From the Editor
“I didn’t know Kate Spade, who hanged herself with a red scarf in her bedroom on Tuesday at the age of 55, other than through the prism of her insistently cheerful and whimsical accessories. But everything about Ms. Spade and her designs suggested a sunny temperament, from her candy-colored aesthetic to the perky image she projected. We have a hard time squaring a seemingly successful woman — one with a highflying career, a family and heaps of money — with a despondency so insinuating that it led her to end it all. All this helps explain why Fern Mallis, the former director of the Council of Fashion Designers of America and a friend of Ms. Spade’s, called her death ‘so out of character.’ In fact, it turned out that the bubbly girl from Kansas City ‘suffered from depression and anxiety for many years,’ as her husband, Andy, said.”
So writes novelist Daphne Merkin The New York Times. In the essay, Merkin writes about her depression and her own suicidal thoughts.
Kate Spade. Then Anthony Bourdain.
It’s been a remarkable few days.
Anthony Bourdain with President Barack Obama
In this Reading, we look at the new CDC report on suicide in the United States. Suicide rates south of the 49thparallel have risen nearly 30% since 1999. We consider the paper and its implications.
Suicide and the United States
“Vital Signs: Trends in State Suicide Rates – United States, 1999–2016 and Circumstances Contributing to Suicide – 27 States, 2015”
Deborah M. Stone, Thomas R. Simon, Katherine A. Fowler, Scott R. Kegler, Keming Yuan, Kristin M. Holland, Asha Z. Ivey-Stephenson, Alex E. Crosby
CDC Morbidity and Mortality Weekly Report, 8 June 2018
In 2016, nearly 45,000 suicides (15.6/100,000 population [age-adjusted]) occurred in the United States among persons aged ≥10 years. From 1999 to 2015, suicide rates increased among both sexes, all racial/ethnic groups, and all urbanization levels. Suicide rates have also increased among persons in all age groups <75 years, with adults aged 45–64 having the largest absolute rate increase (from 13.2 per 100,000 persons  to 19.2 per 100,000 ) and the greatest number of suicides (232,108) during the same period. Suicide is the tenth leading cause of death and is one of just three leading causes that are increasing. In addition, rates of emergency department visits for nonfatal self-harm, a main risk factor for suicide, increased 42% from 2001 to 2016. Together, suicides and self-harm injuries cost the nation approximately $70 billion per year in direct medical and work loss costs.
The National Strategy for Suicide Prevention calls for a public health approach to suicide prevention with efforts spanning multiple levels (individual, family/relationship, community, and societal). Such a comprehensive approach underscores that suicide is rarely caused by any single factor, but rather, is determined by multiple factors. Despite this call to action, suicide prevention largely focuses on identifying and referring suicidal persons to mental health treatment and preventing reattempts. In addition to mental health conditions and prior suicide attempts, other contributing circumstances include social and economic problems, access to lethal means (e.g., substances, firearms) among persons at risk, and poor coping and problem-solving skills. Expanded awareness of these additional circumstances contributing to suicide risk and action to address them can help reach the national goal, established by the National Action Alliance of Suicide Prevention and the American Foundation for Suicide Prevention, of reducing the annual suicide rate 20% by 2025. To assist states in achieving this goal, CDC analyzed state-specific trends in suicide rates and assessed the multiple contributing factors to suicide; this report presents options for strategies to include in comprehensive suicide prevention efforts that are based on the best available evidence.
Deborah M. Stone
So begins a report just released by the CDC.
Here’s what they did:
- The authors drew data from the National Vital Statistics System (which uses death certificate records) across six consecutive 3-year periods, 1999 to 2016, by state and gender.
- Children (age 9 and under) were excluded.
- With data from the CDC’s National Death Reporting System (2015), they considered DSM-5 diagnoses for people in 27 states.
Here’s what they found:
- Suicide rates increased significantly in 44 states; in 25 states, increases were more than 30%.
- In the majority of states, rates increased for men and women (34 and 43 states, respectively).
- The most recent overall suicide rates (representing 2014–2016) varied fourfold, from 6.9 (District of Columbia) to 29.2 (Montana) per 100,000 persons per year. See figure below.
- In 27 states where data was available, 54% of those who suicided didn’t have a known mental condition.
- Demographically: people who died by suicide tended to be white (83.6%) and male (76.8%); many had served in the military (17.8%).
A few thoughts:
- This is a good study.
- While the trend is clear, there is striking variation among the different states. In North Dakota, the rate increased by 57%; in Delaware, only 6%. Nevada, for the record, saw a decline.
- The suicide rate in the United States has fluctuated with time, and seems strongly influenced by economic factors. Consider that in 1932, at the height of the Great Depression, it was 22 per 100,000 (in contrast to today’s rate of 15.4 per 100,000).
- Why the rise in suicide from 1999 to 2016? Obviously, there is no single answer. It should be noted that suicide is a rare event, and that a small shift in actual suicides will have a big impact (statistically speaking). But the rise is strong, and sustained over time. Some of the biggest increases occurred in states like Oklahoma and Montana where drug use, economic woes, and gun ownership are common.
- What needs to be done?
The authors note that many people who suicide have mental illness, and they argue for “the need for additional safety supports, including broader implementation of affordable and effective treatment modalities, such as doctor-patient collaborative care models and proven cognitive-behavioral therapies. In addition, increased access to behavioral health providers in underserved areas is needed, as is expansion of health care systems that integrate physical and behavioral health, with a priority on suicide prevention and patient safety, especially through care transitions.”
They also note half of those who died by suicide have a known mental condition and struggled with relationship problems and other stressors. They call for: “Prevention strategies include strengthening economic supports (e.g., housing stabilization policies, household financial support); teaching coping and problem-solving skills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social connectedness to increase a sense of belonging and access to informational, tangible, emotional, and social support; and identifying and better supporting persons at risk…”
The authors don’t discuss real-world experiments in suicide prevention. There is promising work going on, such as the Nuremberg Alliance Against Depression – a thoughtful, multi-prong strategy including work with community leaders.
- Canadian data doesn’t show this upward trend.
Statistics Canada data:
More recent ICES data, from 2006 to 2012, shows that the suicide rate is basically unchanged.
So, the good news: we haven’t experienced the trend seen south of the 49thparallel. That said, despite the decline in stigma and the record number of prescriptions of psychotropic medications, the Canadian suicide rate hasn’t dropped, and it is higher than in many western European countries.
- As we consider these statistics about suicide, we should never forget that there are people behind the numbers – people like Spade and Bourdain, yes, and also our friends and our neighbours and our family members. Last September, Sean O’Malley, the Senior Media Relations Specialist at CAMH, put together a powerful piece in which 13 members of that hospital’s community talked about suicide. You can find it here: https://www.camh.ca/en/camh-news-and-stories/camhs-13-reasons-why-not. The testimonials are beautiful.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.