Indiana University Bloomington

Indiana Prevention Resource Center (IPRC)

Suicide, a National and Local Problem

As International Survivors of Suicide Loss Day (November 22) approaches, the Indiana Prevention Resource Center is calling attention to the problem of suicide in Indiana and nationally. Suicide is the 10th leading cause of death in the U.S. In 2011, the most recent year for which we have data, more than 39,500 people died from suicide, a rate of 108 per day, one death every 13.3 minutes. (American Association of Suicidology, Suicide in the USA, 2014). In addition there are about a half million attempt suicides per year. (HHS, 2012 National Strategy for Suicide Prevention, 2012; US Dept of Defense, Suicide, 2013). [All of the items referenced in this article can be found in the IPRC HOME Library of e-Resources. Go to the Library tab on the IPRC homepage.]

Suicide is the 11th leading cause of death in Indiana at 13.1 deaths per 100,000 persons. Suicide rates in Indiana are higher than the nation and also than the Midwest. On the positive side, suicide rates in Indiana have decreased slightly, except for seniors aged 65 and older. (Indiana State Health Department, Suicide in Indiana Report, 2013)

The Substance Abuse and Mental Health Services Administration has made suicide a focus of concern in their 2015-2018 targeted goals. The first goal is preventing substance abuse and promoting emotional health and well-being. The third of four objectives under this goal is “preventing and reducing attempted suicides and deaths by suicide among populations at high risk.” (SAMHSA, Leading Change 2.0, 2014)



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Risk and protective Factors

Substance abuse is the second biggest risk factor for suicide after anxiety and depression. (“Substance Abuse Prevention IS Suicide Prevention,” NPN Conference, Hartford, 2015; SAMHSA, Substance Abuse and Suicide Connection: White Paper, 2009) Research shows that people with severe depression or substance abuse disorders are at elevated risk for suicide. (Fran Harding, “Setting the Stage,” NPN Conference, 2014)

According to the CDC, leading risk factors for suicide include: a family history of suicide and/or child maltreatment; previous suicide attempts; a history of mental disorder, especially of clinical depression; a history of alcohol and other substance abuse; feelings of hopelessness; impulsive or aggressive tendencies; cultural or religious beliefs that suicide is a noble way to resolve a personal dilemma; local epidemics of suicide; isolation or feelings of being cut off from others; obstacles to access to mental health treatment; loss related to a relationship, social life, work or finances); physical illness; ready access to firearms or other lethal methods; a refusal to seek help because of stigma associated with mental health disorders, substance abuse or with having suicidal thoughts. (CDC, Suicide: Risk and Protective Factors, 2013)

Protective factors named by the CDC include: receiving effective clinical care for mental, physical or substance abuse disorders; having ready access to several options for clinical intervention, along with having a support system for doing so; being connected to family and community; receiving support from established physical and mental health care givers; being skilled at problem-solving, conflict resolution; the ability to use environmental ways to deal with disputes; having cultural beliefs that affirm the natural instinct for self-preservation and discourage suicide as an optional strategy. (CDC, Suicide: Risk and Protective Factors, 2013)

Shared risk and protective factors. Some risk and protective factors are shared for both substance abuse and suicide. Shared risk factors include health challenges, adverse childhood experiences, parental/family problems, exposure to violence, and experiencing prejudice or perceived prejudice. Shared protective factors against both substance abuse and suicide include: healthy self-esteem, access to mental health services, parent/family support, social support, and cultural pride. (Stout, “Substance Abuse Prevention IS Suicide Prevention,” NPN Conference, 2015)

Suicide warning signs. Most, though not all, people who commit suicide exhibit signs of their intention to do self-harm. Suicide warning behaviors include showing manifestations of depression, anxiety and/or low self-esteem. S/he may be feeling that there is no reason to live. The person may be focusing his/her thoughts on death and suicide, talking or writing about these topics or indirectly, e.g., about going away, or making preparations, such as giving personal treasures away or obtaining a lethal weapon. Changes in behavior may be dramatic, like sharply dropping grades, suddenly taking risks, violent acts, or mood reversals. Use of alcohol, tobacco, or other drugs may increase. A potential or recent severe loss can trigger thoughts of suicide. Unwillingness to accept help from others is also a cause for concern. (Department of Defense, Defense Centers of Excellence, 2013)

Age

Nationally, based on the most recent available data (from 2011) the largest number of suicides occur among middle aged adults, 45-54 (19.8/100,000), followed by the elderly ages 85 and older (16.9/100,000). Though the numbers are lower, suicide is the second leading cause of death for teens and young adults, ages 15-24, where suicides outnumber homicides. (American Association of Suicidology, Suicide in the USA, 2014).

Based on data from 2010, Indiana mirrors the nation with the highest number of suicides occurring among ages 45-54, followed by ages 55-64, and ages 35-44. The highest rate of suicides is among those ages 85 and older (17.6/100,000). Suicide is the second leading cause of death in Indiana for young adults 15-34, third for teens ages 10-14, and fourth for adults ages 35-54. (ISDH, Suicide in Indiana Report, 2013)

Good news from the 2014 Indiana Youth Survey is that, compared to high school students nationally, is that Indiana students reported lower rates of mental health conditions related to suicide as follows: 9th -12th graders reported lower rates than the nation for “feeling sad or hopeless;” likewise 11th - 12th graders for “considering attempting suicide” and 10th- 12th graders for “planning to attempt suicide,” and 11th-12th graders for “attempted suicide.” (Gassman, et al, Indiana Youth Survey, 2014)

College students in Indiana who took the Indiana College Substance Abuse Survey responded to questions related to mental health status and suicide. Asked how many days in the past month they experienced poor mental health in the form of stress, depression or problems with emotions, the response was an average of 5.9 days, with females reporting 6.5 days compared to males, 4.6 days. For those under 21, the average was higher at 6.1. In answer to other questions, 14.3%, or one in seven students, had thought during the past two weeks that he/she would be “better off dead” or had thought of “hurting themselves in some way.” More female students (15.2% versus 12.9% of males), generally, and more students of either gender under age 21 (15.9% compared to 12.6% of older students) had thoughts of harming themselves or of suicide. (King & Jun, Indiana College Substance Abuse Survey, 2013)

Race and Gender

Both nationally and in Indiana, white males have the highest rates of suicide. Nationally, rates among males are four times higher than among females. And whites constitute 90.5% of suicide deaths. In Indiana for white males, rates are highest in the 45-54 age group, followed by seniors 65 and older, and thirdly those ages 35-44. (ISDH, Suicide in IN, 2013)

Although Blacks and Hispanics have lower rates of suicide than whites, this does not hold true for youth. Indiana Black high school students reported rates of suicide attempts that resulted in injury or harm at a rate nearly twice that of the general high school population (7.6% vs. 3.9%). (CDC, 2014) Compared to other Indiana female high school students of any race or ethnicity, Hispanic females reported the highest rates for feelings of sadness, suicidal thoughts, making a plan, attempting suicide and for attempts that resulted in injury or harm. (CDC, 2014) Compared to white non-Hispanic females, most striking are Hispanic females’ rates of having had thoughts of suicide, 30.2% vs. 19.5%, having made a plan to commit suicide, 27.2% vs. 12.4%, having made a suicide attempt, 15.6% vs. 9.2%, and having made an attempt that resulted in injury or harm, 5.2% vs. 3.5%. Perceived discrimination (Seaton, et al, 2008; Tummala-Narra and Claudius, 2013) and the stresses of acculturation (Forster, et al, 2013) are risk factors for depression among youth.

Method used to commit suicide also varies by gender, with firearms most popular among males and poisoning most popular among females. Overall in Indiana 53.6% of suicides are by firearms, 18.6% are by poisoning, compared to 50.6% and 16.6% respectively for the U.S. (ISDH, Suicide in Indiana, 2013).

Populations at HighRisk

Nationally one in 15 high school students has either made a suicide gesture or attempted suicide in the past year. (SAMHSA, Preventing Suicide: A Toolkit for High School, 2012) For high school students the association between substance abuse and suicide is clear. A study based on data from the CDC Youth Risk Behavior Survey (YRBS) looked at the association of each of ten substances and suicide on five different levels (suicide ideation, plan, attempt and serious attempt). Researchers found the use of any of the ten substances was associated with increased risk of suicide. The strongest association was found for heroin use, followed by steroids and methamphetamine. In contrast, high academic performance is inversely associated with suicide (higher grades – lower risk). (Wong, et al, “The Risk of Adolescent Suicide across Patterns of Drug Use,” 2013)

Knowing that adverse childhood experience is a shared risk factor for substance abuse and mental health disorders (CAPT, Risk and Protective Factors Shared, 2009) and that clinical depression and substance abuse are risk factors for suicide (CDC, Suicide: Risk and Protective Factors, 2013; SPRC, Suicide Prevention Basics, 2014), it is a matter of grave concern that the 2010 YRBS survey found that 17.3% of Indiana’s 9th to 12th grade girls report having suffered forced intercourse, compared to 10.5% nationally in 2010 (CDC, 2010; CEEP, Sexual Violence Prevention in Indiana, 2012). The following year Indiana again ranked second with 14.5% of girls reporting ever having experienced forced intercourse, compared to 11.8% nationally. (CDC, Youth Risk Behavior Surveillance—US, 2011, 2012:69) (Indiana state data was not included in the 2013 report due to insufficient participation in the survey.) Adding to the seriousness of the situation is the fact that only a fraction of victims report a sexual assault to authorities. One report estimates that nationally 60% of rapes are not reported to the police. (RAINN, Statistics, 2009). A survey of Indiana women age 18 and over in Indiana found that only 15% of those suffering sexual assault short of rape and only 12.5% of those suffering rape reported it to the police. (Cierniak, et al, CEEP, Sexual Violence Prevention in IN, 2012)

LGBTQ youth are disproportionately victims of bullying, harassment and discrimination and are at especially high risk of suicide. (Ellyson Stout, SPRC, NPN Conference, 2014; CDC, LGBT Health, 2014). Risk of suicidal ideation, attempts and suicide are elevated, with more than twice as many LGBT youth attempting suicide as their heterosexual counterparts. (CDC, LGBT Health, 2014).

Suicide has exceptionally high incidence among Native American youth. Among college students risk factors for suicide are very high. Over 50% report feeling overwhelming anxiety and/or feeling very lonely, and over 40% report feeling things are hopeless, and over 30% report feeling very angry. (Fran Harding, Setting the Stage, NPN Conference, 2014).

Military personnel and veterans are also at high risk. Deaths from suicide reached an all-time high in 2012. (Burns, ArmyTimes, 2013) Salient risk factors for military personnel include: sexual assault in adulthood (Preidt, “Physical, Sexual Assault,” 2013) and problems and stresses related to relationships, legal and financial matters. (Department of Defense, Defense Centers of Excellence, Suicide, 2013)

Prevention Responses

Many efforts are underway to reduce the risk factors and fortify the protective factors for suicide to reduce the number of suicide deaths and attempts. The 2012 National Strategy for Suicide Prevention (HHS, 2012) established a series of goals and objectives under four general approach categories: healthy and empowered individuals, families and communities; clinical and community prevention services; treatment and support services; and surveillance, research, and evaluation.

Healthy People 2020 has likewise established targeted goals and recommendations, and is promoting such school-based, evidence-based and SAMHSA certified suicide prevention programs as SOS. Goals associated with Signs of Suicide (SOS) include helping teenagers to recognize the association between undiagnosed, untreated mental illness and suicide, and to empower teen peers to take actions to help. (Belardo, Jose, CAPT, Healthy People 2020, Who’s Leading the Leading Health Indicators? 2013)

The Suicide Prevention Resource Center has developed many resources and is promoting evidence-based prevention programs like the Kognito At-Risk for High School Educators program, which was featured in the SPRC presentation at the 2014 National Prevention Network conference. SRSC also promotes its companion programs for At-Risk College Students and Kognito Family of Heroes for military personnel recently returned from combat zones. (SRSC, Best Practices Registry, 2014) All three of these prevention programs are included on the SAMHSA NREPP registry of evidence-based programs. Another resource from the Suicide Prevention Resource Center is intended to help schools recover after a suicide, After a Suicide Toolkit for Schools. (SPRC, 2011)

Research is producing new insights about the links between suicide and trauma, substance abuse and mental health. The Defense Department’s Center for Excellence has taken steps to address stigma and provided mental health support treatment for stress and depression. SAMHSA has created resources on a variety of related themes and for a variety of audiences. An online print document, “Suicide Prevention Dialogue with Consumers and Survivors: From Pain to Promise,” explores the needs and recommendations of survivors and family members of victims. (SAMHSA, 2011) A second online print resource is a toolkit for high schools which provides extensive information and resources to help high schools plan and implement appropriate protocols and programs. (SAMHSA, Preventing Suicide, 2012). Another is a Youtube production, “Everyone Plays a Role in Suicide Prevention: Turning Strategy into Action.” (SAMHSA, Youtube, 2013).

SAMHSA’s has targeted suicide prevention in two of its six main initiatives for 2015. Initiative 1 is to prevent substance abuse and mental illness. While promoting wellness by focusing on the links between substance abuse and mental illness, part 1.1 of Goal 1 will promote the protective factors of emotional health and wellness. Part 1.3 of Goal 1 explicitly aims to reduce attempted suicides in high risk groups such as young adults and middle age men. SAMHSA proposes use of integrated approaches, braiding funding from substance abuse and mental health sources; targeting at-risk youth and adults, promoting a zero suicide goal (recognizing that in follow ups on suicide attempts substance is usually found in the person’s system); and increasing public awareness and knowledge. (Fran Harding, NPN Conference, 2014)

The need and the challenge call us to action. Much work has been done, and much remains. To succeed in reducing suicides and to progress towards a zero suicide goal, we each need to raise our awareness and our skills in order to do our part.

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By Barbara Seitz de Martinez, 11/22/2014