Today suicide ranks as the 10th leading cause of death in the United States. But in Vermont it’s the eighth leading cause of death. In recent years in Vermont, people have died by suicide at a rate more than 35% higher than the national average.
With the recent deaths of high profile celebrities like Kate Spade and Anthony Bourdain, as well as a recent Centers for Disease Control and Prevention (CDC) report that shows a significant rise in depression and suicide, questions and fears about suicide abound.
Read or listen to the conversation with Thomas Delaney, PhD, assistant professor in the Department of Pediatrics at the University of Vermont Larner College of Medicine and a researcher based in the Vermont Child Health Improvement Program.
What is the incidence of suicide today? Is this really a growing crisis?
Thomas Delaney: Absolutely it is. The CDC recently released a report that got a lot of media attention. It showed that nationally there’s been a pretty substantial increase in suicide death rates: over 20% nationally in the past 20 years.
Vermont is one of the two states with the greatest increases in suicide deaths in the past 20 years. So that’s obviously very eye opening. Those of us who are following suicide trends in Vermont, we kind of knew it anyway. Seeing it come out from CDC and seeing just how bad it was, was really eye opening.
Why is the suicide rate higher in Vermont?
Thomas Delaney: Well, everybody is unique. You could look at 10 different people who died by suicide, and by speaking with their family members and coworkers, you might get 10 different stories. It’s really tricky.
What we try to do as researchers is to understand patterns. There are certainly some things that correlate with Vermont’s very high suicide death rates. These are demographic factors, and they’re things that are generally true for the population. They’re not true for every individual person.
When we think about the things correlated with high suicide death rates, Vermont has really high rates of firearm ownership. We know from recent research that where more people own firearms, or where it’s easier to purchase firearms, there tends to be a slightly higher suicide death rate.
Vermont also has a fair amount of rural poverty. Nationally there is a correlation between states being more rural, and also owning more firearms, and having higher suicide death rates. Poverty, especially rural poverty appears to be correlated, more so than urban poverty, with higher death rates by suicide.
But, Vermont is consistently listed as one of the healthiest states? How can this be?
Well, a couple of ways that we’re not healthy are really, really high rates of binge drinking, and really high rates of other daily substance use … marijuana use, other illicit drugs, what have you. We know from the research that a lot of the people who die by suicide, very often they have alcohol and other substances in their systems.
What we think is happening there is that people who might be experiencing depression, or having sort of urges towards self-harm, are using substances more and it makes them more likely to act on those urges. If you’re somebody who is thinking about suicide as a solution, and if you are using substances more than usual or you become intoxicated, you’re probably more likely to act than you would otherwise be.
You probably know this, but veterans are at a higher risk of dying by suicide. Veterans die by suicide at about twice the rate as non-veterans in the adult population. And Vermont actually has a really, really high proportion of people who are veterans. Either National Guard veterans or one of the five uniform services. And that’s actually a correlate for us. We have a lot of people who served multiple tours in Iraq and Afghanistan, and they may be at higher risk for harming themselves.
The last thing that I think often surprises people is just how white we are. Nationally, having white as your ethnicity or your race is actually associated with greater suicide death risk than being a member of a minority group. Vermont’s still 94%, 95% white.
What are some factors that put people at risk for suicide?
Thomas Delaney: Again, everybody’s different, so people will address or respond to adversity and bad circumstances in very different ways. But the number one risk is actually having mental illness. There’s a whole cluster of things that are associated with increased suicide risk: People who have a history of depression or severe depression, people who have a history of psychotic episodes, or psychotic disorders, where they have trouble regulating their thoughts or keeping a sense of reality. People with severe and persistent mental illness of many different kinds, people who are in recovery from long-term substance abuse, people who have anxiety, people who are survivors of trauma.
This is where I can make a plug for the American Foundation for Suicide Prevention, AFSP. They have a fantastic website with all sorts of resources that you can download for your professional work, for your personal life, things like that.
There are three big categories of warning signs or risk factors.
The first one is just called talk, and it’s focused on the question: is somebody beginning to talk about ending their life? Are they talking about searching for suicide on the internet? Are they talking about hopelessness? Expressing hopelessness, in terms like “My family would be better off without me,” things like that. Hearing something like that is an opportunity for you as friend or a family member, or a coworker to actually engage that person, and maybe say “Hey, are you thinking about hurting yourself?” Try and get a sense if you could help maybe connect that person to some help.
Often times people who are suicidal actually feel great relief at being asked, because they’re not being asked. If you can engage someone that you’re actually concerned about, they may actually disclose to you that they have been thinking about hurting themselves. And that’s an opportunity for you then to maybe reach out and call a crisis line or crisis text line, or something like that. I will briefly just go through the other two.
Another one is changes in behavior. A classic situation would be increased use of drug and alcohol and other substances. Saying goodbye to people, giving away possessions, things that indicate that someone has had a shift in their thinking. Maybe they’re not planning for their future or they’re physically acting out as if they don’t have a future. It could even be something like increasing reckless driving, which is kind of a big warning sign.
Very often what clinical psychologists and psychiatrists and counselors are looking for is changes from the norm. You might normally be a reckless driver, but if you come home one night and you’re telling people about all the crazy stuff you did, maybe that’s something to follow up with. Because changes like that can be indicative of a changed mindset for the worse.
The last category is changes in mood. This one’s kind of obvious, but if somebody normally doesn’t seem depressed, or if they seem sort of mild or moderate depressed, and they’re getting worse – they seem visibly more depressed. Maybe they’ve changed their hygiene, they’re verbalizing things that are more depressive, they’re not engaging in their normal activities, things they used to enjoy. That’s a big warning sign for depression and depression is correlated with suicide attempts and suicide deaths. It’s something worth following up on.
As for anxiety, people often experience anxiety in their normal day-to-day life. But if somebody seems like they’re verbalizing or they’re physically just a lot more anxious and that’s lasting over time, this can be a sign that you should follow up with somebody.
Another is shame. My sense is that this is actually more of a thing for men, often times when people maybe come in contact with the criminal justice system, or there are negative things that are depicted about them publicly, or in their circle of friends. Shame could be a huge trigger for somebody who already might tend towards harming themselves to really act out and actually try and harm themselves, including trying to take their life.
In what ways is suicide different for young people?
This is actually a piece of good news. In Vermont and nationally, this is true – a lot fewer young people actually die by suicide. Across all ages, there are about 25 suicide attempts for every death. And that’s good news, because it means that most people that attempt suicide don’t actually die by suicide.
Most people survive their attempt, go on to recover from their attempt and do not die from suicide later on. Younger people actually have really high survival of suicide attempts. We know from statewide surveys, like the Vermont Youth Risk Behavior Survey, that it’s not that rare for young people to report having contemplated suicide and actually making a suicide plan. Then a small fraction of young people who do the survey will say they actually made an attempt in the previous 12 months.
The relatively good news about that is that young people seem to be surviving when they attempt, more often than adults. Obviously, it’s tragic every time somebody dies by suicide. Most of the deaths that we actually see in our state are among men. And mostly among men that are middle aged and older actually.
How is Vermont addressing the growing suicide rate?
Thomas Delaney: Vermont has really activated around suicide, more so in the last few years. That’s for a bunch of reasons, including the fact that our numbers are so bad.
There has been a big push in primary care to increase screening for depression. That’s probably pretty helpful for detecting people who are at risk for suicide. The simple fact that young people and their pediatricians or family medicine providers are actually having conversations about their risk factors is encouraging. And primary care providers, I think, are becoming more competent and confident about then connecting young people to services, and older people as well.
But I think it’s something that is more on the mind of healthcare, and even mental healthcare providers, than maybe it was four or five years ago. There’s a really cool initiative called Zero Suicide in Vermont. In three of our community mental health agencies in the state, they’re actually implementing this evidence based system, where they’re trying to redesign how they provide care, in order to do a better job of identifying people. This includes finding and assessing kids who are at risk.
Literally hundreds of mental health professionals in this state have been trained in the last three or four years on a couple of different approaches for how to identify and then work effectively with young people and adults who are at risk for harming themselves.
Another thing I would add in this area is that Vermont has trained hundreds and hundreds of people, who are not health care providers, to be suicide prevention gatekeepers. The idea there is that anybody, you don’t have to be a psychologist or a physician, but anybody could have a set of really basic skills that would enable you to help somebody if you became concerned about them.
One example is SAG, which is not a great acronym. But SAG would be used if you were concerned about somebody, a coworker or family member, whoever, you could show you care. This first part is “Say.” You can say, “Hey, I you know, I’ve noticed that things seem really hard for you. And I just want let you know that I’m thinking about you.”
The next part is “Ask” as in, ask a question: “Have you thought about harming yourself? Have you been thinking about suicide, because that’s something that I’m just wondering about?”
And then the G in SAG is: “Get help.” Getting help could be something as simple as encouraging the person to call the National Suicide Prevention Lifeline, to contact the crisis text line, to actually reach out to a counselor or a school-based mental health professional. Somebody like that who could actually do the work of assessing the person to see if they really are at risk.