The death of Robin Williams is a tremendous loss for his family and friends, as well as every one of us who found meaning and joy in his incredible body of work. At the same time, his suicide makes us all stop and think. Tangled up amidst the grief and confusion is the question of what could have been done. While it would be unprofessional to comment on any specifics regarding Mr. Williams' death, I can take the opportunity to reflect on what we know generally about suicide, most importantly that it is preventable.
Suicide is one of society's greatest public health crises, and a leading cause of death across the world and across ages. Every 13 minutes (1) someone in this country dies by suicide. If you take a large corporation of 100,000 employees (2), an employee or family member will die by suicide every seven days. And did you know the Centers for Disease Control and Prevention report that nearly 10 percent (1) of high school students say that they have attempted suicide in the past year? In fact, suicide is the second leading cause of death in 10- to 24-year-olds (3).
The biggest cause for suicide is depression -- a treatable medical illness. According to the World Health Organization (4), depression is the most debilitating disease in the world in middle- and high-income countries, and it will soon take that position everywhere. It is also the number one cause of work-related absences.
The introduction of modern antidepressants such as selective serotonin re-uptake inhibitors (SSRIs; e.g., Prozac, Zoloft, Paxil) helped to drop the suicide rate dramatically across the world (5), reversing the trend that existed prior to their introduction. That is good news -- but it is not enough; we have a long way to go. One of the biggest problems is that most people who need treatment do not get it -- 50 percent to 75 percent (6) of those in need receive inadequate treatment or no treatment at all. This is partly due to stigma and access-to-care barriers, but in the end few are spared from the problem of under-treatment: more than 80 percent of college students who die by suicide receive no consistent treatment prior to their deaths (7,8).
One way to make a serious difference in suicide prevention is to change and expand the way we talk about suicide. We know that almost half of all people who die by suicide visit their primary care doctor within a month of their deaths (9). For the most part, however, depression and thoughts of suicide are not part of the average examination. But they should be: We should be asking about suicide (i.e., screening) like we monitor for blood pressure. If not, we will not find the people who are suffering in silence. In my global work across counties, states, and countries, I have seen first-hand the great need for and benefits of asking a few questions to identify those at risk for suicide.
I once travelled to a Hindu temple in upstate New York that served a disadvantaged population with a high suicide rate. I trained the priests, grandmothers, grandfathers, and high school students on a brief suicide screening my team and I developed at Columbia University and which incorporates a few simple questions that can be asked in a consistent way. The questions help determine whether a person is experiencing suicidal thoughts ("Have you actually had any thoughts of killing yourself?"), and if so, whether the thoughts include method ("Have you been thinking about how you might do this?") and intent ("Have you had these thoughts and some intention of acting on them?"). Importantly, a history of suicide attempts is the number one risk factor for suicide. Therefore, asking about a person's attempt history and other serious suicidal behaviors (e.g., "Have you taken any steps towards making a suicide attempt or preparing to kill yourself, such as collecting pills, getting a gun, giving valuables away, or writing a suicide note?") is essential to identifying his or her level of risk.
Two weeks after my visit to the Hindu temple, there was an article in the local newspaper. A grandmother who had been at the training had noticed that her grandson wasn't looking so good, asked him the questions, and said that doing so probably saved his life. Whether you are a doctor, teacher, parent, coworker, friend, relative or anyone else -- the first step is asking.
If I can say that there is any "good news" about suicide, it is that suicide can be prevented -- which is more than can be said about many of the sources of pain and suffering in the world. We need to get to a place where everybody, everywhere can ask the questions that help identify at-risk individuals and get them the help that they need. Together, we can find those suffering in silence and get them the help they need. The loss of Robin Williams is immense, and should motivate us to work toward a world with zero suicide, which I believe we can accomplish.
Need help? In the U.S., call 1-800-273-8255 for the National Suicide Prevention Lifeline.
1. Centers for Disease Control and Prevention, Youth Risk Behavior Surveillance System. Retrieved from http://www.cdc.gov/HealthyYouth/yrbs/index.htm.
2. Paul, R. (2005). A Workplace Strategy for Preventing Suicide.SPRC Teleconference.
3. Centers for Disease Control and Prevention, Injury Prevention & Control: Data & Statistics (WISQARS). Retrieved from http://www.cdc.gov/injury/wisqars/index.html.
4. World Health Organization, Depression Fact Sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs369/en/.
5. Grunebeaum, M. F., Ellis, S. P., Li, S., Oquendo, M. A., Mann, J. J. (2004). Antidepressants and suicide risk in the United States, 1985-1999. Journal of Clinical Psychiatry, 65(11), 1456-1462.
6. Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., et al. (2005). Prevalence and Treatment of Mental Disorders, 1990 to 2003. New England Journal of Medicine, 352:2515-2523.
7. Gallagher, R. P. (2004). National Survey of Counseling Center Directors. Arlington, VA: International Association of Counseling Services.
8. Kisch, J., Leino, E. V., & Silverman, M. M. (2005). Aspects of suicidal behavior, depression and treatment in college students: Results from the spring 2000 National College Health Assessment Survey. Suicide and Life-Threatening Behavior, 35, 3-13.
9. Luoma, J.B., C.E. Martin, and J.L. Pearson, Contact with mental health and primary care providers before suicide: a review of the evidence. American Journal of Psychiatry, 2002. 159(6): p. 909-916.
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