More than 47,000 Americans killed themselves in 2017, the Centers for Disease Control and Prevention reported Thursday, contributing to an overall decline in U.S. life expectancy. Since 1999, the suicide rate has climbed 33 percent.
Americans are more than twice as likely to die by their own hands, of their own will, than by someone else's. But while homicides spark vigils and protests, entering into headlines, presidential speeches and police budgets, suicides don't. Still shrouded in stigma, many suicides go unacknowledged save for the celebrities – Robin Williams, Kate Spade, Anthony Bourdain – punctuating the unrelenting rise in suicide deaths with a brief public outcry.
And research suggests our ways of living may be partly to blame, in ways that don't bode well for the future.
Alcohol and substance abuse are risk factors, and both are increasing. Isolation raises the risk, and nearly half of Americans say they sometimes or always feel alone. Increasing smartphone use has been linked to suicidal thoughts in teens. Even climate change has been found to have roughly the same effect on increasing suicides as an economic recession.
"We’re trying to reduce suicide death rates in the face of a culture that’s ever more fascinated with violence, that has a bunch of opiates around left and right, where family structure isn’t getting more cohesive and neither is community structure," said Thomas Joiner, a leading suicide researcher. "That’s a lot to fight against."
Suicide is the 10th leading cause of death in the U.S. and is often called a public health emergency.
But money to research and combat suicide continues to lag behind other leading killers and even non-fatal conditions. The National Institutes of Health, the largest public funder of biomedical research in the world, spent $68 million on suicide last year. It spent nearly five times that studying sleep and 10 times more on breast cancer, which killed fewer people in 2016.
"What I’m just painfully aware of is that all of the areas where the top 10 causes of death in the United States have gone down have received significantly more attention," said John Draper, director of the National Suicide Prevention Lifeline. "There’s been so much more put into every one of those causes of death than suicide. ... If you didn’t do anything for heart disease and you didn’t do anything for cancer, then you'd see those rates rise, too."
NIH officials say they do not expressly budget by disease, and research funding in other categories could affect suicide without being suicide-specific. The NIH spent $2.7 billion on mental health, for example.
"A large portion of the research is not disease-oriented but based on human biology. For instance, if we’re studying brain function, it might be pertinent to suicide, but we might not necessarily categorize it as suicide," said Michael Lauer, NIH deputy director for extramural research. "Same with depression, which obviously is linked to suicide."
Still, many in the field wish for dedicated spending. Jill Harkavy-Friedman, vice president of research for the American Foundation for Suicide Prevention, advocates for $150 million a year for suicide research, still far less than the $592 million the NIH allocated to fight kidney disease, the nation's No. 9 killer.
"We are happy that other health conditions are getting the money. ... It’s not an either/or," Harkavy-Friedman said. But "the cost of suicide is enormous, and people don’t realize it."
The cost — in dollars, in suffering, in science
Suicides and suicide attempts cost $93.5 billion a year, most of it in lost productivity, a 2016 study estimated. And that's nothing compared with the cost in human lives and suffering.
Joiner recognized the human toll 30 years ago – even before his own father died by suicide.
As a graduate student in psychology in 1990, Joiner had begun focusing on depression. That summer, his father, a former Marine sergeant turned software pioneer, took his own life.
“He was a successful, visionary, ambitious, intelligent man," Joiner said. "And he had an illness that ended up being fatal. That’s how I see him.”
Joiner, now a psychology professor and clinician at Florida State University, said his father's death helped persuade him to make studying suicide his life's work.
“I’d already inclined toward that decision, and this only made it more stark. I already knew this was a problem," he said. "It was a misery for the bereaved, and that’s not to mention the even more acute suffering suicidal people go through in the hours, days, months before their death – just a lot of suffering all around. And it wasn’t being studied then.”
It's studied now, but given the size of the problem, we still know surprisingly little about it.
"I think that we’ve told the public that we know more about suicide than we know," said April Foreman, a clinician on the American Association of Suicidology board of directors.
When someone dies by suicide, people and the media trot out a series of "maybes," she said: Maybe it was mental illness. Maybe it was losing a job or getting divorced.
"Maybe it was not getting a phone call at just the right moment. Maybe. But maybe something was happening in their brains that in 20 years we’ll understand," she said. "We tell stories about bullying or sadness like it’s a fairy tale. There’s probably real science in there, and we just haven’t decided to treat it like that. ... We’re telling stories about why people kill themselves that aren’t scientifically based, that are very inaccurate, and are just the easier stories to tell because it’s much harder to say we don’t know."
Joiner compares suicide research today to "cancer research about 100 years ago."
"People were so scared of the topic they wouldn’t even say the word," but cancer research has since made great strides, he said. "I think the same thing will happen with suicide research, but that’s decades in the future. Right now we’re in our infancy."
We tell stories about bullying or sadness like it’s a fairy tale. There’s probably real science in there, and we just haven’t decided to treat it like that. ... We’re telling stories about why people kill themselves that aren’t scientifically based, that are very inaccurate, and are just the easier stories to tell because it’s much harder to say we don’t know
Suicide studies reflect the broad sweep of the current science. Some focus on genetic factors involved in maintaining brain circuits and neurotransmitters, biomarkers of at-risk populations, brain PET imaging and medications; others focus on psychotherapies, preventing substance abuse and school nurse interventions.
The effectiveness of prevention efforts has been difficult to determine as suicide rates increase, said Andrew Sperling, director of legislative affairs for the National Alliance on Mental Illness.
"The challenge is there are various suicide prevention programs, and we’re still learning a lot about what works and doesn’t work," Sperling said. "There’s not a lot of evidence we’ve been very effective at it."
Scientific knowledge is limited. Public knowledge is wrong.
Even key discoveries that enjoy broad support among researchers have yet to percolate into the public consciousness.
Public health experts say: Suicide is preventable.
People think: Suicide is inevitable.
Consciously or unconsciously, many Americans write off those who seriously consider killing themselves as hopeless causes, unreachable. A study in 2017 showed that people are skeptical of a suicidal person's ability to recover – the idea that even if we stop the person today, we won't tomorrow.
"If you think once someone’s suicidal that they’re just going to die, then it doesn’t make sense to invest money in that," Joiner said of a common point of "ignorance."
Science tells us that isn't true. So does common sense. Survivors of suicide attempts themselves are walking proof.
In 2016, nearly 45,000 died by suicide, but the number who attempted was almost 29 times that — meaning more than one and a quarter-million survived. Though a previous suicide attempt makes the risk of dying by suicide higher, it is just one of many risk factors. Nine out of 10 people who survive a suicide attempt will not go on to die by suicide later, according to studies that have tracked survivors over decades.
Cliff Bauman, a National Guardsman who struggles with post-traumatic stress disorder, attempted suicide once, but when he faced a crisis again he was able to get through it by using learned coping skills, including being aware of his triggers and having people he can trust.
“I made the conscious decision (after my attempt) to go back into counseling,” he said. “(I) was opening up about why I did what I did and how it got to that point, and I felt suddenly ... the darkness doesn’t seem so dark.”
Another misconception is that suicidal ideation is rare. But one in 33 American adults seriously thought about suicide in 2016, the commonness of the thoughts belied by how rarely they're discussed.
"Suicide is reflective of other issues that we don’t want to talk about," said Adam Swanson, a senior prevention specialist at the Suicide Prevention Resource Center. "We don’t want to talk about the fact that people can’t afford to pay electric bills. ... We don’t want to talk about the ... pain people carry."
Survivors are often the first to distinguish that it's not a desire to die that drove their attempt but a desire to escape pain. It's something Shelby Rowe, a PTSD and suicide attempt survivor who works in suicide prevention, knows firsthand.
"If I could go back to talk to myself that night, when all I could hear in my head was 'You can't live like this anymore, you can't live like this anymore' ... I would have said: 'It's OK, you're right. It is really awful right now, and you can't live like this anymore, but please live, because there is another way. There is another beautiful life waiting for you.'"
Mental and emotional pain is less acknowledged – both by doctors and the public – than physical pain, Foreman noted.
"It is OK for someone to suffer from wanting to kill themselves and to suffer from trying to kill themselves or even die that way, but it’s not OK to feel sick with the flu for a few days," she said.
Stymied by stigma
The lack of compassion people feel for those who die by suicide is reflected in the lack of funding. Stigma goes beyond misconceptions.
"Stigma is about fear, and suicide is associated with our most primal fears – fear of death ... fears of traumatic loss and our fears of mental illness," Draper said.
Fear and discomfort also can be expressed as anger.
Retired California Highway Patrol officer Kevin Briggs said he has heard drivers shout "Go ahead and jump!" to people contemplating suicide on the Golden Gate Bridge.
Stigma is about fear, and suicide is associated with our most primal fears – fear of death ... fears of traumatic loss and our fears of mental illness
The taunts reflect a disdain some people feel toward those who attempt suicide, whom they see as "weak" or "crazy," a 2017 study found. Though mental illness is a risk factor for suicide, not everyone who is mentally ill has suicidal thoughts, and not everyone who attempts suicide is mentally ill.
But even statistics on the relationship between mental illness and suicide are incomplete "because we’re not funding it," Harkavy-Friedman said.
"Every year we go to (Capitol) Hill and we advocate at the state level for fully funding the National Violent Death Reporting System," she said.
The tracking system, now in place in just 40 states, helps health experts and law enforcement officials identify common circumstances associated with specific types of death, including suicide. Suicide can be especially hard to track without a strong system in place because family members may try to cover it up or pressure officials not to enter "suicide" into records. The CDC announced in September that it had received funding to expand the system to all 50 states and Washington, D.C.
In the past, even in clear cases of suicide, families were "not telling anybody for years because they thought they would be blamed or stigmatized," Harkavy-Friedman said.
Stigma is not only an obstacle to accurate reporting, but it also has made politicians shy away. It's part of why suicide wasn't seriously studied or even discussed until the past few decades.
“Twenty years ago when I worked on (Capitol) Hill, you wouldn’t find suicide prevention on federal documents. It wasn’t talked about in the Department of Defense or in the general public. There were no researchers. There was no national strategy for suicide prevention," said Jerry Reed, a doctor on the executive committee for the National Action Alliance for Suicide Prevention.
That changed in 1998, when Congress declared suicide a national problem, Reed said.
"Since then, the country has caught up to the significance of this issue, but it still has a long way to go.”
Congressional support is key because it affects the overall NIH budget. Congress also can pass special provisions regarding certain issues, as it has for Alzheimer's and opioid abuse.
"Congress has made that a clear priority," Lauer said.
Where's the hope? A little bit in a lot of places
Despite challenges, experts agree our understanding of suicide is light-years ahead of where it was just a generation ago. And suicide prevention is at "unprecedented" levels, the Substance Abuse and Mental Health Services Administration reports.
Through interventions, including medication and therapy, Joiner says he sees suicidal patients at his clinic go from "pretty desperate, pretty intent to die" to "turn(ing) a corner – and usually it’s shockingly quick."
Joiner theorizes that suicide results from a combination of factors: feeling like a burden, isolation, and having lethal means and a lack of normal fear of death.
Short-circuit one of those – isolation, for instance – and you might stop someone from hurting himself.
"It stands to reason if you reconnect a little bit then risk should abate, so we just arrange within the context of people’s day-to-day lives small increased doses of social connection," Joiner said. "It's a very simple behavioral idea, but it seems to work if people do it."
Asking a friend to lunch would be a great example, Joiner said, but some patients don't have a friend. They might start simply with "show up to this community event and stay for 10 minutes."
Of course, some people are chronically suicidal, but Joiner and others note that they can also feel relief through targeted therapy.
Shear Avory, a transgender person who sees a therapist (not associated with Joiner), has lived with daily suicidal ideation and continues to hold on to hope.
"For so long I've been stuck in just wanting everything to disappear, from wanting the trauma to go away," said Avory, whose traumatic childhood included foster homes and conversion therapy. "I'm still alive. I'm still here. That feels like an accomplishment. ... Healing is not a linear experience."
With unlimited funding, Joiner said he'd put resources toward practical things proven to work, such as "means safety" – which can include everything from putting pedestrian barriers on bridges to locking up guns and medicine cabinets – and training doctors to identify at-risk patients.
Training primary care doctors and other medical staff is the foundation of the Zero Suicide program.
Zero Suicide founder Mike Hogan said that though suicide is incredibly complex, determining who is at risk can actually be very simple: Once patients are in a health care setting, ask them. Studies have shown that asking people if they're thinking about suicide does not plant the idea in their heads.
"If people are asked, they often really want to get it off their chest, and they want some help, and it opens the door to help," Hogan said. "A little bit does a lot: asking, safety planning, reducing lethal means and reaching out ... turns out to be quite powerful."
A 2014 study found that 83% of those who die by suicide saw a health care provider in the year before their death. That's particularly true for older white men, who account for most suicides.
"We can’t predict when they’ll die, just like we can’t predict when someone might die of a heart attack," Hogan said. "But we can predict who needs a little help just like someone might need help because their lipid levels are high."
Hogan said two nonprofit organizations that offer mental health treatments – Centerstone, which spans multiple states, and the Institute for Family Health in upstate New York – saw roughly 60 percent reductions in suicides after adopting Zero Suicide.
Becky Stoll, vice president for crisis and disaster management at Centerstone, said one of the biggest improvements has been the methodical approach to plugging holes in care. For instance, coordination between the suicide prevention committee and their IT department resulted in a program that changed the font color of high-risk patients if they missed appointments, which would then alert them to start calling the patient. If the patient didn't answer, they'd start calling their friends and family. It was a simple change and it saved lives. In one case, a man's wife called him after she had received calls from Centerstone. He had been standing on a bridge at the time.
"I've been in the field since the late '80s, and I’ve not seen the enthusiasm the results that we’re seeing now," Stoll said. "We don’t win every time, but we win a lot. When we know better, we have to do better. And embedding these frameworks into systems of care … it really does seem like we can have impact. It seems like that’s catching wildfire across the U.S. ... (We need to) make people feel they have lives worth living."
Colorado has embraced Zero Suicide as one tool in its fight. But advocates are more closely watching the newly formed Colorado-National Collaborative, a partnership aimed at reducing suicides there by 20 percent by 2024.
Through a combination of funding from state and federal sources and the American Foundation for Suicide Prevention, Colorado's Office of Suicide Prevention went from an annual budget of $536,000 about 18 months ago to $2.6 million as of Sept. 30. If the partnership between scientists and public health professionals proves effective in the state with the eighth-worst suicide rate in the country, it could be adopted nationwide.
Colorado and other states also have joined the Gun Shop Project, in which gun store owners and firing range instructors distribute suicide prevention materials as part of an effort to reach people who might be looking for a tool to commit suicide.
Guns were used in 23,000 of the 45,000 suicide deaths in 2016.
These interventions focus on the "means," or how suicides are completed.
"We may not understand suicidality very well ... (but) we know people don’t die of feeling suicidal – they die from a gunshot wound, they die from a medication overdose. Just like you don’t die by (a driver) having poor depth perception, you die from them striking the car and your head hitting the windshield," Foreman said.
'On the cusp'?
Many in the suicide research and prevention field describe it as being on a precipice – the science is not where it needs to be, but it shows promise; the funding is not where it needs to be, but it has increased. On the other side, they hope, are the results: a nation in which fewer lives are lost to suicide or tormented by suicidal thoughts.
"With suicide I hope that we’re on a cusp of a movement," Foreman said. "Where the people who have survived suicide attempts, the people who live with chronic suicidality, the families, the loved ones, the people who are left, that they get up and say: This suffering is the same as someone who has died by HIV ... or cancer. It deserves the same quality science."
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