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Deadly Stigma: Robin Williams' Suicide Exposes Silent Epidemic

Suicide remains a largely silent epidemic, the rare killer that fails to inspire celebrity PSAs. Robin Williams’ death could change that fact.
Warm, funny Robin Williams wasn’t so alone when he died in an apparent suicide on Monday, leaving behind his grieving family and a nation of bewildered fans. Recently self-harm has been taking more lives annually around the world than war, murder, and natural disasters combined. In more advanced countries, only three causes of death steal more years of life expectancy, according to data prepared last spring by the Institute for Health Metrics and Evaluation at the University of Washington.
And yet suicide remains a largely silent epidemic, the rare top-10 cause of death that fails to inspire celebrity sing-alongs, bake-sales, and all-night telethons. Last year the Centers for Disease Control flagged self-harm as “an increasing public health concern.” But even with grabby data—like the fact that U.S. suicide deaths now outnumber deaths by automobile accident—the subject drifted off the op-ed pages and out of the public mind.
Williams’ death could change that fact. It’s a tight-focused tragedy, of course, but on Tuesday suicide researchers expressed hope that the case may bring broader attention to one of humankind’s oldest and most elusive killers. They see the potential for a much-needed public tipping point, a moment that pushes suicide awareness into the mainstream like AIDS after the death of Rock Hudson, or heroin after the overdose of Philip Seymour Hoffman.
“It would be nice to see the same thing happen for suicide,” said Matthew Nock, a Harvard professor of psychology and one of the world’s leading suicide researchers. “It’s a really big problem,” he added, but the funding for suicide research and prevention “just pales in comparison to cancer and AIDS, and all this other stuff because of the stigma associated with it.”
Part of the attention-gap lies in suicide’s deceptive toll on society. The suicide rate—the number of people per 100,000 who kill themselves each year—dropped in developed countries between 1990 and 2010, according to the University of Washington data. In the United States, meanwhile, the rate has jumped almost 20 percent in the last decade, according to the CDC. But take a longer view back to World War II and the American suicide rate has not changed much at all.
The alarming part, say researchers, is that suicide remains an untamed cause of death. Heart disease, cancer, HIV, most infectious diseases, almost every kind of accident: they’re all in relatively steep decline, while suicide floats along, or even rises. It’s among the only major threats to get significantly worse in this century than in the last. And the reason is darkly profound: as more people survive into middle and old age by the grace of modern medicine, more people are left to die by their own hand—starting with Williams’ own generation.

Williams, whose bright life was emblematic of the Baby Boomers, is leading them still in death. The suicide rate among Americans 45 to 64 has jumped more than 30 percent in the last decade, according to the CDC, and it’s possible to slice the data more finely than that. Among white, upper-middle-aged men, the rate has jumped by more than 50 percent, according to the public data. If these men were to create a breakaway territory, it would have the highest suicide rate in the world.

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“We absolutely have to start focusing attention on the middle aged,” said Julie Phillips, a sociologist at Rutgers and among the first researchers to notice the rise in Boomer suicides. In a paper she presented last year, she argued that Boomers are “the tip of the iceberg.” They have the highest suicide rate right now, she found. But everyone born after 1945 had a higher suicide rate than expected—and everyone is on pace for a higher rate than the Boomers.

She calls it, “the new epidemiology of suicide.”

Fortunately, there is also a new science of suicide risk and prevention, with researchers like Nock leading the way. Patients themselves are a not a reliable source on their own suicidal thinking. There are more than a 100 proven risk factors for suicide, but they can blind like a snowstorm, making it hard to differentiate people who want to live from those who want to die.

Williams was depressed, his publicist said on Monday, and he has admitted to substance abuse problems, two notorious risk factors for suicide. But on the journey from depression or drug abuse to death by suicide the vast majority of people will stray. Until recently, the literature offered no reliable way to tell which people, however, and that was a huge hole in the field.

Nock and colleagues have tried to fill it with a novel diagnostic exam. It’s a short, computer-based quiz, originally designed by social psychologists. The social psychologists wanted to gauge a person’s unconscious bias against, say, a certain race. Nock redesigned it to gauge a person’s “bias” against living or dying. And it seems to work: in recent studies, the exam has done a better job than patients and doctors in predicting real world suicide attempts.

“I don’t think this is going to solve all our problems,” conceded Nock, who won a 2011 MacArthur grant for the work. “But within 20 years I think we’ll be much, much more scientific and systematic in how we detect and predict suicidal behavior.”

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This fall, with a record million-dollar grant from the American Foundation for Suicide Prevention, Nock plans to test the exam in a live emergency room setting at Boston’s Massachusetts General Hospital. Rather than just have a doctor ask a person whether they are considering self-harm, Nock’s team will give psych patients a tablet computer.

They’ll be asked to fill out a questionnaire, run through a pair of tests of unconscious interest in death, or bias against life, and then sign a form allowing a computer to frisk their medical records for additional predictors. If the results work, they could revolutionize the way doctors target their suicide prevention efforts.

Thomas Joiner, a psychologist at Florida State University, is also working on quantifying the risk of suicide. He’s the author of a comprehensive theory of suicide, an explanation, as he likes to say, “for all suicides at all times in all cultures across all conditions.” Like Nock, he was trying to make order out of the blizzard of facts and figures on suicide risk.

What he came up with was a “danger zone,” a set of three overlapping conditions that create a dark alley of the soul. If the conditions align, he argues, the result is a suicide attempt. The first two conditions are related to the desire to die. He says that the desire begins with loneliness, in essence, a thwarted need for inclusion and connection. He says it deepens with a feeling of “burdensomeness,” the sense that one is a liability to those around them.

But while these two conditions may create a hunger for death, suicide requires something more: the ability to die. He calls it a “fearlessness” that’s not laudable but not weak either. His point is that it’s hard to die by suicide, to break through the instinct to flee from death.

Now Joiner, who directs the Pentagon’s $30-million-dollar Military Suicide Research Consortium, a multi-year effort to reduce the suicide rate among veterans, is also testing a diagnostic tool. He hopes to measure the presence of his three conditions. If he’s right about them—and numerous studies suggest that he is—then the ability to foil them is the ability to save a life.

Nock and Joiner are getting help from outside psychology as well. A study published last month in The American Journal of Psychiatry provides promising evidence of a gene that predisposes a person to suicide. Participants were given a blood test for the gene, related to a part of the brain that regulates stress, and based only on the results of that test researchers were able to predict with 80 percent accuracy which people were considering suicide, or had already attempted it.

“We still have a long way to go,” said Joiner, who wasn’t part of the blood study. He was commenting on the state of the field from outside a suicide research conference in Texas, one where attendance has jumped from dozens to thousands in just over a decade. “But the overall trends are very positive.”