attempts never come to medical attention, and some are never disclosed even to peers or parents.

It is also relevant that suicidal behavior is generally more prevalent among girls than boys, while boys suicide death rates are higher than girls. Presenting to the ED for suicidal concerns could be reflective of both higher rates of distress among the 12- to 17-year-old girl population but also could also be a measure of increased help seeking behavior. Average ED visit rates for mental health concerns and/or risk factors for suicide attempts could have potentially increased as adolescent females have been spending more time at home due to physical distancing and remote schooling, allowing them to express mental health distress and talk more about suicidal thoughts and behaviors than ever before, prompting adult figures in their lives to take them to the ED. When help seeking behaviors increase, suicide risk is generally mitigated.

Again, this data does not mean there was an increase in suicide deaths. The takeaway from this finding is that we need to pay attention to our youth regardless of age, gender, race, or ethnicity. We know some youth have higher rates of suicidal thoughts and behaviors (prepandemic), (eg, LGBTQ youth, youth who engage in bullying behaviors, and concerning trends in Black and Latinx youth) and so keeping in mind that there are known higher risk factors that were present before the pandemic is an important consideration.

If there is a young individual in your life and/or if you have pediatric/adolescent patients, now is the time to engage them in open, authentic conversations to understand where a child is with their mental health, and—if necessary—help them get support or treatment customized to their needs. It may be reasonable to utilize mental health services at an earlier stage of symptoms or concern, given the protective effect for suicide risk that mental health treatment and support affords.

PT: Girls aged 12 to 17 are especially at risk, with suspected suicide attempt ED visits 50.6% higher in early 2021. What advice would you give to mental health professionals treating girls in this age group?

Moutier: The difference in suspected suicide attempts between adolescent males and females could be attributed to the possibility that adolescent females disclose suicidal ideation or behavior more than adolescent males. It is also possible that there are differences between the pandemic’s impacts on mental health and suicide risk between the genders. The pandemic’s potential impact on family and parental stress, coping and mental health, social distancing, remote schooling, and other factors may be impacting girls in some unique or disproportionate ways compared with boys. This could relate to how boys and girls are socialized differently, possible differences in baseline social dynamics between girls and boys’ social networks, possible differences in how screen time, social media and video game engagement impacts youth, and their developmental needs being differently disrupted in some way.

PT: How would you like to see emergency psychiatric care evolve in the future to cope with the problem of youth suicide?

Moutier: The CDC’s data from syndromic ED surveillance speaks to the importance of improving suicide preventive care both during and after ED visits. There are evidence-based steps and tools for clinicians and health systems, detailed in the National Action Alliance for Suicide Prevention’s Recommended Standard Care for People with Suicide Risk, that can be implemented in routine medical care for patients, including universal screening for suicide risk, safety planning, lethal means counseling, and providing caring communications that bridge transitions in care.¹ All of these steps are included in an app called ICAR2E codeveloped by AFSP and the American College of Emergency Physicians (ACEP).

It is critical to strengthen care transitions so once individuals leave the ED they do not fall through the cracks, but instead have a seamless transition that keeps them safely recovering well after the suicide attempt or suicidal crisis. It has been shown that caring contacts and follow up with patients after their visit to the emergency department, including 6 to 12 communications over the course of 18 months in addition to treatment as usual, can reduce subsequent suicide attempts by 40% to 60%.² Key resources to assist in strengthening care transitions include Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care.

Suicide is a complex public health problem so we must ensure suicide prevention is infused into community-based settings as well as health systems to carry out prevention activities and interventions that are effective and culturally appropriate.

PT: What are some of the myths surrounding youth suicide?

Moutier: For many complex health issues throughout history, misinformed views tend to promulgate, leading to a multitude of negative effects, deeply stigmatizing the experiences where these health issues are involved. Without science, untruths and stigma continue to thrive.

In the past, before a body of scientific research led to an understanding of what drives suicide risk, many myths prevailed about suicide. These myths not only shaped stigmatized and erroneous views of suicidal behavior but resulted in harshly punitive ideas and judgment of those who experience suicidal thoughts, who attempt, or who ultimately lose their lives to suicide. Now that a multidisciplinary group of scientific fields are shedding tremendous light on the actual drivers of suicide risk, cultural views are changing, bringing an understanding that, while complex, suicide is a health issue.

One myth that may still have echoes in the current day is the erroneous idea that certain individuals are bent on suicide, and therefore very little can be done to change course once someone becomes suicidal. Today, scientific research in a broad range of domains—from neuroscience to clinical research to epidemiology and community/public health interventions—shows that despite its complexity, suicide is 1) a health-related outcome and 2) can be preventable.

Another common misunderstanding might be related to conflation between suicide contagion and asking about suicidal thoughts. One might think if “I ask if someone if they are suicidal, I will put the thought in their head” or “I am going to increase risk,” because they have heard of the concept of suicide contagion, but asking in an open, caring manner will not increase risk. When you ask someone about suicidal thoughts directly, it provides them with the opportunity to share what may have been not disclosed and therefore not been addressed. Whereas suicide contagion stems from unsafe messaging that sensationalizes suicide and details suicide methods through media, social media, or other key moments of messaging, such as during the postvention period after a suicide has occurred.

PT: You recently participated in a World Suicide Prevention Day Facebook Live Event. Can you share with us what you thought were some of the most important discussions of the day?

Moutier: AFSP hosted an 8-hour livestream for World Suicide Prevention Day on September 10, and we heard from musicians, celebrities, and experts that elevated the conversation about supporting one another; the power of safe, effective self-disclosure by a number of influencers; and about some important initiatives going on in suicide prevention. For example, a conversation between AFSP’s CEO Bob Gebbia and policy makers highlighted the important opportunity for transforming our national crisis response system with the implementation of 988, which will go live July 2022. I spoke with our partners at the American Academy of Pediatrics and the National Institute of Mental Health about our national youth suicide prevention blueprint, which will be released in early 2022. It will engage pediatricians in the important role they have to play in preventing youth suicide.

PT: One of the other panels you attended was on music and mental health. Do you think music is integral in mental health care, and why? How can psychiatrists leverage the powerful effects of music to help their patients?

Moutier: The music industry is engaging with the topic of mental health and suicide prevention in some very positive ways. For example, AFSP has partnerships with Audacy, a global radio network, as well as Universal Music Group, which is hosting opportunities for musicians to discuss mental health and coping as a way to inspire their followers to become more proactive about their own mental health. Music can also be a beneficial outlet for individuals who are experiencing depression or struggling with their mental health, as it provides an opportunity to process overwhelming emotions as well as communicate how they are feeling through safe and creative expression. Sometimes music resonates with listeners, lets them know that they are not alone in how they are feeling, or alone in what they are going through. That can provide immense comfort.

Music is a fantastic tool for improving patient outcomes, and research has shown us it can be extremely beneficial in treating mental health conditions like depression. Psychiatrists should consider incorporating music as a topic for example related to a patient’s Safety Plan for internal coping, as a way to distract from suicidal thoughts, and to tap into healthier coping strategies.

PT: The Netflix drama “13 Reasons Why” put the spotlight on youth suicide in the media. Do you think shows like that help youth recognize they are not alone and should seek help?

Moutier: The portrayal of suicidal struggles and suicide is complex, and research shows that viewers respond to entertainment content in a variety of different ways. The same content that can lead to increased awareness and interest, and even empathy in many, can also lead to worsening of mood, anxiety, or self-image, or even increased suicide risk for others who are vulnerable or struggling. Research also shows that for individuals who have certain vulnerabilities—either related to their present mental health, or past experiences, especially trauma—some of those individuals have a special susceptibility to identification with others they see struggling in similar ways. If the vulnerable individual sees a fictional character struggling and then dying by suicide, especially when portrayed graphically or in a manner that glorifies the death or the decedent, the vulnerable viewer can become more at risk of imitating this suicidal behavior.

The Annenberg Inclusion Initiative, in collaboration with AFSP, released a study in 2019 on the portrayal of mental health and suicide in film and television, which found that it is sparse (1.7% of speaking roles appearing in film and 7.1% on television, versus 20% of the American public who we know have a diagnosable mental health condition), and portrayals tend to be extremely distorted, showing a grave misunderstanding of mental health and the experiences patients have living with psychiatric illnesses. This misrepresentation includes frequent derogatory name calling, inaccurate linkage to violent behavior, and an overall lack of understanding about the experiences of individuals with mental health conditions. We know most people with mental health conditions live full lives, but this is not shown in most television programs or in movies.

PT: If a patient starts discussing shows, music, or other media around suicide, should clinicians consider that a warning sign?

Moutier: Absolutely, I would hone in and explore that further. It is possible that it is an avenue for them to begin discussing their own suicide risk factors such as past trauma, family history of suicide, or prior suicidal thoughts or attempt. Exposure to another’s suicide or to graphic or sensationalized accounts of suicide is a risk factor too. If a patient starts discussing their exposure or accounts of suicide in shows, music, or other media, I would encourage asking about their connection to the content or artist and probing for possible suicide risk factors. Consider it an appropriate time for a reassessment and formulation of suicide risk. To learn more about how to do that, Drs Pisani, Stahl, and I cover that in our recently released clinical handbook, Suicide Prevention: Stahl’s Handbooks.¹ 

PT: September is National Suicide Prevention Month. What are some ways people psychiatrists and other mental health clinicians can get involved this month to help put a stop to suicide?

Moutier: In observance of National Suicide Prevention Month, there are a multitude of ways everyone including psychiatrists and other mental health clinicians can help prevent suicide, including:

- Adding crisis resource numbers to your patient resources, to your own cell phone, and encouraging loved ones to do the same, so that it is ready when/if you need it.

- Considering additional training in Safety Planning, Lethal Means Counseling, and other brief risk reducing interventions.

- Encouraging your health system’s leadership to engage in system-wide suicide prevention policies and practices.

- Advocating for mental health and suicide prevention policies at the national, state, or local levels that ensure everyone in your community has access to mental health care, suicide prevention training, and funding for local crisis resources.

- Getting involved with your local AFSP chapter and helping transform your community into one that is smart about mental health, where everyone has support when they need it.

Additionally, AFSP provides opportunities for everyone to get involved with the organization and raise awareness for suicide prevention within their community, including joining a local chapter, participating in a community walk, and creating a suicide prevention awareness and fundraising event.

To see more of Dr Moutier’s thoughts on suicide, watch Concerning Trends in Suicide.

Dr Moutier is Chief Medical Officer, American Foundation for Suicide Prevention, New York, NY.

References

1. Moutier C, Pisani A, Stahl S. Suicide Prevention: Stahl’s Handbooks. Cambridge University Press; 2021.

2. Luxton DD, June JD, Comtois KA. Can post discharge follow-up contacts prevent suicide and suicidal behavior? A review of the evidence. Crisis. 2013;34(1):32-41.