Responsible Reporting of Suicides

NB: While the commentary below originally appeared in The Philadelphia Inquirer in 2004, the issues discussed are, sadly, just as relevant today.  There have been some changes in the manner in which suicide is reported in the media, however there are still glaring misconceptions about the appropriate way to cover a suicide, if it is appropriate in the first place, terms to use and terms to avoid, and a lack of knowledge about facts, risk factors, and warning signs.  The hope is that this article will serve as a reminder about the importance of responsible reporting of suicides and the responsibility of media outlets to provide relevant facts and information.  

Report Suicides Responsibly

by Tony Salvatore, MA

Like many, I was saddened to read of the deaths of David Wallace and his wife, Joan, particularly of the means by which they died (“Eminent architect dies in double suicide,” July 20).

Given David Wallace’s stature, and the comparative rarity of double suicides, I understand why this tragic situation would receive significant media attention. However, from my suicide-prevention perspective, the nature of The Inquirer’s coverage raises a number of concerns.

First, the article appeared on the front page. Second, it included a fairly detailed description of the method by which the couple ended their lives. Third, it made no effort to put the deaths into the context of suicides among elders. Sadly, these are increasing in what is often called a silent epidemic.

A number of organizations have offered guidelines for coverage of suicide. They seek to raise awareness that some vulnerable, high-risk individuals may carry out their own suicides by reading detailed news accounts of how others took their own lives. One such set came in 2001 from the Annenberg Public Policy Center of the University of Pennsylvania, acting in concert with national suicide-prevention organizations.

The report, “Reporting on Suicide: Recommendations for the Media,” explicitly discourages the placement of such stories on the front page or at the top of a broadcast. It is understood that suicides involving prominent persons, public circumstances, multiple deaths, or the very young are generally considered newsworthy. The Wallaces’ deaths fell into two of these categories and merited coverage. However, front-page treatment was not necessary.

Of greater concern was the detailed description of the lethal means that the Wallaces employed – another practice that the Annenberg report discourages.

These details, which I obviously choose not to get into here, were not essential to reporting this loss. Moreover, given that some may see these deaths as rational suicides – Joan Wallace was in hospice care; David Wallace had cancer – some circumspection was in order.

So-called copycat suicides are not limited to youths. It is to be hoped that The Inquirer would not have described the means used in reporting a high-profile teen suicide. The same judgment should have applied here.

Lastly, the Wallaces, David Wallace in particular, were in an age group at high risk of suicide, a fact not well known. According to data from the Centers for Disease Control and Prevention, there is a suicide by someone over 65 every 90 minutes, which amounts to 16 such deaths daily in the United States. Elders account for 20 percent of all suicides but represent only about 12 percent of the population. White men over 85 have a suicide rate six times higher than the national average.

Statewide, says the Pennsylvania Department of Health, there were more than 1,200 suicides among people 65 and over from 1997 through 2001 and fewer than 400 among those 19 or younger.

This same pattern prevails in Southeastern Pennsylvania, where elders accounted for more than 18 percent of all suicides in the same period and youths represented less than 6 percent of the losses.

The point is not that greater numbers make elder suicides more distressing than those at the opposite end of the age spectrum. Rather the point is that The Inquirer, having chosen to highlight the deaths of David and Joan Wallace, could have used this opportunity to inform its readers about the little-known incidence of suicide in the “golden years.”

Depression and hopelessness play a prominent role in elder suicide. Neither condition is normal at any age. Caregivers and health-care providers could have been alerted to these possible precursors to suicide in elders.

The Inquirer could also have noted that frailty makes the elderly less likely to survive suicide attempts. And it could have mentioned that greater social isolation makes it less likely that elders attempting suicide will be discovered in time to save their lives.

With the accelerated aging of our society, we must pay more attention to elder suicide and how the media should treat it. Suicide prevention is obviously not the media’s primary job. Nonetheless, it can play a powerful role in educating the community about this preventable problem.

Tony Salvatore is director of development of Montgomery County Emergency Services Inc., a nonprofit emergency psychiatric agency in Norristown.

Suicide Attempt Survivor Support: A Critical Unmet Need

Montgomery County has a serious problem with suicide, losing over one-hundred residents yearly.  It is probably less well-known that the county has a much bigger problem with non-fatal suicide attempts, all of which raise the individual’s life time suicide risk, and many of which subsequently become fatal attempts.

There is little data on the incidence of suicide attempts, an act in which a person with intent to die acts on a plan using potentially lethal means.  Many attempts occur without coming to anyone’s attention. Those that do usually are as a result of a need for medical treatment, self-reporting by the individual in seeking help, or when there has been an intervention.

Depending on age and gender, the ratio of suicide attempts to fatalities varies widely. Youths make more attempts than adults, men make considerably fewer attempts then women, elders tend to die on their first attempt.  Lethality of means, particularly firearms, accounts for these disparities.

Individuals with serious mental illness, especially schizophrenia, bipolar disorder, and major depression, attempt suicide more frequently than those without these conditions.  Alcohol abuse and dependence figure highly in suicide attempts. Imminent and actual suicide attempts account for a significant number of voluntary and involuntary psychiatric hospitalizations.

We could go on, but suffice it to say that focusing suicide prevention on individuals who have made a suicide attempt would likely save a lot of lives, enhance the recovery prospects and duration of those who may re-traumatize themselves when beset by even passing suicidal thoughts, and free up ERs and psychiatric hospitals to address other needs.

In 2012, the Action Alliance, a national suicide prevention coalition, identified support for attempt survivors as a priority for focus in the revised National Strategy for Suicide Prevention (NSSP).  This led to a national Suicide Attempt Survivors Task Force to help forge a path for stopping suicide attempts and deaths by engaging and supporting people with lived experience of a suicidal crisis.

In 2014, the Pennsylvania Adult Suicide Prevention Plan included an objective (9.1) to “identify all suicide strategies and services that respond to and care for individuals affected in the aftermath of a suicide attempt…and promote awareness of these resources.”  This state plan will presumably motivate the implementation of aftercare resources for suicide attempt survivors at the county level.

 

There are few suicide attempt support groups anywhere.  A 12-step based “Suicide Anonymous” group met for several years in Norristown, but ceased when its leader moved out-of-state.  At present, the only such support resource that we know of anywhere near Montgomery County is a “Suicide Anonymous” group in Burlington County, NJ:

Rise Above/R.I.T.E. Center

Twin Oaks Community Services

693 Main Street Building C

Lumberton, NJ 08048

1st Floor, Center Door

Group and Skype: 7:00pm 2nd and 4th Thursdays

Skype Only: 1st, 3rd, and 5th Thursdays

 

So why such a paucity of support groups in a major metropolitan area that probably has support groups for every other malady known to humanity?  Liability for self-injury or fatalities among group participants is often cited.  This probably would not apply to a peer-led group and has not proved insurmountable in the few provider-based groups around the country.  Bigger problems are stigma and finding peer facilitators.  (It is likely that there are a number of Certified Peer Specialists who have “lived experienced” of a suicide attempt as well as group facilitation skills.[i])  Indifference toward the needs of attempt survivors is an issue.  Perhaps those affected by recurrent episodes of acute suicidality will at some point step up.

 

Repeatedly hospitalizing those who make or almost make suicide attempts may be more part of the problem than part of the solution.  Clearly inpatient care may be indicated for stabilization and safety but there is no evidence of any long-term preventive value.  Moreover, the first 30 days after discharge from a psychiatric facility are a very high risk period for suicide.  Many readmissions within 30 days of discharge involve suicidal behavior.

 

Here are some on-line information resources on this topic:

 

 

 

[i] See “Peer Specialists can Prevent Suicide” Behavioral Healthcare, September 30, 2010 at http://www.behavioral.net/article/peer-specialists-can-prevent-suicides

The Nature of Suicide Threats

by Tony Salvatore, M.A.

The term “suicide threat” brings to mind an anguished “cry for help” by someone at imminent risk of suicide.  This may be the case and warrants immediate crisis intervention when it is.  However, there are suicide threats that are less a “cry for help” than an effort to bypass the established channels to get it.  This second form of suicide threat is usually devoid of any imminent risk.  Both variations are frequently encountered by emergency responders and behavioral health staff.

 

Basically, a suicide threat is a type of “suicide communication” and the common signal of potential suicide risk.  It is “any interpersonal action, verbal or nonverbal, without a direct self-injurious component, that a reasonable person might interpret as…communicating that suicidal behavior might occur in the near future” (Silverman et al., 2007).   Suicide threats may convey definite suicidal intent, involve no suicidal intent, or be unclear as to suicidal intent (Silverman et al., 2007).

 

A suicide threat may not always be a reflection of suicidal ideation involving any thought of death.  However, any suicide threat connotes the possibility of pending more active and possibly harmful suicidal behavior so it must be taken seriously.  At the very least this should involve screening the individual for signs of suicide risk, a specific suicide plan, and intent.  When these factors are present a voluntary or involuntary psychiatric evaluation may be in order.

 

A suicide threat grabs most people’s attention, particularly if those it is directed at care about the person voicing the threat or have some responsibility for her or his well-being.  This gives suicide threats the power to provoke a response whether or not suicidal intent is actually present.  Suicide threats get a gatekeeper’s full attention and can immediately open doors.  This feature has not been lost on substance abusers and others who wish to elude contact with the criminal justice system or expedite admission to an inpatient treatment setting.

 

While we must take a suicide threat at face value as a sign of potential suicide risk, it would be helpful to know when this is actually so.  It has been suggested that the nature of a threat may indicate if it is accompanied by intent.  Consider these two threats:

 

“I am going to kill myself tonight by [insert lethal means].”

“I will kill myself tonight if I have to go back to jail.”

 

The first is an unconditional statement of intent with a plan comprising a definite timeframe and means.  The second also gives a timeframe, but it is conditional and “sets the terms” under which “intent” may become effective.  The first is a “non-contingent suicide threat” which is passive and does not include any demands; the second is a “contingent suicide threat” which may be dramatic and predicated on secondary gain to the individual (Lambert, 2002).

 

Whereas emergency responders, crisis center and ER staff, and facility admissions personnel have probably heard both types of suicide threats, it is likely that they more often hear threats that are conditional in nature.  This is borne out by the research.  Those who make contingent suicide threats are more likely to have diagnoses of substance dependence and also to be at low risk of suicide (Lambert, 2002).  On the other hand, those making non-contingent threats are more likely to be characterized by severe depression rather than substance dependence, and also to be at high risk of suicide.

 

The nature of the suicide threat may give some indication of the nature of the suicidality and, correspondingly, the level of suicide risk that may be present.  Non-contingent threats tend to be associated with acute suicidality; contingent threats are more often linked to what has been called chronic suicidality.  It is hoped that further research may provide screening and assessment tools that can validly distinguish each type of suicide threat.

 

 

Do 90% of Suicide Victims Really Have Serious Mental Illness? (Part 1)

By Tony Salvatore, MA

Anyone who turns to the print or electronic sources for insight on the topic of suicide and mental illness will encounter this statement in some form: Ninety percent of suicide victims had a psychiatric disorder.(1)  The implication of this contention is almost causal in nature, and it has taken on the trappings of a veritable “truth” of suicide prevention that is rarely questioned.  Mental illness has been shown to be a factor in suicide, but “the relative importance of mental disorders compared to social strains is not fully clear.”(2)

Here we will look into the origins of this assertion and consider some issues with its underlying methodology.  In Part 2, we will look at some actual data on the incidence of mental illness in suicide victims, examine mental illness and suicide from the perspective of current theories of suicide, and show mental illness in its proper role as a suicide risk factor. Continue reading

Do 90% of Suicide Victims Really have Serious Mental Illness? (Part 2)

By Tony Salvatore, MA

In our previous blog, we looked at the use of the psychological autopsy method in suicide research and questioned this approach and its results.  Here we will consider some “hard” data on the incidence of psychiatric diagnoses in suicide victims at the time of death, look at how the role mental illness plays in two current theories of suicide, and argue that mental illness is a serious suicide risk factor but not necessarily the key independent variable in the onset of suicidality in at-risk persons.

Some Countervailing Data

The Centers for Disease Control and Prevention’s National Violent Death Reporting System (NVDRS), has collected data on suicide from death certificates and other sources from sixteen states.[1]  In 2008, of 9276 suicides, approximately 45.4% had a diagnosed mental illness at death.  The NVDRS has found that “mental health problems were the most common circumstances among suicide decedents” in the US.  However, the incidence in a very large population of victims is half that reported by psychological autopsy studies.  Continue reading

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Behavioral Health’s “Elephant in the Room”

By Tony Salvatore, MA

Among the many unwieldy problems in behavioral health, one looms especially large. This pachyderm-sized concern is “chronic suicidality.” This is repetitive parasuicidal behavior involving suicide threats and acts without any intent to die. It may arise at any time and convert low-risk situations into what appears to be a potential life-threatening psychiatric emergency.

Chronic suicidality seems to co-occur with a desperate “need” for shelter, inpatient care, or residential rehabilitation. Dramatic and emphatic suicide threats are voiced with an effect that comes from much practice. Immediately, urgent attention is forthcoming, doors open, and then the suicidal crisis usually subsides.

Curiously and incongruously such “suicidal” individuals who project themselves to be at imminent risk of self-destruction may still feel the need for a smoke break or a sandwich. Equally surprising is that despite the depth of their despair they have often managed to pack for what they hope will be a long stay in a hospital or rehab. Continue reading