Suicide rates are likely to increase all over the world during the COVID-19 pandemic. Nearly half of Americans say their mental health has been negatively affected by stress and worry over coronavirus. A convergence of multiple factors brought on by the pandemic can aggravate suicidal tendencies: social isolation, anxiety, fear of contagion, uncertainty, chronic stress, financial difficulties, insomnia, and grief if a loved one was lost to the virus. The most vulnerable groups are those with pre-existing psychiatric disorders (whether under treatment or not), people who have difficulty coping (low resilience), those who reside in high COVID-19 prevalence areas, or those who have had a loved one die from COVID-19.
In the US, suicide rates have been on the rise the last two decades. From 1999 through 2017, the suicide rate in the US grew 33%. Men are 3.5 times more likely to die by suicide than women. In 2018, White males accounted for nearly 70% of suicide deaths in the US. I lost two beloved friends to suicide, Carl Lindberg and Dr. Richard Whittaker, and this blog is in honor of them and with the hope to spare other lives. Suicide is a serious problem in our country and everyone in our community, especially mental health professionals, need training on how to intervene and help someone in danger of suicide. The following excellent article on the topic was originally published in Psychology Times, Vol. 5, No. 13, September 1, 2014, and was used with permission.
Need for Training in Mental Health Professionals, Experts Say
Robin Williams’ Death Points to Rising Suicide Rates
The death of beloved actor-comedian Robin Williams of suicide last month brings into sharp focus the tragedy and challenges related to the nation’s 10th most common cause of death, and the disturbing increases in suicide rates, especially for baby boomers and White males.
Williams, one of the creative geniuses of our times, was a comedian, actor, screenwriter, and film producer. From his early Mork & Mindy, to critically acclaimed films such as The World According to Garp, Good Morning, Vietnam, and The Fisher King, to box office successes like Mrs. Doubtfire, audiences loved him.
Sources note that Williams was exhausted from a straight 18 months of work and was dealing with career and health problems. In early July he entered Hazelden, a medical addiction treatment facility. His publicist said he was “taking the opportunity to fine-tune and focus ….” Only a few weeks after being discharged Williams took his own life. He had just turned 63.
Increase in Suicide Rates
According to the Center for Disease Control (CDC) suicide rates have been increasing. In 2009 the number of deaths from suicide surpassed the number of deaths from automobile accidents. Last year CDC researchers reported that the annual, age-adjusted suicide rate among persons aged 35 to 64 years had increased 28.4 percent from 1999 to 2010.
CDC Report for 1999 to 2010:
Suicide Rate Up 28%
Men, age 50 to 59, Up 48%
For men aged 50 to 54 and 55 to 59 years, the rate increased 49.4 percent and 47.8 percent respectively. For women, there was a 59.7 percent increase in the 60 to 64 year olds.
Looking at racial/ethnic groups, Black Americans, who have a lower suicide rate overall, had no change over the decade. But suicide rates for Whites increased by 40.4 percent and the rate for American Indian/Alaska Natives increased by 65.2 percent.
President of the American Association of Suicidology, Baton Rouge psychologist, Dr. William Schmitz, Jr., writing for the August CNN Opinion, reminded readers that more than 39,000 people commit suicide each year. “When I learned about Williams’ suicide on Monday,” Schmitz wrote, “it knocked the wind out of me.” He noted his affection for the actor and his work. But, Schmitz also pointed out that 107 other people died that same day from self-inflicted injuries.
The Times asked Dr. Schmitz about the rising suicide rates over the last decade. “Suicide rates have been gradually, and rather steadily, increasing,” he said.
“There are several theories regarding this trend, though a specific and definitive explanation has not emerged,” Schmitz noted. “We do know that suicide attempts, across the lifespan, tend to become more lethal,” explaining that the ratio of suicide attempts to death is 100-200 to one for adolescents and young adults, but for those over 65 the ratio is four to one.
“Coupled with this,” Schmitz said, “I would also add that help-seeking and mental health treatment remain very stigmatized among the older adult populations. There is lingering doubt and fears associated with institutionalization, asylums, and being ‘locked up’ if one divulges any thought of suicide,” he explained. “This is very disconcerting given the clear evidence that even people determined to be at high risk for suicide have been shown to respond to intensive outpatient therapy.”
Dr. Frank Campbell is a Licensed Clinical Social Worker and expert from Lacombe, Louisiana, former Executive Director of the Baton Rouge Crisis Intervention Center, and also Past-President of the American Association for Suicidology.
“It is important to accept that suicide is a very complex and paradoxical cause of death to develop clear understandings from,” Dr. Campbell told the Times. “It is an N of 1 and by that I mean each suicide is unique.”
Campbell is certified in Thanatology and practices in Forensic Suicidology. He and colleagues currently provide “Postvention Workshops and Training,” through Lossteam, a program to aid newly bereaved from a death by suicide and to help reduce the multi-generational impact of risk that can follow. Dr. Campbell’s work has been featured in a documentary for the Discovery Channel.
“For me the most comprehensive micro or individual answer to any death by suicide,” he said, “is that it happens as a result of a self-defined crisis where the individual’s ability to cope with the precipitating event which brings on the crisis response––decline in coping and possible increase in maladaptive coping––was unable to keep that person safe from suicide,” Dr. Campbell said.
“Data is helpful in awareness but each death impacts the community in ways that are unique and little research has been conducted on the impact suicide has on generating additional casualties both in the short term or long term for a community,” he said.
“The macro response would include considering the impact of social and economic changes in the past 10 years,” Campbell said, “because economic conditions have historically correlated with upward trends in suicide.”
Also, “… a growing number of citizens who are veterans of military service––mostly men– which are estimated to equal one out of each five deaths by suicide,” he said.
Is the Help, Helping?
Dr. Schmitz pointed out that there is growing evidence supporting various approaches that help those at risk. “There are treatments that work, there are warning signs and basic skills of suicide assessment and management that should be core clinical competencies,” said Schmitz.
“Unfortunately, the majority of mental health professionals do not obtain this training in either their graduate studies or continuing education,” he said. “Providers that are not engaging their patients in active discussions about means restriction and crisis response planning really terrify me,” he said.
“Right now, I focus a lot of my attention on promoting education for providers––and consumers. Too many people who reach out to mental health professionals in a trusting/vulnerable state are marginalized, invalidated, or avoided––‘quick, get them in the hospital, they said the word suicide.’ If providers were more comfortable talking about and working with suicidality, I believe that we would have better outcomes and an improved image among the general public,” he said.
“The general public simply expects that all licensed mental health professionals are ‘the experts in working with suicide’ and the various mental health disciplines seem content to perpetuate this myth,” Schmitz said.
“The general public simply expects that all licensed mental health professionals are ‘the experts in working with suicide’ and the various mental health disciplines seem content to perpetuate this myth.”
-Dr. William Schmitz, Jr. President, American Association of Suicidology
Kansas licensed psychologist Dr. April Foreman, is also an expert in suicide prevention efforts, focusing on media and social education. During the past legislative session, Foreman helped Senator Ben Nevers develop his measure that would have mandated six hours of suicide prevention training for mental health professionals.
Foreman points to a serious problem regarding competency in suicide prevention within the mental health community. “Only 9 to 10 percent of mental health professionals can pass a competency exam,” in this topic, explained Foreman previously. “This is a big training deficit.”
Nevers’ bill was eventually passed, creating resources under the state, but the mandate was dropped.
“What are we doing right? Not much, truth be told,” said Foreman. “When 90 percent of our licensed psychologists cannot pass a basic competency exam on suicide risk assessment and intervention––the number one mental health emergency––then we have a real problem. You expect your doctor to know what to do if you walk into his office with chest pains. We should similarly expect licensed psychologists to know what to do during a mental health emergency.”
Foreman points out that licensed psychologists and other behavioral healthcare professionals should know some basic knowledge and skills. She outlined these as: 1) How to assess for suicide risk; 2) How to differentiate between ideation, plan, intent, and means; 3) The six steps of a safety plan––including means restriction; 4) How to be able to clearly articulate the risks/benefits of hospitalization for a given patient; and 5) How to either provide, or effectively refer patients with risk of suicide to competent care that focuses on reducing and stabilizing suicide risk.
Dr. Schmitz previously told the Times, “It is the number one emergency in mental health and the most lethal situation a professional will encounter. But, no one is required to have training.”
Schmitz is the first author of a 2012 white paper, “Preventing Suicide through Improved Training in Suicide Risk Assessment and Care,” a report of the American Association of Suicidology Task Force, which pointed out that training is limited, inconsistent and mostly didactic. “An hour of didactic training may increase knowledge,” Schmitz explained to the Times, “but it doesn’t do anything to actually change competency.”
So currently, training in this area is left to the professional’s judgment. Some are responding to that need, such as Dr. ValaRay Irvin, Psychologist and Director of the University Counseling Center at Southern University in Baton Rouge. She has looked at additional training for herself, her faculty and staff.
“Just last week I spoke with an individual in an effort to align my Center with the Historically Black Colleges and Universities – Center for Excellence at Morehouse School of Medicine, where they are funded through a SAMHSA grant to offer a number of ‘critical’ trainings for HBCU Counseling Centers,” she told the Times.
She is looking at one of the training programs that teach individuals a five-step plan to support other developing signs and symptoms of a mental health crisis, including specifics with risk of suicide. Her goal is to install the training for others, including key Student Affairs units, as well as faculty and staff, after she completes the training herself.
What is the role of psychiatric drugs?
Williams’ close friend, actor Rob Schneider publicly blamed Williams’ death on the medications Williams was taking. According to reports these medications were for depression, anxiety, and early stages of Parkinson’s. Other reports said he was sleeping hours a day and withdrawn.
Science writer Dr. Gary Kohls, a family physician and mental health specialist, and author at Global Research, wrote that the focus is on Williams’ pre-existing mental health problems but that the suddenness with which Williams took his life and what psychiatric drugs he was being given is being ignored.
“Knowing that Williams had been under the care of psychiatrists for the last six weeks of his life, certain taboo questions need to be asked and answered,” wrote Dr. Kohls in a recent article on Global Research about the dangers of combining psychiatric drugs.
“What are we doing right? Not much, truth be told. When 90 percent of our licensed psychologists cannot pass a basic competency exam on suicide risk assessment and intervention––the number one mental health emergency––then we have a real problem.”
-Dr. April Foreman Expert in Suicide Prevention, Media, and Education Content
Suicide Rates by Groupings:
Comparison of 2001 and 2011
Statistics prepared for American Association of Suicidology by John McIntosh, PhD and Christopher Drapeau, MA. Source is the Center for Disease Control. (Information, courtesy of Dr. Campbell.)
“There will be no answers unless we get them in the secret details of what happened at Hazelden, including what brain-altering drugs [Williams] was on.”
Kohls wrote that every SSRI class medication bears a black box warning indicating that it doubles the risk of suicide, but that this is often ignored. Kohl directly pointed to seeking help at Hazelden, writing, “In retrospect, that decision had fatal consequences,” wrote Kohl.
Kohls analysis parallels science writer Robert Whitaker’s Anatomy of an Epidemic, who concludes that as the use of medicine has risen, so has mental illness.
Reports were that Williams was exhausted, and dealing with emotional stress.
Cass Nelson-Dooley, owner of Health First Consulting, noted, “What that means, is that he was depleted in multiple ways.” She helps medical professionals and organizations treat hidden nutritional, biochemical, and metabolic causes of disease as part of their health programs.
“In a person who struggles with alcohol or drug addiction, we often see that their neurotransmitters and hormones are imbalanced. These systems are necessary for a healthy mood. A person with alcohol or drug addiction might also have nutritional deficiencies that can be missed by most doctors. Neurotransmitters, hormones, and nutrients would be very important areas to analyze in someone who is self-medicating with alcohol or drugs. These areas are also often abnormal in depression and suicide.”
“Someone who we know has vulnerabilities, who we know uses drugs and alcohol to try and feel better, to try and prop themselves up, will likely become very depleted over an 18-month push.”
“Without testing, we don’t know about Robin Williams’ underlying biochemical make-up,” she said. “But given what we see in other patients like him, he probably had imbalanced neurochemistry that predisposed him to struggle with depression and addiction. Eighteen months of stress could have worsened an already precarious nutritional and hormonal imbalance. He may have been unable to resist the severe depression that resulted in his suicide.”
“It is no wonder someone with his known vulnerabilities would have been teetering on the brink of a danger zone, and with added stressors, even lose hope that he could ever feel better,” she said.
Dr. Campbell said, “Managing transitions in life if not easy and when health and loneliness are isolating factors along breakdown geographically of the family and health care challenges it is a lot to manage. Generational expectations are not always shared or expressed clearly to family who might be wanting to help but just don’t know how.”
“My thought is that if we had the number of folks who die by suicide each year drowning then we would train more lifeguards to stand by those in the water.
“The river of suicide is large in this country and it is up to all of us in our communities to become trained as lifeguards,” Campbell said. “One such training that is for all care givers is the two day ASIST (Applied Suicide Intervention Skills Training) that helps anyone help another at risk, from the river to safety, for now.”
Cass Nelson-Dooley, MS, is a researcher, author, educator, and laboratory consultant. She studied medicinal plants in the rain forests of Panama as a Fulbright Scholar and then launched a career in science and natural medicine. Early on, she studied ethnobotany, ethnopharmacology, and drug discovery at the University of Georgia and AptoTec, Inc. She joined innovators at Metametrix Clinical Laboratory as a medical education consultant helping clinicians use integrative and functional laboratory results in clinical practice. She owns Health First Consulting, LLC, a medical communications company with the mission to improve human health using the written word. Ms. Nelson-Dooley is an oral microbiome expert and author of Heal Your Oral Microbiome. She was a contributing author in Laboratory Evaluations for Integrative and Functional Medicine and Case Studies in Integrative and Functional Medicine. She has published case studies, book chapters, and journal articles about the oral microbiome, natural medicine, nutrition, laboratory testing, obesity, and osteoporosis.