Addressing a sobering public health issue.
This piece first appeared in The Vermont Standard.
Cory Gould says that no one in her family expected her to live to age 21. She had caring parents and siblings, a “wonderful” childhood, and no real reason to be upset or depressed. But as she approached puberty, an ugly darkness began to overtake her; even as an eleven year old, she says, “I wrestled with this idea that I was standing at the edge of the world, and that I was somehow an alien here.” Gould struggled through adolescence, dogged by misery and sadness, unable to shake an “otherness” that had her feeling way out of whack with kids her age. She attended, impassively, therapy arranged by her parents, but as a college student Gould decided that she could not go on. On September 3, 1977, she locked the door to her dormitory room, wrote a few good-bye letters, and swallowed what she thought was a fatal dose of medication that she had stolen from her physician father.
“I had a major mental illness that nearly killed me,” says Gould, who is now the Director of Care Management and a Mental Health Practitioner at Gifford Medical Center in Randolph, Vermont. She’s talked about suicide almost every day of her long and successful career, as she tries to give back in homage to her own survival by spreading the message that it is mental illness that causes suicide, and that, thankfully, effective treatments are available.
Suicide is a sobering public health issue, both nationwide and in Vermont. The Centers for Disease Control and Prevention reports that more than 36,000 Americans died by suicide in 2008; 94 of them were Vermonters, and 9 of those from Windsor County.
And while the number of deaths in Vermont may seem relatively modest standing beside the nationwide figure, suicide in fact kills Vermonters at a rate that exceeds the national average.
Here, there were 15.1 suicide deaths for every 100,000 people in 2008; nationwide the average was 11.9. Over the last few years, that rate seems to be ticking slowly upwards across the United States, and increasing more quickly in Vermont. Some suicide prevention advocates in the Green Mountain State fear that the personal and financial losses inflicted by Tropical Storm Irene, combined with the on-going grind of a slow economy, will create stresses that may break the will to live of more Vermonters already at risk.
Psychological autopsies and other studies show that 90 percent or more of those who have died by suicide were suffering from psychiatric illness, most often clinical depression, says Dr. Timothy Lineberry, Medical Director of the Mayo Clinic Psychiatric Hospital, Associate Professor of Psychiatry at the Mayo Medical School, and Board Chair for the American Association of Suicidology. Changes in sleep and appetite patterns, lack of energy, inability to concentrate, anxiety, loss of interest, and excessive feelings of guilt that persist for more than two weeks may all be symptoms of depression that goes beyond normal, occasional sadness.
For Cory Gould, the depression that is part of her now diagnosed bipolar disorder “feels like a dragon inside my head and when it is roaring it obliterates any sense of reason,” she says, “it just throws its weight and crushes my perceptual faculties. It’s horrible.”
Deaths by suicide happen not solely because of depression, though, but because of combinations of many factors, says Lineberry. “Multiple things go wrong all at once,” he says, “there is almost invariably a precipitating event, but it is in the context of severe depression, perhaps multiple losses, access to a way of killing [one’s self], as well as other things that may be going on.” And, misuse of alcohol or drugs contributes to 25 to 60 percent of suicide deaths. “When people are intoxicated, they will do things that they wouldn’t ordinarily do,” Lineberry says.
The numbers of deaths by suicide do not fully measure the depth of the underlying mental health problem. Many, many more than just the 94 Vermonters who succumbed in 2008 thought about suicide or tried to kill themselves. According to the 2008/2009 National Survey on Drug Use and Health published by the Centers for Disease Control and Prevention, an estimated 19,000 adults in Vermont had serious thoughts of suicide, and 8,000 made plans to take their own lives. About 2,000 attempted suicide, but survived.
And although these sizable numbers paint a grim picture of a mass of lives potentially and needlessly lost, the good news for those persecuted by suicidal thoughts is that their disease is treatable.
Therapy regimens can include exercise, dietary and life style changes, psychotherapy, and medication. “We want people to get help, we want people to know that things will get better,” says Lineberry, “Hope is a huge thing, in both psychiatric and medical illness, but in particular with suicide. There is hope that people will get better, that’s why I do what I do.”
When Cory Gould woke up in her dormitory room back in 1977, two days after downing an overdose of medication, she was angry. For a while, she was filled with rage. “I stormed around thinking that I was so grossly incompetent that I couldn’t even kill myself,” she says. But after a few weeks, it occurred to her that her body had defied science, and that ignited a belief in the mysteries of the universe, and in her own concept of the divine. She sought out treatment, and this time she embraced it, not to please her parents as before, but for herself. She acknowledged the sources of stress in her life: her sexual orientation, the keen intelligence that often spawned her unique perspectives and values, and her diagnosis with a major mood disorder. “I decided that I would live, and live however I wished as long as it didn’t hurt anybody else,” she says.
Gould’s therapy began with counseling, and a little over a decade later she began taking prescription medication, which was, and continues to be, a “terrific benefit” for her.
That dragon in her head is still there, but most of the time, it is small, in a corner, and on a short chain. “When it stirs, I pay attention,” she says.
She’s established relationships with a psychiatrist and a psychotherapist, who she can call on as needed. Life is mostly good, “I lose maybe a couple of days a year, maybe as much as a week, to my illness,” she says.
While the national rate of death due to suicide has inched up from 11 per 100,000 in population in 2005 to 11.9 per 100,000 in both 2008 and 2009, Dr. Lineberry sees the overall rate as relatively stable. “The factors that are associated with suicide don’t change,” he says, but a poor economy may have an impact by adding another source of stress for people already at risk. He cites Asian and British studies that found that increases in unemployment do affect suicide rates; one study estimates that, for moderately increasing unemployment, every 1 percent rise results in a .79 percent increase in the suicide rate among people under 65, with the rate rising more steeply when there are particularly large increases in unemployment.
The number of deaths by suicide over the last two and a half decades in Vermont has moved up and down between a high of 95 in each of years 1987, 1988, and 1989 and a low of 63 in 1999. John Pandiani, Chief of Research and Statistics for the Vermont Department of Mental Health, feels there is no conspicuous progression in the data. “I see some noise, but I don’t see any clear long term trend,” he says. There has, however, been concern here about a recent year-over-year increase in deaths by suicide. A report released by the Vermont Department of Mental Health in November indicates 87 Vermonters died from suicide between September of 2009 and the end of August of 2010. The following year, from September 2010 through August 2011, there were 100 deaths by suicide, a 15 percent increase, driven primarily by more deaths among men aged 18 to 49. In Vermont and nationally, many more men than women die by suicide; about as many women attempt to take their own lives, but men tend to choose more lethal means.
With the lasting impacts of Tropical Storm Irene, which wiped out the homes and livelihoods of a number of Vermonters when it hit on August 28, some suicide prevention advocates see little prospect for abatement of the short-term trend. “I’ve been very worried about what’s going to happen here as the winter sets in,” says Mental Health Practitioner Gould, “the people who have lost their physical tether to the world and have nothing left, not even photographs, those folks are at high risk.”
In addition, health care providers and advocates, and other stakeholders are currently debating the impacts of Governor Peter Shumlin’s proposal to replace the Irene-flooded Vermont State Hospital with a more decentralized, fewer-beds system. Some feel the new plan contracts capacity in the state to care for the mentally ill most acutely in crisis, which among other things, could add to deaths by suicide.
Mayo Clinic’s Dr. Lineberry says that prevention programs can have an impact. “We do think that factors that make a big difference are being aware of warning signs, individually getting help, and improving care, medical and psychological, in terms of recognizing and treating depression,” he says.
Staff at the Vermont 2-1-1 call center use protocols proscribed by the Applied Suicide Intervention Skills Training (ASIST) program and a robust database of information about mental health resources to help people who dial 211 because they are having suicidal thoughts. Since its launch in 2005, the United-Way-and-State-of-Vermont funded call center has been assisting Vermonters on a wide variety of problems, including where to find fuel assistance or a food pantry, or even with information about how to get a marriage license or a passport. Over the years, it has developed into a suicide prevention tool available to anyone with a telephone. Since 2009, the center has also been answering Vermont-originated calls to the National Suicide Prevention Lifeline (NSPL), 1-800-273-TALK or 1-800-273-8255.
When someone with suicidal thoughts calls, either through 211 or the NSPL, “we [try to] de-escalate the situation, talk them down a little bit, and get them to work with us to keep themselves safe. If they have a plan, we try to disable that plan,” says MaryEllen Mendl, Director of Vermont 2-1-1, “and then we try to get them linked to resources so that they can get help right away.”
Friends and family of someone who is feeling suicidal can help, also. The person most likely to thwart a suicide plan is somebody close to the person who is thinking of taking his or her own life, says Cory Gould. “If you think someone is suicidal, you should ask them, and listen,” she says, “research shows that most of the time, they won’t lie, they will tell you.” The next step is to persuade, to help the person see that there are options other than death, and then to get him or her to a mental health professional as quickly as possible. That could be through a primary care physician, a hospital emergency room, or a local mental health agency, which for Windsor County residents would be Health Care and Rehabilitation Services headquartered in Springfield. Gould also recommends that a person in crisis take someone with them when they visit a health care provider or emergency room, because a person who is depressed and suicidal is not always able to adequately advocate for him or her self. “People can intervene successfully,” she says, “It hurts, it is scary, but if something seems different, don’t let it go.”
Next, Part 2: Preventing Deaths by Suicide Among Teens and Young Adults