Image: Kevin Hines
John Storey  /  SF Chronicle via Corbis file
Kevin Hines sits on the rocks next to Fort Point underneath the Golden Gate Bridge. Hines survived jumping off of the bridge in a suicide attempt.
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updated 12/4/2008 9:07:57 AM ET 2008-12-04T14:07:57

John Kevin Hines had been pacing on the Golden Gate Bridge for 40 minutes in anguish, crying. If one person asks me what's wrong, I won't go through with this, he thought, over and over.

Eventually, a woman wearing giant sunglasses approached him. "Would you take my picture?" she asked. The 19-year-old accepted the camera from her and clicked it five times. Then he snapped. The moment Hines released his hold on the 4-foot-high railing, he regained his grip on reality.

During the 4 seconds between jump and splashdown, he could think clearly. All the problems that had made him want to die moments earlier? Those seemed less overwhelming than a 220-foot plunge into San Francisco Bay. Oh, my God, I don't want to die, he thought. What have I done? God, please, save me. It's a prayer seldom answered. Since the bridge opened in 1937, someone has jumped from it every 2 weeks on average. Out of roughly 2,000 attempts, only 28 "failed."

The psychologist Edwin S. Shneidman, Ph.D., a pioneer in suicide research, once said that it's a bad idea to kill yourself when you're feeling suicidal. That's no joke: You're not solving problems well. You're unable to step outside your troubled mind. And those things make you a very, very dangerous man. Realization of the risk comes too late for many, from bottom-rung stragglers to men whose lives and achievements seem worthy of celebration, not self-termination.

Their final act perplexes family and friends. It saddens them, sickens them, and even angers them. And in the end, it worries the rest of us, too. Because any of us could be walking that bridge one day. The numbers are so gut-churning, it's like looking over a bridge railing. Nearly 26,000 men took their own lives in 2005. That's nearly four times the number of women who did the same thing, even though three times more women than men attempt suicide. (For every completed suicide by a man or woman, 25 attempts fail.)

Whereas a woman might swallow pills halfheartedly, a man is four times more likely to complete the act, mostly because men tend to use guns — and their aim is true. As grim as that sounds, it gets worse. Mark S. Kaplan, Dr.P.H., who researches suicide at Oregon's Portland State University, believes the suicide death toll may be up to 25 percent higher than officially recorded. Many single-car accidents seem mysterious. When an overdose occurs and toxicology results are ambiguous, as in the case of Heath Ledger, was it a tragic accident or an exit strategy? Some medical examiners will certify a death as suicide only if the victim leaves a note, and yet only about 20 percent of people who kill themselves do so. Sometimes insurance companies pay the survivors less, or nothing at all, in cases of suicide. The denial of friends and family is a factor, too: It's less painful to think a loved one didn't die by his or her own hand.

The Centers for Disease Control and Prevention's National Violent Death Reporting System, which tracks the circumstances surrounding violent deaths (including suicides), might be able to sort all this out — if it were funded in more than 17 states.

'Uniquely dangerous moment'
There's always an internal detonator with suicide, but an external spark helps light the fuse. One factor that comes along every few generations is economic distress. During the Great Depression, when banks went bust and people's life savings vanished, suicide rates soared. Another instigator: large numbers of veterans returning from armed conflict, many of them with troubled (or injured) minds, lousy job prospects, and fractured families. Which begins to explain why suicidologists, who study the phenomenon, are feeling a little edgy themselves these days. "For those who serve in the military, the suicide risk may be even greater considering multiple deployments, possible brain trauma from concussive blasts, and combat-relatedpost-traumatic stress," says David A. Jobes, Ph.D., a professor of psychology at the Catholic University of America. "This may be a uniquely dangerous moment for young American men and suicide, given the recent economic upheaval."

As a cause of death, suicide is different from disease; the ripples from each event extend much further than a single splash in San Francisco Bay.

At the Boston Park Plaza Hotel & Towers, the 20th-anniversary "Healing After Suicide" conference is under way. The room is dark except for candlelit tables surrounded by survivors — an umbrella term for friends and family members of the deceased. (Currently, nearly 5 million people in the United States have had a suicide in their family.) I stroll among large bulletin boards covered with photographs of faces: smiling, serious, shy, handsome, nondescript, friendly, distant. This isn't a gallery of misfits; these are the kinds of expressions that fill all of our family albums.

In a side room at the conference, I see a haunting echo of the smiling victims pinned on the bulletin boards. The last row of academic posters ends with disturbing photographs of men and women striking suicidal poses. These aren't actual suicides; the images are from the International Affective Picture Set, designed to provoke responses in psychology experiments. The researcher, Donald H. Marks, Ph.D., M.D., is the hepatitis clinic director at Cooper Green Mercy Hospital in Birmingham, Alabama. Ten of Dr. Marks's hepatitis C patients became suicidal while they were taking an interferon drug. The drug's prescribing information warns that this could happen. So when Dr. Marks performed functional MRI scans on the brains of these suicidal patients while they looked at the creepy photos, they all showed "activation" in specific brain regions that might be associated with suicidal thoughts. Might there be a self-destruct button embedded in our CPU, one that could be identified and disarmed in at-risk individuals? Jobes, for one, thinks suicide will never be reduced to something so simple.

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"After all, we know the brain chemistry of depression, but most depressed people don't take their own lives," he says.

On stage in the other room, a mother is recalling one of her five children, the brightest of her brood. He could have done anything in life, she says, but in high school, with no warning, he shot himself in the head. Suicide is murder for your loved ones. Much of her adult life has been an attempt to find meaning in a devastating loss.

Thomas Joiner, Ph.D, a professor of psychology at Florida State University, is also dealing with that kind of loss. I'd studied his research and prepared my questions on my way to Tallahassee to meet with him, but it's only when we sit down across from each other, alone in a huge, impersonal conference room, that it occurs to me: I need to ask this 43-year-old father of two sons about his own father's death — by suicide.

"I'm comfortable talking about it," says Joiner, who also lost his maternal grandfather to suicide. "It's important to discuss, as a way of learning more about an important public-health problem."

As a kid growing up in Atlanta, Joiner knew his father felt down once in a while. But he suspected nothing more. Even later on, when he studied suicide as a graduate student at the University of Texas at Austin, he didn't make the connection. The day his dad died, his mother called to say he'd disappeared. The police wouldn't find the body until 2 1/2 days later. The cause of death: a self-inflicted knife wound.

"My response was extreme shock," says Joiner. "Just a deep, agonizing sort of loss and sadness — what most people feel in such sudden-death scenarios."

The final page of his father's life would remain blank; there was no note. Only in hindsight does Joiner suspect that his father had a variation of bipolar disorder. The hidden nature of suicidal thoughts makes me wonder if perhaps a lot of men entertain these urges.

"I take your point," says Joiner. "There is this other layer: Why did it happen? How much anguish and pain must he have been enduring? That was there for me, and it remains there for me to this day."

The vague threat, the unvoiced desire for death, is not unusual in men who will eventually kill themselves. They may make an offhand crack or casual remark. "They'll hint that something's wrong and then take it back," says suicide expert Lisa Firestone, Ph.D., coauthor of "Conquer Your Critical Inner Voice." Even doctors don't know what to do half the time. Kaplan randomly chose primary-care doctors in Illinois from the files of the American Medical Association and sent them a survey, asking how they managed depression and suicidal tendencies in their patients. Roughly 50 percent of the doctors said they wouldn't ask those patients if they had access to a gun at home.

Mental health professionals often don't have all the training they need to help at-risk patients, either. As part of his master's degree program in psychology, Jason Spiegelman served an internship as a therapist at the San Fernando Valley Community Mental Health Center, in California. "Learning the theory and actually practicing it are two very different things," he says.

Sitting in a Baltimore restaurant, Spiegelman describes a Monday morning that began for him like any other — until he arrived at work. As he walked in, he says, the secretary glanced up. "One of your clients committed suicide over the weekend," she said, as if announcing the arrival of a FedEx package. A feeling of nausea flooded the young therapist's body as he climbed the stairwell to his boss's office. "I'll never forget it," he says. "The fear. The self-loathing. Am I going to lose my internship? And then, a second later: How can I be thinking of myself?"

Spiegelman instantly knew who was gone. Juan (not his real name), a Latino man in his 30s, had been in therapy for years. The man's case file spilled over with notes outlining years' worth of mental doodling about suicide — what the experts call ideation. For all of his formal education, Spiegelman hasn't taken a single class on suicide. That's the norm, not an exception.

"Most clinicians learn on the fly rather than in school or professional training programs," says Jobes. "It's the most common clinical emergency, and yet clinicians are not typically well trained to deal with it." Spiegelman had done everything he'd been trained to do with such clients, including taking a suicide assessment: He'd asked Juan a series of questions designed to gauge the immediacy of the threat. The more specific the suicidal thoughts are, the greater the chances they'll be acted upon, the theory goes." As often as we did the assessment, he never went beyond a vague fantasy of suicide," says Spiegelman, 35, who today works as an assistant professor of psychology at the Community College of Baltimore County, Maryland. Juan's father would later say his son's mood brightened in the days before he died. When Juan did commit suicide, he hanged himself — an approach he had never mentioned.

Spiegelman doesn't blame himself. His supervisor's review noted that he hadn't missed anything. Mostly, though, he credits Juan's father with keeping the tragic event from destroying the life of a second man. "He was as gracious as you could imagine," says Spiegelman. "He said it wasn't my fault, that his son spoke highly of me. The father took care of me, which was a nice thing, because it doesn't always go down that way."

Suicidal men tend to share certain characteristics: They feel trapped in their lives. They're commonly substance abusers. Depression, bipolar disorder, and schizophrenia are highly correlated with suicide risk.

But there are still miserable men with no desire to check out early, thank you, and others who seem well adjusted but who flirt in their minds with suicide. Psychotropic drugs that dampen depression don't always douse a death wish.

"I think every man is capable of reaching a desperate place where suicide can move onto his psychological radar screen," says Jobes. "But who goes there, when, how, and why is this unique interplay of biochemistry, social forces, family modeling, and other factors. How those queue up is remarkably complex and specific to the man who's struggling at that moment. "I'd always thought of suicide as a tragedy primarily affecting two groups of men: adolescents, for whom upheavals that would seem manageable soon enough instead become matters of life and self-inflicted death; and the aged, who might feel miserably alone or who simply can't stand the thought of another day of nursing a hurt that's been aching all their lives. There's a reason for that misperception.

"Several years ago, colleagues of mine organized a National Institute of Mental Health conference on suicide and middle-aged men, and there was sort of a ho-hum reaction," says Jobes. "Like, who cares about those guys? Most suicide prevention focuses on subgroups, whereas few seem to notice the 800-pound gorilla."

"Men in the overall U.S. population just haven't been the focus of a lot of suicide-prevention efforts," adds Kerry L. Knox, Ph.D., director of the Canandaigua Center of Excellence for Suicide Prevention of the U.S. Department of Veterans Affairs. That's mind boggling, since 70 percent of all suicides by men occur in life's prime, not its dawning or twilight. Suicide rates are comparatively low under age 16, rise gradually through age 18, and then jump through age 24; the normal four-to-one male-to-female ratio of suicide deaths rises to seven to one between the ages of 20 and 24. But rather than tumbling after age 24, the rate actually levels off at the high point. One cause of the spike is that mental disorders often tighten their grip in a man's early 20s.

"[Patients with] bipolar disorder and schizophrenia have a higher risk of suicide during the first 5 years of the disorder rather than later on, when people often have learned to accept it and deal with it," says Firestone.

Recognizing psychological land mines
These individuals are usually prescribed drug regimens, which can help if they remember to swallow all of their pills. But that's a tacit admission of mental illness, one that's often resisted. In rare cases, taking mood-altering drugs can make a bad situation worse. Even if a man reaches his 20s in good shape, psychologically speaking, suicide land mines — like the ones mentioned below — remain scattered along the journey throughout his 30s and 40s.

Relationships:Joiner estimates that "romantic disruptions" and other relationship issues trigger depressive episodes in about 75 percent of men between the ages of 20 and 40 who commit suicide. "Especially in their early 20s, guys can think,This one person was right for me, I've lost her, and it's all over," Firestone says. "They lack the perspective that they're going to have other relationships, maybe even better relationships, in the future."

Career Failure:Data going back decades shows that, like clockwork, economic downturns push more men over the brink — a fact that should concern us all now. Men draw much of their identity from their careers, and when unemployment rises, that underpinning falls away. Many men at that highly vulnerable age for suicide — the early 20s — may struggle simply to begin a fulfilling career in a sharp economic downturn. The feeling of being a burden doesn't apply only to people failing at life. Even the most successful, driven men, the ones we perceive as being on top of their game, can buckle under a heavy load.

Which might explain why Tennessee Titans quarterback Vince Young was reported to have mentioned suicide to a therapist earlier this season. "With so many people identifying with and riding on his success, the burden of failure can loom large," says John Draper, Ph.D., director of the National Suicide Prevention Lifeline program. The higher the stakes, the more there is to lose.

Shame and Humiliation: It's one thing to fall from grace; it's another to have that fall subjected to public display and ridicule. That prospect was a major contributor to "executive suicides" such as those committed by Clinton lawyer and confidant Vince Foster, and Enron vice chairman Cliff Baxter. Fame isn't a prerequisite, either; going public can mean having your own family and social circle learn embarrassing news. "There's this very male lineage of suicide being a face-saving way of resolving dire circumstances," says Jobes.

Modern Warfare: Historically, suicide rates among soldiers have dropped "in theater" during times of actual combat, but that trend has been turned on its head in Iraq and Afghanistan: The number of suicide attempts in the U.S. Army has increased sixfold since the war on terror began. Nearly 600 soldiers in that military branch alone — the size of an infantry battalion task force — have died by suicide. The Army itself estimates that up to 11,600 times during that span, an Army soldier has attempted to harm or kill himself. That doesn't bode well for returning veterans, who are at heightened risk for suicide once they leave the structure of military life.

When Mark Kaplan and colleagues used national health surveys to track 320,890 men for 12 years, they learned that the veterans in that group were no more likely than the others to die from natural causes or by accident — but twice as likely to die by their own hand. Recent reports suggest 1,000 suicide attempts per month among V.A. vets, a total that the V.A. spokesperson I interviewed wouldn't dispute.Self-preservation is our most basic instinct, so suicidal people must be mentally ill, right? Not necessarily. Joiner believes men learn fearlessness every time they play a contact sport, fight in a bar, or experience pain or injury. This eases the brakes that stop us from doing something contrary to our nature. Sometimes, that includes killing ourselves.

To test his theory, Joiner asked student-subjects to fill out self-reporting questionnaires on how much pain they could withstand. Male subjects scored higher, and it wasn't just frat-house bravado. When participants were then asked to place their forearms in water barely above freezing or have their fingers pinched by a mechanical device, men lasted longer than women did. At the suicide conference I attended, researchers presented the results of an experiment that tested Joiner's theory on recent veterans of the Iraq war.

Never is "learned fearlessness" so prevalent as it is during the violence of combat, and the participants did report becoming more tolerant of mayhem and danger. "When I was overseas, I kind of lost connection with reality... and my feelings," said one subject. "If you don't have any emotions, you aren't scared or afraid, either."

If Joiner is right, many of these vets will be at high risk of harming themselves, perhaps fatally, as civilians. Learned fearlessness is particularly dangerous when it's combined with the feeling of being a burden to others.

"Those pieces — isolation, fearlessness, and feeling like a burden — simultaneously lead to suicidal behavior," says Joiner. "You think, 'my death will be worth more than my life to people I love.' "From study reviews, suicide experts find that isolation usually emerges as the biggest risk factor of all. Jobes has seen this dynamic unfold among soldiers. But when men do reach out, they can regain their footing quickly. "Once you pull them out of that internal world, they respond well to a two-heads-are-better-than-one approach to problem-solving in therapy," says Jobes. "But it's a conundrum because they're not seeking treatment."

For a man who tried to kill himself, John Kevin Hines is pretty lucky. On his descent from the Golden Gate Bridge, he threw his head back during free fall, which allowed him to hit the water in a seated position — albeit at 75 mph. He opened his eyes as he plunged 50 feet, and as it became darker, he thought, I didn't die. What am I going to do now?

A man who moments ago tried to kill himself was desperately fighting for his life now. He broke through the surface just before passing out. At the moment he jumped, a woman who had a Coast Guard friend on speed dial just happened to be driving over the bridge — which is the only reason two Coast Guard members fished Hines out of the water.

"Do you know what you just did?" one of them asked."Yeah, I just jumped off the Golden Gate Bridge." "Why?" "I don't know," said Hines. "I guess I wanted to die." "Do you know how many people we pull out of this water who are dead already?"

Of course, the best way to prevent suicide is to keep men like Hines off those bridges in the first place. In 1996, John Draper founded a crisis hotline for the Mental Health Association of New York City. Three years after gaining national attention for its work surrounding 9/11, the organization won a grant to run the national network of suicide hotlines. Every month, the network's 133 independently operated call centers receive more than 40,000 calls. A recent study in the journal Suicide and Life-Threatening Behavior found that when people call a hotline they experience a decrease in hopelessness and psychological pain (but no reduction in intent to die). The effect lasts for weeks afterward. Twelve percent of callers said the hotline kept them alive.

"Sometimes when a man's mind is locked in to suicide, there's a paradoxical openness, too," says Draper. "If you're open to killing yourself, might you be open to less absurd notions as well? They just have to stay alive long enough to find other options."

Another sobering truth is that a prior attempt makes you more likely to eventually kill yourself. But Draper turns that upside down. "Past attempts carry a lifetime risk estimated at about 7 percent," he says. "That means 93 percent of those who attempted suicide found ways to survive periods when they were convinced life wasn't worth living and to go on to live out their lives. What might they have missed otherwise?"

Back From The Brink
Leading suicide expert Lisa Firestone, Ph.D., director of research and education at the Glendon Association, details suicide's progression, and how to halt it.

1. Losing interest in school, work, or hobbies
"A male friend won't tell you he's sad, but he will tell you if he's lost interest in his hobbies," says John Draper, Ph.D., director of the National Suicide Prevention Lifeline. "Disruptions in those areas are real signs."
What he's thinking: What's the use? My work doesn't matter anymore. Why bother even trying? Nothing matters anyway.
Warning signs: Decreased work or academic performance, giving up hobbies or other previously enjoyed activities.
Don't: Cajole or demean. Nor should you assume that this is just a slump, and wait for things to pass.
Do: Gently but persistently point out that he may have a problem, and that treatments are readily available.

2. Directing hatred toward himself
"Tearing oneself apart creates the psychological pain and desperation that drive the suicidal person," says Firestone. "Suicide becomes a way to escape the pain and aggravation." I'm incompetent, stupid.
What he's thinking: I'm ugly, disgusting. I'm a fool, a creep, a reject. I don't deserve anything; I'm worthless.
Warning signs: Statements of helplessness, extreme psychological pain, desperation, increased irritability and anger.
Don't: Judge, turn away, or otherwise feel that these are feelings "real men" shouldn't have or talk about.
Do: Listen. Allow him to express his feelings. Offer him a more com- passionate evaluation of himself.

3. Feeling like a burden to family and friends
"I've had patients insist in front of their wives, 'No, no, you'll be better off without me,'" says David A. Jobes, Ph.D., a professor of psychology at the Catholic University of America. "Family members don't feel that way."
What he's thinking: See how bad I make everyone around me feel? They'd be better off without me. I'll just stay away and stop bothering them.
Warning signs: Moodiness, lack of communication, lethargy, exhaustion, hopelessness.
Don't: Ask vague questions like, "You're not thinking about doing anything, are you?" This telegraphs disapproval.
Do: Talk openly. Ask, "Are you thinking about killing yourself?" If his answer doesn't sit right, ask him again.

4. Talking about suicidal thoughts
"As simple as it sounds, talking about wanting to die by suicide is a very clear and dangerous warning sign," say Joiner. Unfortunately, that sign is often missed or ignored.
What he's thinking: I'd better plan it. It's the only thing I can do. I have to buy a gun and then find a deserted back road, maybe. Reading or writing about death, reminiscing about a dead person, saying things like, "I might as well be dead."
Don't: Assert that suicide is immoral and leave it there. He desperately needs help. Don't let him reassure you he's fine.
Do: Empathize with the pain but not the solution. Find a counselor. Call the hotline numbers.

5. Initiating his own demise
"People can become so despondent, and yet they hide intentions," says Eric Caine, M.D., co-director of the Center for the Study of Prevention of Suicide at the University of Rochester. "They might tell a doctor they're fine."
What he's thinking: I can't even do this! I've thought about this long enough. Look, I'm miserable every minute. Just end it. It's the only way out!
Warning signs: Preparing a note, a will, or both; giving away prized possessions.
Don't: Be sworn to secrecy. What's more important: his confidence or his life?
Do: Remove means (guns, pills, poisons). Connect him with crisis counselors. Time is running out.

6. Sudden, dramatic mood change — for the better
"In his own mind, he may finally be at peace with his decision — not the decision to seek help, but the one to end it all," says Firestone.
What he's thinking: This is the solution to all my problems. I have made my decision. I am in control now. All this pain will soon be over.
Warning signs: An unexpected, even jarring brightening of his disposition, especially one that doesn't feel natural to you.
Don't: Think, Whew, everything's fine now! I can stop worrying about him for a while.
Do: Ask him to give help a chance — tell him he can always decide to kill himself later. Arrange for help immediately!

© 2012 Rodale Inc. All rights reserved.

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