By Carl C. Bell, M.D., D.L.F.A.P.A.
A recent research letter published in May of 2018 in JAMA Pediatrics entitled “Age-Related Racial Disparity in Suicide Rates Among U.S. Youths From 2001 Through 2015,” asserted that the suicide rates among black children, aged 5 to 11 years old, increased from 1993 to 1997 and from 2008 to 2012. While this finding was upsetting, the results are misleading and need to be explained.
The reality is that completed suicide is a very rare event. Overall suicide rates in the U.S. usually are 11 people per 100,000 people and for adolescents the suicide rates are a bit higher, 20 people per 100,000 people. One suicide is one too many, but in order to form public health prevention and intervention strategies, things need to be put in perspective.
For example, 20,000 out of 100,000 people get depressed, and about 5,000 out of 100,000 people attempt suicide, yet the actual deaths from suicide range from 11 to 20 per 100,000 people. Therefore, how does a public health response system identify those 11 to 20 people who are at risk for completing suicide out of the 20,000 people who are depressed or out of the 5,000 people who attempt suicide? It is like looking for a needle in a haystack.
Accordingly, the JAMA research letter reported that ‘the rates for African-American children rose from 1.36 to 2.54 per million and decreased among European-American children from 1.14 to 0.77 per million.’ The denominator is so large and the numerator is so small that there is virtually no difference in these numbers and statistics. The problem is that these rates are so low, even if there is a legitimate increase; suicide is a very rare event. So, technically, there was an increase in African-American youth suicides, but practically there has been no change.
A lesson from the Institute of Medicine’s report, “Reducing Suicide: A National Imperative”, was that something must be protecting the 19,980 youth who were depressed but did not complete suicide and the 4,980 youth who attempted, but did not complete suicide. Further, if we could increase the protective factors surrounding people at risk we might be able to lower suicide rates.
Shortly after the “Reducing Suicide” report was published, the U.S. was experiencing a “rise” in college suicides. As mental health treatments improved the outcomes of youths with mental illness, they were able to complete high school and attend college. Unfortunately, many colleges were ill-prepared to deal with students who needed mental health treatment at a time when traditional psychiatric support was limited.
Preventing risk factors from becoming predictive factors by using protective factors is one pathway to pursue. Decades of research on risk and protective factors for problems like violence, drug use, and other self-destructive behaviors have revealed seven guiding principles that can be extremely protective: 1) social fabric; 2) connectedness; 3) modern technology; 4) social and emotional skills; 5) activities that increase a sense of power, models, and uniqueness (i.e. self-esteem); 6) adult protective shield; and 7) the ability to minimize trauma.
People can be very emotional at times however, if they are surrounded by family, friends, neighbors, etc., they get influenced by informal social controls and behave in an appropriate manner. Some things are just not socially acceptable, but if people are shunned by social contacts and isolated, there is little to guide them and help them control their impulses and drives. So, one major recommendation is for learning institutions to foster connectedness and be inclusive and not exclude anyone. Modern technology in the form of digital communication and social media can facilitate connectedness when used appropriately.
Having social and emotional skills to resolve conflicts or have hard conversations with people guards against adversity and prevents people from engaging in rash or unhealthy behaviors. Self-esteem (a sense of power, models, and uniqueness) also buffers people from adversity. Accordingly, giving young people a sense of purpose and accomplishment is protective.
Adult protective shield is also protective against suicidal behavior. If a person was getting counseled for feelings of depression, it would make sense for a responsible adult to restrict their means of self harm, e.g. removing a loaded gun from the home.
Lastly, minimizing trauma is protective. It is not the stress, distress, or traumatic stress that are damaging to the human spirit, rather, it is the helplessness in confronting stressors that does damage. Helping people turn learned helplessness into learned helpfulness is a great way to combat stress and help people to be resilient.
It is very doubtful science and psychiatry will be able to identify the rare suicidal individual who will complete suicide, but we will continue to try. By adding protective factors to people’s lives, we can give them a better chance at thriving and flourishing.
Carl C. Bell,M.D., D.L.F.A.P.A.,is a professor of psychiatry and public health at the University of Illinois at Chicago. Bell is a National Institute of Mental Health international researcher, an author of more than 575 books, chapters, and articles addressing issues of violence prevention, HIV prevention, isolated sleep paralysis, misdiagnosis of Manic depressive illness, and children exposed to violence. Bell is the former President/C.E.O. of the Community Mental Health Council, Inc. a large not-for-profit community mental health centers in the U.S. He is also the Director of the Institute for Juvenile Research (Birthplace of Child Psychiatry) at the University of Illinois at Chicago. He is a staff psychiatrist at Jackson Park Hospital and Medical Center on Chicago’s Southside.