SALT LAKE CITY — Nearly 45,000 Americans died by suicide in 2016, a statistic that includes increases in a majority of states between 1999 and 2016, according to a new report from the Centers for Disease Control and Prevention.
Bucking a common public perception, fewer than half of those who took their own lives had been diagnosed with a mental health disorder, the report says.
Instead, the CDC notes suicide typically arises from a combination of factors. Its list ranges from relationship problems (42 percent), acute crisis (29 percent), problematic drug and alcohol use (28 percent), and poor health (22 percent), to job loss and money trouble (16 percent), legal issues (9 percent) and loss of housing (4 percent), among others.
"It's never just one thing," says Michael Staley, suicide prevention research coordinator in Utah's State Medical Examiner's Office. "Anybody who reduces suicide or an explanation for our rate of suicide in any population to one or two things is sadly mistaken. I think that mentality is an impediment to us moving forward."
He likens attempts to "demystify and simplify" suicides' causes in ways that ignore the real complexity to peering into "rabbit holes — and what they really do is dangerously, perhaps, convince people to put resources in one place, when we need a lot of resources in many different places."
Public health issue
Suicide is now the 10th leading cause of death in the United States. The CDC's Vital Signs report released Thursday notes that the rates of most causes of death have been declining.
Nevada alone saw a decrease in the suicide rate since 1999 — and that decrease was just 1 percent, according to the report.
The most recent suicide rates, taken from data between 2014 and 2016, ranged from 6.9 per 100,000 residents in Washington, D.C., to 29.2 per 100,000 residents in Montana. The report said suicide rate increases ranged from below 6 percent in Delaware, which had the smallest increase, to a more than 57 percent increase in North Dakota.
Other states with particularly large increases included Utah, Idaho, South Dakota, Kansas, Oklahoma, Vermont and New Hampshire, each with increases of between 43 and nearly 58 percent. Overall, the increase exceeded 30 percent in 25 states.
Reducing the number of suicide deaths and reversing a nearly two-decade trend toward higher rates will require cooperation, creativity and doggedness, says Kimberly Myers, Utah's State Coordinator for Suicide Prevention and Crisis Services in the Department of Human Services.
"One thing this report emphasized is we are never going to have the opportunity to rely on just one strategy," Myers says. "There needs to be a comprehensive approach touching all systems, all community partners."
Suicide prevention is a public health issue and a community challenge that reaches into families, too, she says.
"The mere fact my position exists says we know we have a problem," says Staley, whose job includes interviewing family members and friends after a suicide to understand contributing factors. "We know some of the factors, but there's a great deal more we have to learn about the problem."
Who and why
The CDC report notes differences among those with and without mental health conditions who die by suicide. The vast majority of those with no known mental health diagnosis — 84 percent — are male. Females make up nearly a third of those with known mental health conditions who die by suicide, compared to 69 percent who are male.
There are a couple of gender differences when it comes to suicide. Men tend to choose more lethal means than women, such as firearms, which offer little chance for one to have a change of heart or survive. Women attempt suicide at higher rates and are somewhat more likely to survive because of those differences, Staley says.
Utah's demographics are "fairly consistent" with the rest of the country, he adds, including the "modal age" for suicide, between 36 and 45. While a lot of prevention efforts target youths "for very good reasons," those ages 10-17 years old account for between 5 percent and 7 percent of the total number of suicides.
Similar to the CDC's national numbers, in 2015, 51.2 percent of Utah residents who died by suicide did not have a known mental health condition. That same year, 40.7 percent were being treated for a mental illness at the time of death, while 48 percent had been treated for a mental illness at some point in their lives.
Those numbers have a caveat, says epidemiologist Elizabeth Brutsch of the Utah Health Department. They are based on the information investigators were able to gather, but not all reports mention mental illness diagnosis or treatment, so the number with undiagnosed mental illness could be overestimated.
Both Staley and Myers say that when the 2017 numbers are finalized, officials expect Utah's suicide rate to have dropped slightly. But for now, Utah ranks No. 5 in terms of suicide.
"Even if it does level off from where we are, we'd be leveling off from a very high rate," says Myers.
Making a difference
National and local experts agree prevention is everyone's business — and many things can make a difference.
Because relationships are a factor in so many suicides, Myers says to be mindful when you're going through a rough relationship patch — and watch out for loved ones who are doing so, too. "We need to be considering, as a community, have we identified the people to reach out to for support and do we reach out when we see others in relationship problems?"
Two of the mostly common ways people choose to die — firearms and medications — offer families and others opportunities to intervene and change the numbers, experts say, so part of suicide prevention efforts focus on reducing access to lethal means. Having immediate access to means increases the likelihood of an "impulsive" suicide. Nearly half of Utah suicide deaths result from self-inflicted gunshot wounds.
"The thing that we say until we're blue in the face on the prevention-advocacy side is that families of all ages need to restrict access, mainly to firearms and prescription drugs. We will probably be saying that in 40 years. It might be true someone can find another way, but it's also true if you provide five more minutes to think of an alternative or five more minutes to think of a reason to live or five more minutes for someone to arrive home," you've provided time that can make a difference, says Staley. "You can change the outcome."
He says to store ammunition and firearms away from each other — and lock it up.
Myers says to properly store and dispose of medication, too.
Utah's suicide prevention efforts are varied. Besides reducing access to guns and medications, Myers says they include improving the quality of health care to make it more responsive to people who have suicide risk. Part of the effort involves changing social norms to be more supportive of getting help for psychological pain and suffering.
"Everyone goes to the ER for a broken arm or to a pediatrician with a new baby. But with emotional suffering, not everyone's getting care," she says. Strategies include awareness and communication campaigns.
Officials are also encouraging training — a kind of mental health first aid — to understand and treat mental health crisis, addiction and related issues.
One tool for crisis in the Beehive State is the SafeUT app, which connects people to a crisis counselor. When the app is connected to a particular school it can also serves as an anonymous tip line for school districts. It can be used if someone's being bullied, a kid is seen drinking in the bathroom or if a person is worried a friend might be suicidal, among other things.
The national report is bad news, the CDC acknowledges, but people are not helpless to prevent suicide.
Myers agrees. "I think we are making progress and, at the same time, there's a lot of work to do. We are learning what's working and what's not. We've started a lot of initiatives and good strategies, but we really have to dive in in a more meaningful way."
Utah and the nation are making inroads messaging youths, she says, in part because they're easy to find, through the schools. "That's where we have more experience and comfort. Now we're pushing, as well, to say how do we think about middle-aged men and prevention? It's a big learning process. We still have a lot to learn but we have to figure it out."
The CDC suggests people review the warning signs and how to respond and keep handy the number for the National Suicide Prevention Lifeline, manned around the clock to talk to those who are considering suicide or know someone who is. That number is 1-800-273-TALK (8255). In Utah, use the SafeUT app or call its crisis line, 801-587-3000.
"Suicide is a leading cause of death for Americans — and it's a tragedy for families and communities across the country," said the CDC principal deputy director, Dr. Anne Schuchat, in a written statement. "From individuals and communities to employers and health care professionals, everyone can play a role in efforts to help save lives and reverse this troubling rise in suicide."