How are Iraq and Afghanistan war veterans dying? Is there an epidemic of premature deaths, relative to their civilian counterparts, among the still relatively young men and women who saw combat deployment over the past decade? In an era of big headlines and the twenty-four hour news cycle, the average American citizen might justifiably presume that suicide is the leading cause of death among veterans of the Iraq and Afghanistan wars. We have all heard variations on these startling pronouncements: “More Iraq veterans have died by suicide than were killed in combat operations!” “One Iraq war veteran commits suicide every hour!”

Despite the media-driven answers one might think exist to the question that heads this post, the factual truth is no one really knows. The reason we do not know is that all-cause mortality among these veterans has not been carefully studied or tracked.

Texas-based study

A few months ago, the Austin American-Statesman published results of an examination of all-cause mortality among Iraq and Afghanistan war veterans who were listed as VA beneficiaries in Texas. Their results, published in a three-part series September 30, October 1 and 2, 2012, indicated that drug overdoses or toxic combinations of drugs (mostly prescription medications, such as painkillers like Oxycontin) accounted for approximately as many deaths as those that were clearly suicide. Of the 266 deaths with known causes in this study, 16.9 percent were ruled as suicides, 18.8 percent were as a result of motor vehicle accidents and 17.7 percent were drug-related deaths.

This is important information, and yet the Statesman study raises more questions than it answers. This is true for several reasons:

1. We do not have a clear understanding of the number of veterans who were VA beneficiaries in each year of the study. Without this denominator, it is impossible to calculate rates of the various causes of death.
2. Causes of death were only obtained in about two-thirds of the cases, leaving us with many individual mysteries about how and why these veterans died.
3. We have no contextual information to compare these data to. How do these Texas veterans’ deaths compare to an age-gender-race matched comparison group of non-veterans from Texas? 

What remains are some very interesting raw numbers, but we still do not have all the answers needed to guide prevention efforts.

Now what?

So, where does that leave us?  As we wrote in a blog post for the Huffington Post recently, there is good reason to be more concerned about prescription medication deaths among veterans. This is an issue that has received only scant attention. Few people involved in the national dialogue on combat veterans’ issues are talking about this or seem to recognize the grave threat it poses to the health and well being of our active-duty troops and more than two million veterans. This is despite the fact that prescription drug use of opioids rose dramatically over the past half-generation, and is now America’s deadliest drug epidemic. The CDC reports that more than 15,000 people in the U.S. die each year from overdoses or toxic combinations of prescription medication painkillers. This is more than a 300 percent increase since 2000, and the numbers continue to rise. In fact, more people die from abuse of prescription painkillers than from cocaine, heroin and all other illegal drugs combined. Three years ago opioid-related deaths surpassed traffic accidents to become the leading cause of accidental death in America.

Young veterans, with their catalogue of blast injuries, headaches and chronic back/joint pain, may be especially vulnerable to the dangers of opioid prescriptions. Even for those who do not overdose, opioids change the brain, rewiring neural circuitry that leads to a host of other ripple effects – physical, emotional and social. Of course, we also should be concerned about the tragedy of suicide among our veterans. Especially since suicide has risen dramatically over the past decade among active-duty military personnel and since suicide may be more prevalent than it was historically when compared to wars of the past, such as the U.S. Civil War (1861-1865).

In an encouraging follow-up story, the Statesmen reported that since their study ran – and possibly because of their effort – the VA has announced plans to conduct a large national study of all-cause mortality among veterans of Iraq and Afghanistan. This is good news, as it will shed light on veteran suicides and drug overdoses, and will help answer the question posed in this post’s headline. As a nation we have a duty to help veterans live long and productive lives. An important step toward realizing this is to ensure that we fully understand all causes of veterans’ deaths, especially premature deaths. It is encouraging that perhaps we are about to begin a national effort to do this.

Perhaps the commonest observation about the 2012 election was that it painted a picture of “a nation divided,” red in the middle and blue around the edges. But there’s at least one sentiment that unites us all: relief that it’s over. One more attack ad might have been just too much to bear.

That’s the good news.

The bad news is, as we put the drama behind us, we now face the suspense of the “fiscal cliff.” Unless you’ve been without television or Internet access for the past several months, you know that the fiscal cliff refers to the calamity we face at the end of the year (that’s this year), when terms of the Budget Control Act of 2011 are scheduled to go into effect. At midnight, as we ring in the New Year, an assortment of tax reductions will end and more than 1,000 government programs, including the defense budget and Medicare, will be automatically cut by more than $800 billion. Economists tell us that this almost certainly will wipe out the economic gains of the past few years and drag the economy back down into recession and higher unemployment.

Why is a mental health professional writing about this in a forum devoted to promoting human well-being? Take a look at the chart below, from a recent issue of The Lancet.

It shows how the steady increases in U.S. suicide rates in recent years have tracked with the struggles of the U.S. economy, the unemployment rate in particular. According to this analysis, during the recession, 4,750 people lost their lives to suicide who might have survived in better economic times. This is not a unique observation; for example, the suicide rate in Greece has risen more than 60% since the onset of the economic crisis in 2007.

This makes complete sense from a psychological standpoint. Suicide occurs when people with vulnerabilities, such as depression, schizophrenia and certain personality traits, encounter stressful situations that push them beyond what they are able to manage. Unemployment is one example; equally pertinent to recent struggles in the U.S. is the mortgage crisis, in which hundreds of thousands of people lost their homes to foreclosure. Divorce and addictions, both suicide risk factors, also worsen during hard economic times.

So, it is not an overstatement to state that lives depend on resolving the fiscal cliff dilemma.

Of course, we might reassure ourselves, “With stakes so high they’re bound to figure something out at the last minute.” But this once safe assumption might not be consistent with a new normal in Washington; for this election has left us with essentially the same Congress that not long ago stalled so long on increasing the debt ceiling that Standard and Poor’s actually lowered the credit rating of the U.S. Government, an unprecedented event that most had considered unimaginable.

It is time to tell our elected officials that their responsibilities regarding the fiscal cliff extend beyond any partisan political agenda or message that they may want to send to their respective bases. Lives literally hang in the balance, and the fiscal cliff is not a problem that mental health professionals are in a position to treat.

These days “friend me” has become an action, indicating someone wanting to establish contact on Facebook. What started as a purely social networking site has expanded into a medium for change, but nothing so important as the Facebook service designed last year to help prevent suicide.

When on Facebook, users can provide support and help to friends when they identify comments that appear to indicate thoughts of self-harm or suicide. If someone has concerns for a friend, they can use either the Report Suicidal Content link or other report links throughout the site.

The person who posted the suicidal comment will receive an email from Facebook encouraging them to call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). Alternately, the person can click on a link to begin a confidential online “chat” with a crisis worker.

The Lifeline is a toll-free hotline that has 152 local crisis centers across the country and is funded by the Substance Abuse and Mental Health Services Administration. The hotline is answered 24/7 and has answered over 3 million calls since it started in 2005.

The Surgeon General of the United States, Regina Benjamin, MD, MBA, serves on the National Action Alliance for Suicide Prevention. On the Surgeon General’s website, she points out,

“Nearly 100 Americans die by suicide every day, which is 36,035 per year…. These deaths are even more tragic because they are preventable.”

“Identifying those at risk is the cornerstone to suicide prevention,” says Kelly Posner, director of the Center for Suicide Risk Assessment at Columbia University/New York State Psychiatric Institute.  “Facebook’s innovative services enable concerned users, or ‘friends,’ to intervene immediately and initiate this life-saving identification process. Reaching people through venues they use and providing them with referrals is an important and encouraging step in the right direction.”

The military is keenly aware of the problem of suicides. According to Veterans Affairs Secretary Eric K. Shinseki, a retired Army general, former Army Chief of Staff, and a combat-wounded Vietnam veteran, “Suicide is the second-highest cause of death for young people ages 25 to 34.”

It is a problem the military has seen acutely in the last 10 years, and the Veterans Administration has also focused this month on prevention of suicides. Since many armed services personnel keep in touch with family and friends by using Facebook, this service can help identify and refer active-duty military when a concern is raised, saving Americans even far away from home.

For those who want information on how to help identify someone at risk for suicide, I recommend the American Foundation for Suicide Prevention. The site offers clear guidelines about psychiatric disorders, warning signs of imminent danger and some concrete things to do to help.

Once a concern is raised, a referral to a crisis intervention hotline or other professional treatment is needed to prevent the senseless loss of life to suicide. What better act of friendship could there be?

Today, September 10, is World Suicide Prevention Day. This is potentially a time to reflect and celebrate how far we’ve come.

Would that we could.

Death rates from many of the top killers in this country – AIDS, cancer, heart disease, homicide – have dropped, dramatically in some cases, over the past couple of decades. 

You might assume that suicide, the number 10 leading cause of death, would have shown a similar decline. You would be wrong.

More than 100 people per day die by suicide in the U.S., 37,000 in 2009, the most recent year for which data are available. This translates to a rate of 12.0 deaths per 100,000 population per year. The rate 10 years ago was 11.0. Fifteen years ago it was 11.4. Twenty years ago it was 12.0.

Picking up a pattern here? These number drive suicide researchers like me to distraction.

Have we made no progress? Actually we have – lots. We understand the factors that make certain individuals vulnerable to suicide better than ever, and this knowledge is leading to the development of tailored treatments that show great promise.

But no major cause of death has ever been defeated simply by treating people with the illness. Public health problems like suicide require major artillery aimed at reducing vulnerability before it becomes a problem (think seat belts, one reason why deaths from traffic accidents have decreased in recent decades).

To begin to understand why suicide has remained stubbornly entrenched as one of the leading causes of preventable deaths in this country, consider these facts:

This table shows several leading causes of death in the U.S. and levels of research funding by the National Institutes of Health. One quickly sees that the funding levels do not match up well with the numbers of lives lost. This becomes more apparent when we display these numbers by dollars per death, as shown in this bar graph:

In the words of the famous philosopher, “What’s up with this?”

Lacking an obvious answer, we can only speculate, but the question of stigma must be raised. AIDS once killed more Americans than suicide; now, more than three times more lives are lost to suicide than AIDS. AIDS activists, including many celebrities, have done a remarkable job of combatting the stigma that AIDS sufferers experienced early on, and their work has been rewarded with the funding reflected in these figures.

We are only beginning to see such movement on the suicide front. For example, I recently wrote about the commendable work of Sports Illustrated has done in shining light on mental illness and suicide among elite athletes.

But, as these figures remind us, we have a long, long way to go.

So, no, World Suicide Prevention Day is not about celebrating our gains; to the contrary, it is to remind us that we have work to do. Millions of people in this country, perhaps including you, have suffered the trauma of losing a loved one to suicide. We have an election coming up. Take the opportunity to ask a meaningful question of your elected officials, to wit:

“What’s up with this?”

Editor’s note: If you enjoyed this blog post, check out two of Tom’s other recent posts on SayNoToStigma.com:

• Is the Internet making my child crazy?
• On Junior Seau, toughness and an anti-stigma hero you might have missed

The July 23 cover story in Time magazine reminded us that the suicide rate among active-duty U.S. military personnel has essentially doubled over the past decade, accounting for more deaths than actual combat in Afghanistan during that period. This sad fact is all the more tragic because we do not understand why the rate has increased so dramatically.

Finding context in history

Compounding our inability to understand this current epidemic is a lack of historical data to provide context. In an empirical study that was just released online in the Journal of Anxiety Disorders¹, we reviewed historical medical records on suicides among Union forces during the U.S. Civil War, which took place 150 years ago.

We found that suicide rates for white active-duty Union military personnel ranged from 8.74 – 14.54 per 100,000 during the war. For black Union troops, rates were 17.7 in the first year of their entry into the war (1863), and 0 in their second year.

These numbers compare to a current rate of just over 20 per 100,000 for the U.S. military. Said another way, there were more military suicides in 2010 alone (total suicides = 295) than during the entire four years of the Civil War, for which we found 278 documented Union suicides.

Combat intensity

In an accompanying commentary², Harvard University psychologist Richard J. McNally noted that these findings on military suicides during the Civil War occurred within the context of shockingly intense combat operations. That is, the death rate for Union forces during the Civil War was 48 times higher than for modern U.S. troops serving in Iraq and Afghanistan. Thus, the data from the Civil War indicate that combat intensity by itself is not necessarily a strong predictor of military suicides. This is underscored by the authors of Time’s cover story, who point out,

“Nearly a third of the suicides from 2005 to 2010 were among troops who had never deployed; 43 percent had deployed only once.”

We hope that considering a historical perspective can help us better understand and begin to reduce the tragic occurrence of suicide among our nation’s warriors.

References

1. Frueh BC, Smith JA. “Suicide, alcoholism, and psychiatric illness among Union Forces during the U.S. Civil War.” Journal of Anxiety Disorders; 2012.

2. McNally RJ. ”Psychiatric disorder and suicide in the military, then and now: Commentary on Frueh and Smith.” Journal of Anxiety Disorders; 2012.

There’s a notable journal in the mental health arena that you might not have considered for your must-read list. It contains thorough, highly informative articles on mental health issues that are scientifically informed yet highly relevant to experiences of real human beings.

It’s called Sports Illustrated.

Of course, SI is not exactly a scientific journal or a clinical periodical, but you should know that it has a consistent track record of taking readers beyond the machismo and glamor of elite athletics to zoom in on the human beings whom millions of us watch and identify with week after week. A recent issue, for example, told the stories of four minor league baseball players, one of whom made a deliberate decision to use performance-enhancing drugs, was the only one of the four to make it to the big leagues and who paid the price in emotional problems, addictions and thoughts of suicide. Also enlightening has been SI’s regular reporting on the toll of concussions on football players and the reluctance of the NFL to take action to protect the players.

However, what has impressed me most has been SI’s stories on mental illness among high-performing athletes. The leadership of the magazine, together with the courage of the athletes who talk publicly about their struggles, has been of incalculable value in reducing the stigma of mental illness and making it more acceptable to seek help.

Sharing stories

For example, about this time last year, in an article titled, “A Light in the Darkness,” SI writer Pablo Torre told the stories of three major league baseball players who were willing to speak about their emotional problems, substance abuse and suicidality, as well as their journeys in treatment. In it, Torre noted, “Baseball is taking the lead in pro sports in addressing depression, anxiety and other mental health problems.”

More recently, in telling the story of Junior Seau’s suicide (blogged about recently by colleague Michael Ulanday), SI eschewed any inclination to present a sanitized, hero-worshiping piece in favor of one that spoke to the humanity of the man, for better and for worse. Seau was the stuff of football legend: a fierce, hard-hitting linebacker, perennial all-pro and well-liked teammate, who seemed impervious to pain. (In a 14-year career in the NFL, he missed a total of 9 games.) A retrospective on his personal life revealed many red flags that went largely unacknowledged by others or even by himself.

Indeed, in a soul-searching commentary in the same issue, Peter King confessed that he was among the writers who lionized Seau for his disregard for pain:

“Seau insisted that if you could walk, you could play. And we all ate it up. There’s much in that to be admired, certainly. But when you don’t acknowledge pain in your professional life…how will you ever acknowledge pain when the cheering stops? By all accounts, Junior Seau never acknowledged his personal pain – whether it was the black veil of depression or the misery of not having a life he wanted to live – to anyone.” 

Thus, what might have been an idealized but empty tribute to an icon, with shrugged shoulders about the “mystery” of why “a guy who had everything” would suddenly kill himself, unfolded instead as a poignant lesson in reality: the blood, bone and psyche of a giant.

Suicide theory

It is worth noting that a prominent current theory of suicide maintains that a key factor that makes suicide possible, despite our robust survival instinct, is repeated exposure to injury. This desensitizing process is thought to take some of the fear out of self-harm, to the extent that depression and despair are able to evolve into self-destructive action. Might this be a factor in the suicide of athletes, when combined with depression, substance abuse, loss and other vulnerabilities? Should we, in fact, be discouraging “toughness” in sports?” 

Not at all, in my view. There is a place for toughness in sports, just as there’s a place for toughness in the military, in the healthcare professions, in ballet and in life in general. But the lesson here is that there is an overriding need for balance in health and well-being, comprised not only of toughness, but also of self-knowledge, self-nurturance and knowing when to persist in the face of pain and when to yield to it. The last of these qualities is much easier named than accomplished and requires perspective that is often missing in sports and too often missing in other life arenas as well.

We can hope that in telling stories such as Junior Seau’s, Sports Illustrated is helping athletes and their mentors develop this too-rare form of wisdom.

NFL great Junior Seau commits suicide at 43.

When the news of Junior Seau’s death broke on May 2, my mind immediately flashed back to Dave Duerson. I wondered if Seau was the victim of some heartless act or if he had done this to himself. However, as more details began to emerge — he was found in his home alone, dead from a gunshot wound, a gun near his hand — it became clear Seau had taken his own life. The circumstances of his death instantly drew parallels to Duerson’s own suicide, and naturally, speculation arose about the role chronic traumatic encephalopathy (CTE) may have played in Seau’s death.                                                                        

It may be weeks before an autopsy determines what (if any) role CTE played in Junior Seau’s death, but the paramount concern in this tragedy shouldn’t be what drove him to this end; rather, it should be what could have been done to prevent it. In the wake of Seau’s suicide, scores of opinion pieces and memorials have come out, often offering commentary on the issue of concussions and player safety in professional sports. Brandon Marshall, for example, recently wrote an op-ed for the Chicago Sun-Times, but rather than look for somewhere to lay blame, Marshall looks for a means to preventing further tragedy. 

A professional football player, Brandon Marshall recently announced he had been diagnosed with borderline personality disorder and had been seeking treatment for it. In doing so, Marshall became a passionate advocate for not just mental illness issues, but for treatments available to help individuals with mental illness. In his op-ed piece, Marshall briefly broaches the topic of CTE, but mainly focuses on the stigmas associated with mental illness, gender roles regarding emotion, the idea of the machismo persona in sports and the interplay between the three.

He also talks about the attitudes toward emotional expression that are espoused early on in life (it’s okay for girls to cry, but not boys), and how those attitudes set up misguided perceptions of what defines strength. Marshall argues that this stigma is only exacerbated in professional sports, where an athlete’s ego is the measure of toughness and ultimately, success:

In sports, those who show they are hurt or have mental weakness or pain are told: ‘You’re not tough. You’re not a man. That’s not how the players before you did it.’

“It’s a cycle,” Marshall writes. While in treatment, Marshall had to learn “how to think, not what to think.” Indeed, overcoming decades of a stringent way of thinking takes effort, competent guidance and a good deal of faith. While it was too late for Dave Duerson and Junior Seau, Brandon Marshall saw that he was fortunate enough to break the cycle and understands that it’s not too late for the living. He ardently endorses the various forms of therapy he utilized in treatment — namely DBT, and mentalization therapy — and calls for fellow athletes to utilize the resources at their disposal to get the proper help they need. 

Marshall speaks to the greater need to eradicate stigmas associated with mental illness, thus lifting any potential barriers to successful treatment. The unfortunate fact is that with mental illness, a definitive diagnosis is much more elusive than a broken rib or a sprained ankle. It is not a body part that can be wrapped, iced, stretched and rested back to health. It’s an entire state of being that has to be dealt with in a coherent and comprehensive manner.

What brought Marshall back from the brink could prove to make a difference in so many lives. As vital as it is to discern the causes of mental illness (physical trauma, emotional trauma, genetics, etc.), an equal emphasis must be placed on effectively treating these issues as they come to light. Brandon Marshall’s position as an advocate is important in light of this tragedy, but all could be for naught if others don’t step up and reclaim their mental health.

The legendary Whitney Houston

My treasured colleague, Tom Ellis, wrote an impassioned post protesting simple-minded thinking about Whitney Houston’s death. I, too, am irked by glib media interpretations of the behavior of stars. I find it challenging to fathom the complexity of individual patients who courageously confide their inner life in psychotherapy; I am loath to pretend to understand anyone I observe only from afar. And diving into the murky territory of death wishes in my part is a prime example of fools rushing in where angels fear to tread. Far more foolish than angelic, I proceed.

Muddling through

I agree with my colleague in some respects. We can kill ourselves in the quest for pleasure — witness heart-stopping doses of cocaine. I am partial to the idea that addictive drugs “hijack” the normal brain reward systems. And there is no reward greater than escape from unbearable pain. Karl Menninger viewed nonsuicidal self-injury as “anti-suicidal” behavior. Cutting, banging or burning oneself can reduce emotional distress dramatically. Such behavior appears “self-destructive” only to the outside observer; to the person engaging in the behavior, it is self-preservative, a way of muddling through to live another day. The same might be said of addiction.

Penchant for self-destruction

I am less sanguine than my colleague about a thoroughgoing constructive orientation in human nature. He writes, “…All of us have the same basic agenda to find happiness and manage physical and psychic pain the best we can.” I find myself more sympathetic than he with Freud’s view of divided forces in our nature, constructive and destructive. Freud gave us a naturalized version of the age-old battle between good and evil, an enduring contest. I find ample evidence that destructiveness can be self-directed.

Granted, we are the products of evolution, and survival is the engine of evolution. But we should be humbled by the fact that well over 99 percent of species that ever lived are now extinct. Evolution does not necessarily lead to progress, much less to perfection. Perhaps we humans are not unflawed in our orientation toward life. We are hardly single minded, as Freud well understood.

Our capacity for gaining knowledge through science is stunning, but we also are developing increasingly sophisticated, life-threatening technology. Prescient about the human species’ capacity for self-annihilation and the anxiety that goes with it, Freud wrote before the advent of nuclear weapons. I wish our sociological knowledge were keeping pace with our dangerous technological advances. We humans might be unique among species in our seeming penchant for self-destruction. Above all, we need to learn how to cooperate before we join the other 99 percent (not the non-super-rich, the extinct).

Death instinct

I have no idea what was on Whitney Houston’s mind in the hours, days, weeks, months and years before her death. And I have no idea if Freud’s idea about the death instinct is best regarded as crazy or as something we should take very seriously as we witness horrific destructiveness across the globe. Our consciousness is misleading; we are aware of a tiny fragment of our mental activity, and we have little idea what our brains are up to. I think we should be more modest in our conjectures about others and, as Freud showed us, even about our own motivations. And we must be careful about generalizing about addicted persons or any other group in light of enormous individual differences — another engine of evolution.

I am not ready to throw up my hands in the face of destructiveness and self-destructiveness. I cannot fathom solutions to global problems. I cling to one uncommonly wise young woman’s reply when I asked patients in an educational group, “What gives you hope?” She replied, “I can be surprised!” But I take heart in small-scale victories. Day in and day out in this clinic, we help patients grapple more successfully with their self-destructiveness.

Whitney Houston dies at 48.

Fox TV personality Bill O’Reilly has encountered a firestorm of protest in defense of Whitney Houston following his provocative remarks about her death. However, he may have done all of us a favor by opening a door to discussing something on all of our minds.

Here’s what he said (as part of a general statement opposing efforts to reform drug laws):

Nobody takes drugs for that long if they want to stay on the planet. She follows in the footsteps of Elvis, Janis Joplin, Michael Jackson, and scores of other entertainment figures. The hard truth is that some people will always want to destroy themselves, and there’s nothing society can do about it.

If we filter out some of the harshness (and perhaps add names like Judy Garland and Joseph McCarthy), we might express this as a question:

Just as a healthy lifestyle reflects desire to live, doesn’t it make sense to assume that people with unhealthy or reckless lifestyles have a death wish?

While this brings us uncomfortably close to “blaming the victim,” one can’t help but notice something appealing about this perspective. It certainly gives us something to do with the anger we inevitably feel about poor decision-making by someone we cared about. And, conveniently, we note that the issue gets buried with the individual. After all, the problem was in the mind (soul?) of the deceased. Case closed. Better yet, as seen in O’Reilly’s remark that such will always be the case and “there’s nothing society can do about it,” we are forever excused from worrying ourselves, looking for ways to address other influences, whether social, psychological, biological or otherwise. Nope, not much you can do about human stupidity.

Must feel pretty crummy to Whitney’s family…

Here’s the fly in the ointment: Applying this mindset, we suddenly all have a wish to die. Certainly this includes all smokers and couch potatoes, who we know have shorter life expectancies. But even among us non-smoking, exercising, healthy-eating, seatbelt-wearing respectable citizens with good judgment, which of us adheres perfectly to our medication prescriptions? (Studies say less than half.) Who among us never exceeds the speed limit or occasionally takes a peek at our cell phones while driving? Doesn’t this point toward at least a hint of a death wish?

A death instinct?

Probably not. Sigmund Freud thought this was an intriguing idea and wrote at length about a “death instinct,” but eventually abandoned it as unsupportable. Suicidologists still occasionally talk about “indirect suicide” in the form of everything from unsafe sex practices to sky diving; but as we do so, we soon find that the construct of suicide itself evaporates, because it ultimately becomes identical to living itself.

A human agenda

A more reasonable idea is that we — all of us — have the same basic agenda to find happiness and manage physical and psychic pain the best we can. The fact that some get lost on this quest and end up destroying themselves in the process does not change the fact that the wish in most cases is not to die, but to find a path, at least, to a more tolerable existence.

By the way, here’s another problem with observations like O’Reilly’s: A circular explanation is one that loses meaning because it turns back onto itself. To wit: Why did Whitney do those unwise things, resulting in her own death? Because she wanted to die. How do we know she wanted to die? All together now … because she did all those unwise things!

Really, O’Reilly. We can do better than this. Scientific research over the past few decades has revealed a great deal about motivations behind unhealthy and self-destructive behaviors, and effective treatments have resulted. We still have a lot to learn, and we still lose battles more often than we would like. But stigmatizing and blaming the sufferers only impedes our efforts to win the war.

Try a thought experiment: Imagine you’ve been asked to predict whether it will rain day after tomorrow, and someone’s life depends on your accuracy. And the loved ones of that someone are looking to you to get it right. If you fail, and this person dies, they not only will be devastated (not to mention how you will feel), but they may very well hold you responsible in court for their loved one’s death.

Assessing risk

Feeling a little (or a lot) nervous? Then you’ve begun to understand what it’s like for a mental health professional doing a suicide risk assessment. Believe it or not, much like the weather, suicide is not predictable with a high degree of accuracy. To the contrary: Even highly sophisticated statistical models get it wrong more often than they get it right. Although researchers have identified a wide variety of risk factors associated with suicide (such as depression, social isolation and substance abuse), the vast majority of people with these risk factors do not kill themselves. Thus, predicting suicide based on risk factors results in huge numbers of “false alarms.” Likewise for questionnaires: helpful but not prophetic. 

To add to the frustration, merely asking an individual if he or she is planning to end his or her own life raises a bundle of other issues. The last thing on the mind of a seriously suicidal individual is sharing that information; anyone knows that this would likely move others to intervene. Preservation of life, a given among loved ones and professionals, is not a goal that this person shares. 

This is enough to make a mental health professional fantasize about a blood test or some other kind of crystal ball that would solve this terrible conundrum.

Genius at work

Matthew Nock, PhD (photo courtesy of John D. and Catherine T. MacArthur Foundation)

Dr. Matthew Nock*, a Harvard psychologist and recent recipient of a MacArthur Foundation “genius” grant, doesn’t have a crystal ball, but he is asking an interesting, fundamental, question: Might there be a way of detecting suicide risk otherthan asking the patient or looking at the patient’s history for clues to the future?

Enter the Implicit Association Test (IAT).** This is a pretty straightforward, computer- administered task that requires the test taker quickly place words presented on the screen in one category or another. For example, does the word “apple” belong in the category “red” or “blue”? Sweet or salty? Food or tool? Now try this one: Obama – me or not me? This one’s a little different, for now we begin to get into matters of values and emotions. And such internal processes as these are not fully known to us; they are often unconscious (hence the term “implicit”), but the IAT has shown that they are detectable.

So, how about this one: Death – me or not me?

A better predictor?

The actual task is a bit more complicated than this; but, in essence, what Nock has discovered is that people at risk for suicide take slightly more time (in milliseconds) to make discriminations around death and suicide than nonsuicidal people. Moreover, performance on this task predicts future suicidal behavior above and beyond depression, clinical assessment, past suicidal behavior or even the patient’s own predictions. In other words, a measureable process, beneath the individual’s level of conscious awareness, predicts future behavior better than professional judgment or self-report.

This method is still in its infancy and is not nearly ready for “prime time” in clinical practice. But it does inspire some hope that research eventually might enhance our ability to save lives in an arena where clinical wisdom thus far has fallen short. 

Perhaps there’s hope for better weather forecasts as well. 

*To sample this test with respect to such emotional issues as political preference or racism, visit www.implicit.harvard.edu. It’s free and anonymous.

Editor’s note: Dr. Nock will give a presentation describing his work at Grand Rounds October 5 at the Menninger Department of Psychiatry & Behavioral Sciences at Baylor College of Medicine.