- [Jeff] Welcome to "Healthy Minds."

I'm Dr. Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence.

With help, there is hope.

(soft music) Today on "Healthy Minds."

- In the United States, each year, just less than 50,000 Americans die by suicide in that year.

- Unfortunately, suicide affects all ages, different groups being at different types of risk.

- We're learning so much from researchers around the world with regard to not only what drives up risk of suicide, but what constitutes effective prevention as well.

(soft music continues) - Funding for this program was provided in part by The American Psychiatric Association Foundation.

Additional funding was provided by The John & Polly Sparks Foundation.

(music continues) Welcome to "Healthy Minds."

I'm Dr. Jeff Borenstein.

Almost 50,000 people a year die as a result of suicide in the United States.

A tragedy for each of those individuals, and their families and loved one.

Today, I speak with suicide prevention expert, Dr. Christine Moutier, who will share important information that we all need to hear.

(soft music continues) Christine, thank you for joining us today.

- Thank you so much for having me on.

It's my pleasure.

- I wanna jump right in, and talk about the scope of the problem of suicide.

- Certainly.

So in the United States, each year, just less than 50,000 Americans die by suicide in that year.

And what's been happening over the last couple of decades is that unfortunately, the national rate of suicide has been on the rise.

From 1999 through 2018, the increase totaled by 35%.

So it is a time of really, you know, increasing awareness, and I like to think decreasing stigma as well.

And what happened when COVID hit then, well, actually even the year before, there was the first decrease in the national rate of suicide in 2019 for the last couple of decades.

And then in 2020, yet again, another decrease.

But we're seeing provisional data from the CDC for 2021 that is showing, unfortunately, a 4% increase.

That data has yet to be finalized, but, you know, so, and then if we break it down by demographic populations and different subgroups, we could really get into the details about that, but one striking finding was that in 2019, and in 2020, what we saw was that white Americans' rate was going down overall, but Black, Latino, and other non-white Americans' rate was actually on the rise during that period of time.

And so, you know, I think from an equity standpoint, we're also realizing that much more work needs to be done, from a research destigmatization, and treatment standpoint for different populations as well.

- Unfortunately, suicide affects all ages, and the different demographics, as you're describing, with, you know, different groups being at different types of risk.

Could you tell us a little bit about what are the risk factors for somebody to attempt suicide or die by suicide?

- Yes.

We're learning so much from researchers around the world with regard to not only what drives up risk of suicide, but what constitutes effective prevention as well.

So we know with actually quite a lot of clarity about risk factors, and I'll talk about those in a moment, but it's important to preface that by saying that it's not any one risk factor on its own.

And so the tricky part is that there is always really, the psychological autopsy method, studies show us that it's several, usually seven to nine or more risk factors converge, sort of like a perfect storm.

And so those risk factors could be a different combination, a different set of risk factors for each individual person, but there are some common themes and patterns that we see emerge.

And one of them is that mental health, psychiatric conditions, and mental health in general being dynamic and fluctuating, and sort of fluid in people's lives, mental health is critically important.

And that might sound obvious, but it's not mental health conditions on their own, it's always in combination with other factors.

So we've known that changes in a person's life, stressors, transitions are real vulnerable points for all human beings, and especially if there are other risk factors there.

But a previous suicide attempt is a very serious risk factor.

Family history of suicide or mental illness is a risk factor.

Other things like cognitive traits, perfectionism, aggression, history of impulsivity.

So there's some things that are very internal to the person, to the individual.

Genetic loading, again, being one of them.

Then there are things in the external environment that matter very much like attitudes towards mental health, attitudes towards accessing mental health care, and the accessibility of lethal means is another one that's considered in the environment, you know, of a person's setting.

So, you know, those are just some examples.

And again, there are many, many more.

But what I would say is that for all of us, whether we are clinicians, or parents, or coworkers of colleagues, we have our friend group, our community, we can become a little bit smarter about what those patterns look like so that they're on our radar to understand that just like we would approach somebody who, let's say, you know they have a family history of heart disease and early death for cardiac reasons, we know certain basic, you know, ABCs about what that person should be doing.

And we live that out hopefully in our lives, in our families, and in our, you know, just day-to-day conversations.

And that's the thing that we're really looking to do for suicide prevention.

- So just as for like the heart disease example you gave, if somebody's at greater risk, we may be more careful about them, controlling their blood pressure, and their cholesterol, and exercising to decrease that risk.

There are things that could be done, interventions that could be done to decrease the risk in somebody who may be vulnerable to suicide risk.

Tell us about some of the interventions people can be doing.

- Yes.

So I mean, one of the things as a starting point as we're talking about, is learning how to identify suicide risk.

And that is not a simple matter, by any means, but we are developing new tools, and not just screening instruments usually for clinical practice, but again, so that lay people, let's say in a school environment, key people in certain roles like teachers, parents, first responders, coworkers, even employers, believe it or not, are getting very interested in realizing that we all have a role to play in understanding what that looks like in whatever setting you're working, living, worshiping, playing, and that would alert you to the fact that somebody could be developing increased risk for suicide.

And then the interventions depend on what setting we're talking about.

If you're in a school-based setting, then there would be a protocol, a set of policies that teachers, and actually not just teachers, but all staff who work in a school setting, including the bus drivers, and the food servers, and maintenance, that they all have a role to play so that there's sort of a safety net that, an approach, that not only identifies when someone is struggling, but how to ensure that they are cared for, that they get supportive messages, and that also that they get appropriate referrals usually into mental health treatment that can be lifesaving.

If we're talking about in a clinical environment, let's say primary care, then again, screening might be a step that is taken, and in fact, there are some health systems that have taken the step to begin universally screening for suicide risk.

So that's a whole topic unto its own, but it is considered an important way for detecting those at risk for suicide who otherwise are passing through primary care, and emergency medicine and other parts of the health system, and their suicide risk is not getting detected.

Now, once a person screens positive, then there are a number of interventions that can be employed even before they get to the mental healthcare setting.

So things like safety planning, lethal means counseling, really providing a sense of support, and communication, and education to that person, and to their loved ones, when appropriate.

When, you know, we as clinicians, we obviously have to be careful about that, and have the permission of patients, but we at least have to try, and to suggest that the loved ones can be involved in their care in some ways.

- I think an important message, and I want you to comment on this, is sometimes people think that if you're concerned about a loved one being at risk of suicide, if you ask them about it, it may increase the risk, when in actuality, asking about it could help save their life.

And I'd like you to speak about that.

- Yes, thank you so much for the opportunity to speak to this, because it's interesting that there still is a lot of confusion with that.

I think it's a convergence of a bunch of myths honestly, from the past.

One of the myths being that the topic of suicide first of all is so taboo, that we would be offending the person, or somehow, you know, putting them at further risk, either by planting the idea in their mind, or just by somehow raising the topic.

And I think a little bit of the conflation there is with a real phenomenon of suicide contagion that we can talk about in a moment.

But just understand that if a person in your life appears to be struggling in any way, and you can detect that by noticing that their usual patterns of behavior are just... You have a radar in your gut, in your instinct, that something seems off, their tone of voice, their patterns, their sleep patterns, you know, their activities, their mood.

That's really a time to engage them in an open-ended dialogue where you invite them to share their perspective on what's going on in their life.

And so the the way that I would approach asking a person if they're having suicidal thoughts is, one way at least, is in the process of this open conversation that is supportive and non-judgmental, where ideally the person is actually sharing "These are the stressful things going on in my life."

And look, everyone has stress that goes on in their life, but just more than anything, a takeaway for anyone to realize is that, with regard to mental health conditions, as well as suicide risk, we have been writing a lot of it off to stress, and sort of overly attributing to the circumstances of life something that could be a very serious change in mental health and or suicide risk going on.

And so if a person's tone of voice is coming across as hopeless, overwhelmed, like they feel like they're a burden to others, or they feel trapped, those are all indications to me that there's a decent chance that they are also having thoughts of suicide as part of this sense of hopelessness, pain, or the predicament that they're in.

And so if they're coming across that way to me in, you know, I mean my observation, or in this caring conversation that I'm having with them, then that's my opportunity to say, "When you say," and I repeat exactly the phrase that they've said, "It makes me wonder if you're having thoughts of ending your life."

And you can ask it, and put it out there.

And if you don't have a lot of, you know, anxiety, or you know, sort of defensiveness about it, and just ask it in that straightforward way, I think it gives them the best opportunity to be honest, and to either say, "No, I haven't, you know, thankfully I haven't been having those thoughts," or "I have been," and to, you know, to treat it with the care that they've just taken the risk to share something that they might not have shared with anyone, because it doesn't always feel like a safe world, and it's hard to tell who is safe to share these things with.

So I actually thank the person for sharing that with me, I let them know that I wanna be there for them, that I wanna learn more about what they're experiencing, and ultimately would like to help them take whatever next step makes sense to them.

But of course, don't underestimate your role as the caring, whatever your role is, spouse or coworker or friend, to potentially influence them to in a way give them permission to take that next step.

So that is a time when I might say "I've had mental health treatment myself," or "I could help you by helping you look into it, if that's something that you're interested in."

- I think you your emphasis on the sort of supportive nature of a spouse, a friend, other family members, certainly parents, and as parents to sort of start having conversations at a young age where the child could share his or her emotions, and feelings, and just have it as a common thing to talk about these things, is so important to make sure that people are able to get the help that they need when they need it.

- That's right.

You know, we...

There's a layer here in our work of preventing suicide that has to do with the culture.

And I use that term really broadly to just mean the way that we think we need to behave because of all of the unspoken sort of rules that either we grew up in, or, you know, the larger, it has to do with where we live, and you know, sometimes, you know, race and ethnicity, and gender identity, and even some of those things will shape our attitudes, and what seems okay to do.

But I think you're so right that if we can at least introduce opportunities where around the dinner table, or driving in the car together, you know, sort of everyday opportunities, also, you know, this can include in the workplace now, this has become a thing of suicide prevention in every workplace, that where the idea is you tune in, well, first of all you have to establish yourself as a, you know, a safe person, so that you're not gonna judge them or punish them when they share that they're struggling, and, you know, so I think those are very subtle things that we didn't even know we were doing as parents or as friends, you know, even the way that we ask questions about how somebody's doing, as if it's an assumption that of course you're gonna toughen up and get through this, versus really just leaving it open-ended, like "How are you doing with that?"

So I do think you're right that there are ways that I look at the bigger culture with stigma going down around mental health, which is fantastic, but it hasn't necessarily translated yet into how do we then become more actually sophisticated about how we approach the topic of mental health, let alone support another person in your life, or support your own mental health.

- One of the key issues is even for people with the group of risk factors that you mentioned, sometimes when you get over the hump of that danger period that people could have the thought and wanna take action on the thought of suicide, getting through that period successfully without them hurting themselves can make a big difference.

And I'd like you to speak about sort of that, those points in time where help makes such a big difference.

- Yes.

This is, I think one of the old...

Counters one of the old myths of the past as well that really told us the wrong thing about suicide risk.

That if somebody's bent on suicide, thinking of it, has had recurrent thoughts of suicide, that there's sort of nothing that you can do to intervene.

And the truth is that couldn't be farther from the truth, because there's always ambivalence with anyone who is feeling suicidal.

And that means that the human drive to survive and that resilient core is strong in every human being.

It might be getting sort of temporarily dismantled by those, the crisis of the moment, and those risk factors converging.

But you as the person who is just providing a listening ear and a caring approach, could actually tip that balance of ambivalence, and sort of bring them back to a place where hope and coping and that sense of survival can help them reconnect with their usual coping strategies.

So it is absolutely true that reducing access to lethal means as one example for an individual in their home environment or for a population.

In every instance where this has been studied, where there are suicide hotspots, let's say certain bridges, or other means of suicide that turn out to be very common for a particular population, this could be pesticides in Asia, coal gas in the UK from, you know, back in the 1950s, and in every instance where these sort of naturalistic experiments in a way occurred, where those those lethal means became less available either through policies that were happening in the environment, or because, you know, for an individual, they got some help either from their clinician, or a colleague or a family member to actually make their home environment safer by securing or storing all lethal means outside of immediate access to them, that suicide rates go down for those populations when those lethal means are less accessible.

And so the other piece that's really important to know is that among those individuals who have survived a even medically serious suicide attempt, over 90% of them do not go on to die by suicide, at least in the long-term studies that have been done, which are, you know, all different methodologies and timeframes, but it really shows that living through a moment of acute suicidal crisis can be truly suicide-preventive, not only in the short run, but in the long run as well.

- Yeah, your point, I was thinking this as you were speaking, as a psychiatrist, I've had the opportunity to meet many people who had attempted suicide, and fortunately were alive.

So they then were getting treatment, and they, the vast majority, are so thankful that they're okay and getting treatment, and moving forward with their life.

So getting over that hump makes a very big difference.

- Yes, that's right.

And part of the suicide prevention movement, by the way, which in the past was really made up solely by suicide loss survivors, in the advocacy space at least.

Of course, clinicians and scientists as well, joining forces.

And remember, people don't just wear one hat with this, many of us who are professionals are also personally touched with our own lived experience or the experience of loss.

But what has happened as stigma has gone down is that people who've survived their own attempts, we call people with lived experience in the suicide prevention field, they have joined the movement strongly.

They are, and I'll say we, as somebody with my own lived experience, are making our voices heard in a way that is sort of rounding out the picture.

You know, if you think about every other advocacy movement where social change has happened to reduce stigma, and particularly for health issues, let's say cancer, HIV AIDS, really any health issue that was previously stigmatized, the loved ones are involved in speaking out, but what can be the most impactful is when individuals who themselves have experienced it are the ones to, you know, come and testify before Congress, or speak out in a public way to help not only humanize the the issue so that it's not just a clinical sort of entity, but to actually help researchers and clinicians learn more about the fullness of the experience.

So there is an incredibly strong movement, I would say underway, where that kind of sharing of narratives and experiences is happening very strongly.

And it's an incredible thing to be a part of.

At the American Foundation for Suicide Prevention, we have chapters across all 50 states.

And so at every out of the darkness walk, or every education program, or Suicide-Loss Survivor Day, people are sharing their stories and connecting with each other.

And that's deepening the community.

And when I talk about how do we get more sophisticated at moving past just reducing stigma to actually walking the walk, and what does that look like in our lives?

That's what's happening within the community.

- I think your point is so important.

And for somebody who may be at risk of suicide, and thinking about it, hearing somebody who sort of has been there and done that but now is okay, is more powerful than anything else in many ways, to say, "Oh, this person who, oh, I respect, I'm listening to this person, they got through it, maybe I can also."

- Yes, yes, it's so true.

And, you know, you're reminding me of the way that I got my start in becoming interested in suicide prevention was an experience I had in academic medicine at University of California San Diego where I was Dean for Student Affairs and Medical Education and also, you know, psychiatrist.

So I was advising hundreds of medical students and trainees, but also treating patients, and doing research on these topics as well.

And when we...

Unfortunately, the community suffered a number of suicide losses, of physicians, to suicide, over a period of time.

This was, you know, a couple decades ago.

And when the institution became serious about doing something to reduce suicide risk of the physician and trainee population there, one of the most powerful things that happened in addition to, you know, a massive education approach, and an interactive screening program that got instituted, was the sharing of stories.

(soft music) - Please, join me next time as I continue this important conversation about suicide prevention.

(music continues) Do not suffer in silence.

With help, there is hope.

Funding for this program was provided in part by The American Psychiatric Association Foundation.

Additional funding was provided by The John & Polly Sparks Foundation.

Remember, with help, there is hope.

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