In a country as vast and diverse as the United States, creating a national suicide prevention system like Denmark’s would pose significant challenges. In its absence, it’s worthwhile to explore causes for America’s ever-increasing suicide rate and seek solutions there. In this book we’ve looked at common risk factors for individuals and some groups, including Natives, agricultural workers and rural people, Black Americans, and military personnel. Many of the risk factors and social causes contributing to suicide in these groups can be generalized to our entire population.
Poverty and unemployment are recurring themes, as rising suicide rates since around 1999 and accelerated rates since 2007 are linked to periods of increasing unemployment and economic instability. And as we know, people without jobs, benefits, and resources have the most challenging time getting mental health support in America. Here is a chilling example of just one cohort. In the late 1960s, according to Anne Case and Angus Deaton, authors of the excellent book Deaths of Despair and the Future of Capitalism, 95 percent of white men from ages twenty-five to fifty-four had jobs. By 2010, 80 percent had jobs. By 2018, recovering from the 2008 recession, 86 percent had jobs. Of the jobless in 2018, only 20 percent were looking for work and were designated unemployed. The rest were considered absent from the labor force. Case and Deaton determined that places where fewer members of the working-age population were employed had higher rates of suicide, drug overdoses, and alcohol-related liver diseases. Other studies indicate that unemployment adds to suicide risk in both men and women, and that job loss is a stronger predictor of suicide than other economic factors, such as income or education level.
Unemployment can rob individuals of self-esteem, status, job satisfaction, and financial stability. Unemployed people may feel like a burden to their families and develop the idea that friends and family would be better off without them. They may have feet firmly planted in the circles of danger described by Thomas Joiner’s interpersonal theory of suicide. For those with mental health issues, joblessness and its resulting poverty make it even harder to benefit from mental health care. At least with jobs, they had a chance to purchase therapy if they could find it.
In the ever-evolving science of suicide, new and unexpected causes percolate to the surface. For example, climate change. Climate change can contribute to extreme weather events and natural disasters such as floods, hurricanes, and wildfires. Resulting social disruption, including crop failures, loss of livelihood, and displacement, add to mental health stressors and increase the risk of self-harm. Complicating all this is the general anxiety of knowing that we’re methodically destroying our planet, which seems to be most acutely felt by the young.
Interestingly, in the last two decades, researchers have noted that living at higher altitudes lowers mortality from all causes…except suicide. Suicide rates increase by 0.4 per 100,000 individuals for every 100 meters gained. One likely reason is that decreased atmospheric oxygen interferes with brain function. However, the declines in cancer and cardiovascular disease found at altitude surpass the rise in suicide rates.
Further research will determine if higher altitudes in the western and mountain regions of the United States contribute to higher suicide rates. Montana, Wyoming, Colorado, Utah, Nevada, and New Mexico suffer about 30 percent more suicides than the national average, earning this collection of states the nickname the “suicide belt.” More accepted causes include the rural nature of many of these states, their corresponding lack of mental health resources, the high rate of gun ownership, and high rates of population shift. These states have more transient people, which results in weakened social bonds and social institutions like marriage and religion. Decreased social integration raises the suicide rate. Add to that a high population of older single white men, many of whom are unemployed. While 80 percent of suicide deaths in America are among men and women ages forty-five to fifty-four, men age eighty-five and older have the highest rate of any group in the country.
Early puberty, defined as the onset of secondary sexual characteristics before the age of eight in girls and nine in boys, has been linked to an increased suicide risk. The exact causes of early puberty are not fully understood, but factors include genetics, environmental toxins, and obesity. One potential link between early puberty and suicide is through the psychological and social stressors that often accompany this developmental stage. With the onset of puberty comes a significant increase in the levels of the hormones estrogen and testosterone, which can affect brain development and lead to changes in mood and behavior. Adolescence is a time of important social and emotional development, and an early puberty can lead to a mismatch between physical and emotional maturity, causing feelings of discomfort and confusion. Put another way, the brains of adolescents are not developed enough to maturely deal with the flood of emotions brought on by puberty. These emotions can lead to an increased risk of depression, anxiety, and other mental health problems that are known risk factors for suicide.
According to the CDC (Centers for Disease Control and Prevention) the suicide rate among young people ages ten to twenty-four increased by 57 percent between 2007 and 2018. Around 2000, scientists first noticed that puberty had been coming earlier for American children, a trend that continues today. It is plausible that the early onset of puberty and the increase in adolescent suicide rates are connected.
The biggest, most obvious roadblock to reducing suicide in the United States is our profit-driven, deeply inequitable health care system. Rising costs of medical care result in many Americans delaying or skipping checkups and procedures. Individuals are being diagnosed with cancer at later stages than necessary and are rationing or forgoing critical medicines such as insulin. Almost 50 percent of Americans have delayed or skipped medical care because of its steep price tag. Short of making medical care available to everyone, as Denmark has, there are many improvements we can make.
About a third of health care dollars spent in the US go toward administration, which is significantly higher than in other countries. Experts attribute its high cost to lack of standardization in health care systems, which leads to great discretion and variance in billing from one hospital to the next and from one provider’s office to the next. The federal government could enforce standardization. It has chosen not to in large part because of the powerful lobbies of health services and drug and device manufacturers. These lobbies aggressively fight such progressive, lifesaving ideas. Instead, the government has chosen to provide insurance, a job for which it’s uniquely unsuited, rather than reforming health care as a whole.
Insulin in the United States costs ten times more than in Canada, and simple procedures at monopoly hospitals are 12 percent higher than those in markets with four or more competitors. This tells us that unvarnished greed plays a role in our medical system’s dysfunction. The US has more advanced technology and sophisticated medical systems than any other country, leading, for instance, to a greater number of MRIs and cardiac surgeons per capita. But this does not result in better outcomes. Survival rates for heart disease have risen relative to other developed countries, but there’s been underprovision of routine care for conditions such as high blood pressure and mental illness. Treating mental illness and particularly suicidal ideation is not as lucrative or prestigious as other medical services. As we’ve seen again and again, finding affordable, good-quality mental health care is ludicrously challenging and doubtless adds to our epidemic suicide rate. One recent study of young people concluded that living in a county with a shortage of mental health providers was connected to a 16 percent higher suicide rate. About 20 percent of children in the US have a mental health condition, but only about half of those who need mental health care are currently receiving it. This is as stark a rebuke as any I’ve seen of the way our nation faces mental health and suicide.
Experts argue a coordinated national plan is a must to make a real dent in America’s suicide crisis—along with much more funding. In some places, private health care systems and other organizations are making headway in creating comprehensive suicide reduction plans. In particular, the Zero Suicide initiative and CCBHCs (Certified Community Behavioral Health Centers) show promise. But the impact of both is far too small to be felt nationally, and will be so for the foreseeable future.
It may be impossible in a book about suicide to explore every demographic and marginalized group who battle with self-harm. I have failed to address groups whose challenges are deserving of books of their own. Two immediately come to mind.
Studies indicate LGBTQIA+ youth are more vulnerable to suicidal ideation and attempts; they are more than four times as likely to attempt suicide as their peers. This is due to their experiences of prejudice, discrimination, and societal rejection. LGBTQIA+ youth may also deal with other stressors like coming out, the worry of being rejected by their loved ones and friends, and a lack of access to the right mental health supports. To lower the risk of suicide and to advance mental health, it is crucial for our country to adopt proactive measures to assist and welcome LGBTQIA+ people.
The suicide rate for persons seventy-five and older is currently 19.1 per 100,000 people, higher than the general suicide rate of 14.5 per 100,000 people, according to the CDC. Several factors can raise an older person’s risk of suicide. Physical and mental health issues are the primary cause. As people age, they are more prone to develop chronic illnesses such as cancer and heart disease, which can cause discomfort and impairment. Cognitive decline, depression, and other mental health issues may be more prevalent in older persons, and they contribute to social isolation and loneliness. As friends and family members die, many older people face a loss of social connections and may become less engaged in social activities. After retiring, many older persons can feel as though their lives no longer have any purpose. They may not know what their place in society is.
Support and services for older persons are essential, especially for those who might be in danger. This includes having access to programs that encourage social involvement and relationships, support groups, and mental health services. By addressing these problems, we can lower the suicide rate among senior citizens and raise their standard of living in general.
Until our government does what needs to be done and enacts the measures that experts say are necessary to bring our suicide emergency under control, the battle against self-killing will be fought town by town and family by family. Friends and loved ones just like you and me must take on the formidable challenge of facing suicide. Fortunately, as we’ve seen in communities across the country, hope emerges from unexpected places.
Butte Civic Center, Montana, Winter 2018. Outside the gym it’s just 26° Fahrenheit and snowing. Inside it’s deafening with drumbeats, foot stomps, handclaps, and the nonstop roar of two teams’ fans trying to out-stomp and out-roar each other. And the game hasn’t even begun. More than two thousand people pack the stadium, and maybe half have made the 145-mile trip from Arlee to watch the Warriors as they prepare to defend their Title C Division Championship against Manhattan Christian, a private school. They don’t care that they’ll drive more than two hours back home through snow. The Warriors warm up with conspicuously fast displays of three-pointers, behind-the-back passes, wraparounds, layups, and fakes. The Warriors are favored to win—they won the division last year. But can they do it again, subjecting Manhattan Christian to their own personal Groundhog Day by making them relive last year’s defeat? And can the Warriors do it in the middle of a suicide cluster that’s taken twenty lives and is ripping the soul out of the Flathead Indian Reservation?
In the midst of unthinkable pressure, the team takes a time-out in the locker room. They feel a burning desire to do something to address the suicide crisis, to punch a hole in the stigma surrounding the disease that’s been killing their community. Urged on by Coach Zanen Pitts, they decide to make a video for social media. Crowded into a drab cinder-block hallway as hundreds clamor for them mere feet away, the Warriors take a stab at words they’ve committed to memory, each taking a sentence and delivering lines with halting sincerity. Phillip Malatare, Greg Whitesell, Lane Johnson, Darshan Bolen, Will Mesteth, Isaac Fisher.
We the Arlee Warriors are dedicating this divisional tournament to all the families that have lost a loved one due to the pressures of life. We want you to know that you will be in our hearts and in our prayers as we step onto the floor to represent our school, community and our reservation. As a team, we rely on each other to get through the challenges on the court or in life. To all the youth on the Flathead reservation, we want you to know that we stand together with you. Remember, you are the future. Please help us share this message and join our team as we battle against suicide.
The Warriors shoot their video off to social media and take to the court. Coach Pitts takes up the tale. “And then right after that, they ran out and played an epic game and we won. And, you know, the fairy tale continued. So we get on the bus that night and we’re going home and my wife says, look how many views this has. So I look at it. It’s got like a hundred thousand views. I’m like, whoa, it wasn’t even that good.”
That homemade video spawned more videos professionally shot by team videographer Jordan Lefler. Emails, snail mail, and phone calls poured in. The media wanted a piece of the Warriors, but what touched the team the most were young people who wrote to praise, commiserate, and even confess their own suicidal thoughts. Their overwhelming response gave birth to a suicide prevention campaign called the Warrior Movement. Their motto: Together We Rise. Their videos live online at jointhewarriormovement.com. Greg Whitesell and his fellow athletes, young men and women alike, began visiting schools around the state to spread powerful messages of hope and unity in the face of suicide. Greg admits he is by no means a natural speaker, but before crowds of strangers, he tells his tale while revealing the joyful charisma he exudes on the court. He feels compelled to spread the idea without which he probably wouldn’t have survived until the critical night his friends rescued him.
He says, “It’s all about getting to the next minute. I remember Coach Zanen told me that one time, and it wasn’t even about suicide. We were just working out and that really resonated with me. Just get to the next minute, you know. Sure this minute’s hard but the next minute, something new could happen. So if you’re going through a hard time, try to stay positive. It’s hard I know, but there are good things to come.”
“All right. If you have a friend, a family member, a coworker, check on ’em. Check on ’em. It’s the best deterrent—‘how are you doing today?’ Suicide is the most preventable kind of death and almost any positive action may save a life.”
At a packed Charlotte music venue, Fonda Bryant’s hour-long presentation about getting in suicide’s face is part confessional and part revival meeting. Her big personality is set to stun; she holds nothing back. After her near-miss with suicide in 1995, she founded a nonprofit called Wellness Action Recovery, which is her springboard for public talks, podcasts, television appearances, and a whirlwind of suicide-prevention activities. She’s won too many prizes and accolades to list, but they include the 2021 Nexstar Remarkable Woman of the Year award, the 2021 Black Mental Health Symposium Mental Health Advocate of the Year award, and many others.
Fonda thought the high-rise parking garages in Charlotte, some up to nine stories tall, attracted too many people who jumped to their deaths. She wrote letters to garage managers and has so far succeeded in placing signs at strategic points in five garages and counting. They read You’re NOT alone. Need help? along with the National Suicide Prevention hotline number. Fonda’s lifesaving efforts are achieving results. Garage suicides are trailing off.
On countless afternoons like this one before a crowd in Charlotte, Fonda speaks in her role as a Gatekeeper Trainer for QPR Institute, a national suicide prevention organization. People trained in the methods of QPR—which stands for Question, Persuade, Refer—learn to see the warning signs of a suicidal crisis and how to question, persuade, and refer someone to assistance. Fonda draws from her 1995 near-tragedy and recounts her aunt Spankie’s speedy intervention after Fonda told Spankie she could have her shoes.
“Watch behavior clues,” Fonda tells her Charlotte audience. “Talking about wanting to die. Being a burden to everybody. Giving away prized possessions. You all heard what I said; I called my aunt Spankie, my shoes were my prized possession and I told her she could have them.”
Prized possessions might not seem like a big factor in suicide prevention, but they stand for so much more. They embody the web of interpersonal connections most of us inhabit, intimate bonds that help keep us alive or torment us with their absence. So it stands to reason that after her talk in Charlotte, when Fonda paid a visit to Spankie’s house in Gastonia, her aunt would disappear for a few moments, then return with a half-dozen boxes of her own shoes to show off.
“Oh my goodness, look at your shoes!” Fonda’s hands nearly shook with anticipation. Spankie’s collection had a more practical bent than hers, so rather than flowered pumps and elaborate heels, Spankie modeled hiking shoes, equestrian boots, and whimsical sneakers embroidered with images of Bart Simpson. Fonda had something nice to say about each pair.
Spankie said, “I’m renovating my house, so keep in mind some of my shoes I cannot get to right now.” She gave me a conspiratorial look. “And I don’t think I should say out loud how many pairs of shoes I actually have.”
Amber Dykshorn has been a farmer, a farmer’s wife, a widow, and now an insurance agent. But mainly she’s the proud mom of Kalee, Kahne, and Kolbe. If she talks about her late husband, Chris, for more than a few seconds, her voice catches and her eyes fill, but she’s got way too much can-do to let Chris’s suicide define the future for her family or herself. Being a professional widow isn’t in her DNA. On this bright August morning, there’s a family meetup at Lake Francis Case, a reservoir on the Missouri River in South Dakota. Amber’s parents are taking the family boating, which means float-towing and waterskiing. Strapped into flotation devices, the kids grin with anticipation. Standoffish Kahne removes his sunglasses long enough to show me eyes shining with mirth. Kahne, Kolbe, and Amber go first in the big float.
“Here we go, here we go!” Amber wraps her arms around her boys and holds them tight. Kalee, tall and bronzed, is the only real water-skier in the bunch, so she’s up next. Later, Amber tells me, “Chris is still with us in a very big sense. I never want my kids to forget their dad. I am looking forward to seeing my kids grow up. And I don’t want to miss out in any part of their life. Seeing my kids grow up is what gives me hope. Hope of a bright future for each one of them.”
On the subject of hope, SAVE’s Dan Reidenberg draws from his years of guiding suicidal people out of darkness and toward lives worth living. He says, “Ultimately, I really get hope from those that are really close to death that we can keep alive. That we can see that finding a way to connect with them keeps them alive. And sometimes that is through therapy and sometimes it is just through a good listening ear. Sometimes it is by checking in with them when they most need it and being there for them.”
CAMS developer David Jobes finds hope by looking into the future. “What gives me hope in the field of suicide prevention are the young people. You know, I’ve got a lab of twenty to thirty students who are on fire! They are so excited to be part of the solution, to be doing research and learning about this and going on to academic careers or going on as clinicians or working in the field. That’s what gives me hope.”
Anna Whiting Sorrell, in charge of responding to the firestorm of suicides that tore through the Flathead Indian Reservation, and her family long before that, hasn’t been touched by hope yet, but she’s homing in on it. When I interviewed her for the camera, she said, “I am really, really proud to be a Salish woman sitting in this chair today. That, somehow, I can help communicate to a broader world, to understand how this epidemic of suicide has impacted my own family, certainly my community, my tribe overall. And I am so indebted that people are willing to hear our story and help us get to a place of hope.”
Columbia University epidemiologist Madelyn Gould has made a close study of hope in the face of suicide. She’s found hope in the most hopeless and has put her finger on how to cultivate it. Her perspective deeply influenced the creation of this book.
“Rather than the social transmission of suicide, what we’re trying to do is to turn it on its head and start the social transmission of suicide prevention. The way you start a contagion of hope is to start spreading stories of recovery, spreading stories of resilience, spreading stories of hope. Because people don’t think that you can recover from many different types of mental illnesses. But you can.”
If you are thinking about suicide or if you or someone you know is in emotional crisis, please call or text 988 at any time to reach the 988 Suicide and Crisis Lifeline for confidential, free crisis support.