Diagnosing Self-Destruction

Suicide kills twice as many people as murder each year in the United States, and rates in the military recently surpassed those among civilians. But while scientists have identified some risk factors for suicide being white, being male, substance abuse, mental illness — they still have little idea what spurs people to take their own lives.

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IRA FLATOW, HOST:

This is SCIENCE FRIDAY. I'm Ira Flatow. When celebrities and public figures commit suicide, you hear a lot about it on the news. People like hactivist Aaron Swartz, fashion designer Alexander McQueen, writer Hunter Thompson. But who we don't hear about is everyone else because, as one of my next guests writes, on an average day more than 100 Americans take their own lives.

That's a lot if you consider that the murder rate is just half the suicide rate. The grim news doesn't stop there. In 2012, more U.S. soldiers died by suicide than died in combat in Afghanistan. And why is that? That's what researchers are trying to figure out and so far, they've identified certain groups that are at higher risk of suicide - like white males, substance abusers, people with mental illness. But they say we're still not very good at predicting who will actually commit suicide and when.

Can we get better at that to prevent some of those deaths? That's what we're going to be talking about for a good part of the hour. And if you'd like to join in our conversation, our number is 1-800-989-8255. That's 1-800-989-TALK. You can also Tweet us @scifri. Go to our website at sciencefriday.com. Let me introduce my guest. Matthew Miller is associate professor of health policy at the Harvard School of Public Health in Boston.

He's also co-director of the Harvard Injury Control Research Center. He's here with us in New York. Welcome to SCIENCE FRIDAY.

MATTHEW MILLER: Thank you.

FLATOW: Jane Pearson is chair of the Suicide Research Consortium. That's at the National Institute of Mental Health, part of NIH in Bethesda. Welcome to SCIENCE FRIDAY.

JANE PEARSON: Thank you.

FLATOW: And also, Matthew Nock is professor in the Department of Psychology at Harvard in Cambridge. Welcome to SCIENCE FRIDAY, Dr. Nock.

DOCTOR MATTHEW NOCK: Thank you for having me on.

FLATOW: Matthew, let's talk about this. How much do we know about why people commit suicide? Is there even something that you can study scientifically? Matthew.

NOCK: Which Matthew?

FLATOW: Oh, Matthew Nock. I'm sorry. Two Matthews. That's right. Matthew Nock, I'm sorry.

NOCK: So what do we know about why?

FLATOW: Yeah.

NOCK: We know there's no simple answer, and as you were highlighting, we have identified risk factors for suicide, so we know that in the U.S. people who are white, people who are male, people with a mental disorder, people with a family history of suicide or mental disorders, are at higher risk. What we haven't done yet is developed an understanding of why it is that people with these characteristics are at high risk.

Taking this - approaching this from another angle, when we ask people who have tried to kill themselves but survived, whether they're in the emergency department or in the hospital, why they tried to kill themselves, to try and get an understanding of this problem, the primary, the number one explanation that people give is they're trying to escape.

They're trying to escape from some seemingly intolerable situation. They feel trapped. They perceive this situation is unbearable and it's going to go on forever and so they're trying to get out of a bad situation rather than to die.

FLATOW: Matthew Miller, you had a paper out last week on guns and suicide in the American Journal of Epidemiology. Tell us what you found.

MILLER: What we found was that the strongest predictor of how likely somebody is to die by suicide in a given state depends on whether they live in a home with a firearm. Broadly speaking, rates of suicide across the United States vary threefold. The distribution of suicide, the frequency at which people are killing themselves in the United States, is not related to the rates at which they have major depressive disorder, the rates with which they have substance use disorder, the rates with which they're even attempting suicide, because those rates are all by and large pretty similar from state to state.

But what determines the suicide rate in a given place is the prevalence of household gun ownership. States which have higher levels of household gun ownership have much higher rates of suicide, almost entirely because they have higher rates of firearm suicide. The rates of non-firearm suicide are really not all that different, by and large, across the 50 states.

FLATOW: So if you have a gun in your home, chances are higher.

MILLER: If you have gun in the home, your chances are two to fivefold higher that you're going to die by suicide, and the risk does not only reside within the gun owner. It is imposed on all members of the household. The study that we looked at was what's called an ecologic study. It looked at rates in a state, and it mirrored very closely what has been found in case control studies, studies that actually look at the people who have died and ask questions about do they have mental illness, do they have substance abuse disorders, do they live in a home with a gun, and compare them to people who did not die by suicide.

FLATOW: If they had their guns locked up in a case, you know, took two or three steps to get to the gun, did that make any difference?

MILLER: That wasn't something that we addressed in our study, but there was a really brilliant study by a David Grossman, and what he did was he said let's look at homes with guns, and I'm going to look at people who died by suicide and lived in homes with guns and compare them to like people who lived in homes with guns but did not die by suicide. And what he found among teenagers was that the way you stored a gun really mattered. If you stored a gun loaded and unlocked, the likelihood of a teenager dying in that home was much higher, threefold higher, than if you stored the gun unloaded and locked away.

FLATOW: So let me ask all of you. Does that mean that it's - death by suicide with a gun is something that's impulsive, that more likely it's an impulsive thing?

MILLER: Well, it certainly can be. I mean suicidal acts are heterogeneous and so there are some people, let's say somebody who's dying by cancer or Lou Gehrig's disease, where a suicidal act might be more deliberative. But we know that many suicidal acts are in fact impulsive and that the suicidal crisis is fleeting. The vulnerable period can be as short as five minutes. There was a study done that looked at all - people who came to an emergency room and were saved by dying at their own hands because of heroic measures, a nearly lethal suicide victims.

And they asked these people how long did it take between the time you decided that's it, I'm going to kill myself and the time you acted? For one out of four of these people it took less than five minutes. For half it took less than 20 minutes and almost three out of four it took less than an hour. That window of vulnerability closes very quickly and so if that - if you can prevent somebody from reaching for something that's highly lethal during that vulnerable period, and instead they reach for something much less lethal, like pills or cutting, the chances they're going to survive are 100 times higher.

And the last point in this is that if you survive a suicide attempt, even with a gun or jumping in front of a train, the chances you're going to go on to die by suicide thereafter is less than one in ten. The prognosis is good if you survive, which is why it's so important to keep people who you can't prevent from attempting from dying in an act.

FLATOW: And since guns are very lethal, chances are if you use a gun you're going to die, but if you try some other method and you fail, then you're going to survive to go on to live a longer life.

MILLER: You don't get a second chance when you use a gun and you do when you use many other methods, yup.

FLATOW: Jane Pearson, how good - once we talked about going to the hospital following a suicide attempt - how good is our support system in hospitals and clinics and so on to help people who are thinking about suicide?

PEARSON: That's something we would really like to know more about because we don't have a lot of large healthcare systems that are all connected with medical records in an electronic way and then those are connected to death records or even information on who can - who does make an attempt. We're kind of guessing. We have some small studies, we have information from the Veterans Health Administration that has electronic records, and we're slowly encouraging more researchers and healthcare systems to take a look at this.

And that's something really critical because that's something the United Kingdom has learned, that if you improve quality of care, you can save lives.

FLATOW: Matthew Nock, you've been working with a test called the implicit association test, to see whether or not it could predict someone's risk of suicide. Could it?

NOCK: Our preliminary results suggest that it does do a pretty good job at predicting who makes a suicide attempt in the future. And so what we've done is modified the implicit association test, which is a brief, about five-minute measure of how people think about different things. And it's often used to measure how people think about those in different races and different ages, and so on.

And we used it to measure how people think about suicide. And when we administer it - the idea here is people who are suicidal often don't want to tell us that they're suicidal, or they actually say they're not suicidal. One study found that about 80 percent of people who die by suicide in the hospital explicitly denied suicidal thoughts or intent right before dying. So we can't just rely on what a person's telling us.

So what we've been trying to do is develop behavioral tests, reaction time tests that can be administered in clinical settings - like an emergency department or primary care office - and use that test to measure how someone's thinking about suicide, and use it to try and improve prediction.

FLATOW: Why is it we hear so much about murders and things on the news, but we don't hear about suicides so much?

NOCK: I think it has a lot to do with stigma. I think suicide is something that people still don't like to think about, don't like to talk about, and so, as a result, people, you know, society doesn't know a lot about it, and not enough research has focused on it.

FLATOW: Yeah, but the suicide rate is twice the murder rate.

PEARSON: I think some of it might be by design, because there are some, you know, studies showing that the more you report on this in ways that glorify it and so on, I think it does make some reporters and some editors concerned, and rightly so. So the challenge is how to report on it in a safe way that still informs the public, but doesn't increase any risk, because there truly is contagion. And sometimes it takes a longer investigation to figure out if it's suicide or not. So it's multiple reasons.

And we're trying to figure out how to describe the problem of suicide without making it worse, because we do know there's some norming that goes with people understanding that this is an option. Just as Matt Nock was saying, people feel like this is a way of solving a problem, when we would really prefer them not to think of this as a solution. So it's a challenge, because we want to have them get help, we want them to be aware, we want their family members to be aware, but we don't want to normalize it.

FLATOW: Now, you wrote in Nature Medicine last year about how little funding compared to other diseases - I mean, not that suicide is a disease - but other diseases that NIH funds, that suicide research gets.

PEARSON: Well, I didn't write it, but it was reported.

(LAUGHTER)

FLATOW: You were quoted. I should have said - you're right. You were quoted in that article.

PEARSON: So we're doing better now than we did at that time. We're a little bit over 40 million at this point, and we're just wrapping up a research agenda, where we're hoping that both the public and private partners who invest in suicide research can work together more. We do now that the Department of Defense has invested heavily in this, and they're going to far exceed our investment in this because of all of the issues in the military.

So what we do want to do is to learn from them, learn from the Veterans Administration that's also invested in this, and figure out a way to leverage all of our efforts so we can make some progress in this area.

FLATOW: All right. We're going to take a break, and when we come back, talk lots more about the psychology of self-destruction. What do we know about predicting suicide prevention? And your calls: 1-800-989-8255. Stay with us. We'll be right back after this break.

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FLATOW: I'm Ira Flatow. This is SCIENCE FRIDAY, from NPR.

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FLATOW: This is SCIENCE FRIDAY. I'm Ira Flatow. We're talking this hour about suicide, how to predict it, prevent it, from my guests Matthew Miller, Jane Pearson, Matthew Nock. Our number: 1-800-989-8255. Matthew Miller, I know you wanted to jump in there, right at the end, to talk about funding.

MILLER: Thanks, Ira. I wanted to underscore what Jane said about the exiguous finding for suicide research generally, but mention that the funding for firearm-related suicide research is virtually non-existent - in fact, the funding for firearm research more broadly, which is largely focused on interpersonal violence, is terribly underfunded, relative to the toll. There was a single appropriation that President Obama made last year after the Sandy Hook massacre for $10 million to go into funding research for firearms generally.

What proportion of that will go into funding suicide by firearms is not known, even though, as you pointed out at the beginning of the program, there are more firearm suicides - 19,000 per year - than there are firearm homicides. And without more funding, it's very hard for me to recommend to my graduate students that they pursue a career in firearm-related research and preventing suicide by understanding how to prevent firearm suicide without a better guarantee of a steady funding stream.

FLATOW: If people don't have access to a firearm, will they find some other way of committing suicide?

MILLER: That is the central question, and the empirical evidence is usually not. So how do we know that? We know that because when you look at people who live in homes with guns, they are no different from people who live in homes without guns with respect to classic suicide risk factors. They do not have more depression. They do not have more substance abuse. They do not have more suicidal ideation, and they don't attempt suicide more often.

What differentiates people who live in homes with guns from people who live in homes without guns is the likelihood that they're going to complete - that they're going to die, because when, in an impulse, they reach for a gun, they're much, much more likely to die than when they reach for anything else.

FLATOW: Matthew Nock, now many people who end up committing suicide were actually under some sort of psychiatric care or in therapy when they did it? Does mental health treatment work at all?

NOCK: It's a great question. And if I may, many people in the field and many families who've lost one to suicide prefer the term dying by suicide rather than committing suicide. The term committing suicide harkens back to when suicide was seen as a crime, and so when I talk about it, when many talk about it, we think about dying by suicide.

Most people who try and kill themselves - fortunately or unfortunately - have been receiving some kind of health care in the year before their suicide attempt. This is true of adults. It's true of adolescents who are at really high risk. For adolescents, about two-thirds were seeing someone for health care before they tried to kill themselves. So the good news here is that we know that we're identifying people who are at risk, and we're getting them into treatment.

The bad news is that people are still trying to kill themselves, despite the fact that they are receiving treatment. And so a lot of what we've been trying to do as a field in terms of prevention and intervention, while, I think, all coming from a good and caring place, a lot of it does not seem to be working. And so there are currently efforts to try and improve what options are available in terms of treatment and prevention, with some nice preliminary findings showing that some forms of psychological treatment can cut in half a person's risk of trying to kill themselves.

FLATOW: Let's go to the phones. John in Atlanta. Hi. Welcome to SCIENCE FRIDAY.

JOHN: Hi, how are you doing?

FLATOW: Mm-hmm. Go ahead.

JOHN: Okay. Well, I just wanted to, you know, tell my story. I've dealt with depression for my entire life. It started in my early teenage years, and when I got to my late 20s I lost my job, and I had had a severe back injury and was in just a great deal of pain constantly. And, you know, so I had become hopeless, and I actually attempted suicide three times.

And the third time, you know, I had taken a lot of pills, drank alcohol and had actually stabbed myself in the chest. But if I had had a gun, there's no way that I would have survived that at all. But after that third time I did - I had a clarity about, you know, I haven't been anywhere near as depressed ever since then. And so I'm just thankful that I wasn't around a firearm at that time, because I know for sure I would have been successful then.

FLATOW: Interesting.

JOHN: But, you know, I had had been seeing, you know, a psychiatrist here and there, but my medical insurance didn't cover that. So it was very hard to get that taken care of.

FLATOW: All right, John. Thanks for your story, and good luck to you.

JOHN: Oh, well thank you. I'm doing much better now.

FLATOW: That's great. It's good to hear that. Thank you. Matthew Miller, you were shaking your head.

MILLER: Yeah, I mean, I think that his story's emblematic of the difficultly that we have had, despite laudable efforts to prevent people from suffering to the point that they deteriorate into a suicidal crisis. Fortunately, he did not have access to a firearm, because he's right. Nine out of ten times that someone uses a gun, they end up dying.

FLATOW: Let's go to Jonathon in Denver. Hi, Jonathan. Welcome to SCIENCE FRIDAY.

JONATHAN: Thank you. Mr. Nock has said that he created a clinical test to determine if someone is at risk of committing suicide, and that - it sounds like it's an amazing tool, but that clinical element of it sounds like it's not being released to the public. And I was wondering if there's any plans to have an online tool so that people could do the same thing outside of the clinical setting, and perhaps determine themselves if they're at risk of committing suicide if they're not sure.

FLATOW: Matthew Nock?

NOCK: Yes, it's a great point. The test is called the implicit association test. We haven't released it for use by clinicians, because we're still in sort of early stages of testing it out to see how accurate is it when you test out what clinicians should actually do with the information from the test once they have it, how it should be integrated with other clinical information.

We have found that performance on the test outperforms clinical prediction. So with this test, we can predict who is going to make a suicide attempt better than clinicians can do using their own judgment. In terms of making it available, though, to the public, we've created a website that's called Project Implicit Mental Health, and the website address, if I may, is implictmentalhealth.org. And anyone can go and take implicit association tests related to suicide, self-injury, anxiety, depression, mental health more generally, to get an understanding of how they might be thinking about these topics.

FLATOW: All right, Jonathon, thanks for calling.

JONATHAN: Thank you.

FLATOW: You're welcome.

JONATHAN: Thank you.

FLATOW: Jane Pearson, you talked about white older men, white men as a risk group for suicide. Do we know why they're such at high risk?

PEARSON: We have some older psychological autopsy studies that were, you know, like case-controlled, from older adults who didn't kill themselves who were depressed, those who did. So depression is a common risk factor, but we wanted to know what else. Most people who are depressed don't kill themselves - s, some of the personality issues around people not being able to cope well given the challenges of later life.

Maybe they've coped very well in a certain way up to that point, but those kinds of coping mechanisms aren't going to work anymore are possible. And then we've got some new research coming out showing how executive functioning, the part of your brain that's making some decisions and responding and trying to, you know, be adaptive, isn't working so well. So that might fit interestingly with Matt Nock's work trying to figure out, you know, what's going on in the brain. And that's the real challenge here.

We're kind of stuck with self-reports and, as you're hearing, not always are reliable self-reports. So I think that's the challenge for clinicians, and they feel like it's a very difficult task. But we are also working on tools for helping screening. And if we can't necessarily predict who is going to kill themselves, we can screen to see what we can treat, what is there that we can work with. And there's a lot of cognitive behavioral tools we have to help people sort out what seems to be an insurmountable problem.

FLATOW: Let me ask, I have time for one final question, I want to get it in here. Should you be listening to people who say they're going to commit suicide - I'm sorry, or kill themselves. Should they be listened to and taken seriously, and how do you know when if it's someone that you know, or even yourself that's contemplating?

PEARSON: Oh, absolutely, because you never know for sure, and that person definitely is in distress.

NOCK: Yup.

PEARSON: So whether it's suicide or they're having other problems that still could be addressed, it's definitely worth it. You can't take that risk.

FLATOW: And what advice do you give these people?

PEARSON: There's the National Lifeline, which I hope we can put on your website where people can access 24 hours a day, seven days a week. And those folks can help link you to some help in your area. They figure out where you're located, and help make that referral. You can always dial 911 and get help right away. It's very important that you do.

NOCK: Yeah, although most people - many people deny their suicidal thoughts, about two-thirds of people who die by suicide had told someone before their suicide death that they were thinking about killing themselves. So I agree with Dr. Pearson. Absolutely take it seriously and take any action that you can to try and keep people safe.

FLATOW: And Matthew Miller?

MILLER: And don't necessarily wait until someone says I'm ready to kill myself. If somebody is going through a rough patch - whether that's an existential rough patch or clearly a problem related to substance abuse or mental health problems - have them make a decision in their own enlightened self-interest. Get the gun out of the home. If you've got a kid who's going through a bad problem, get the gun out of the home. It buys you time to seek treatment and for things to get better.

FLATOW: Right. Thank you all for taking time to be with us today. Matthew Miller, associate professor of health policy at Harvard School of Public Health and co-director of Harvard Injury Control Research Center. Jane Pearson, chair of the Suicide Research Consortium at NIH. Matthew Nock, professor in the Department of Psychology at Harvard in Cambridge. Thank you all...

NOCK: Thank you.

FLATOW: ...for taking time to be with us today.

PEARSON: Thank you.

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