It is time for a necessary and serious conversation about depression and suicide.
For the millions of viewers who vicariously thrilled to the foods, cultures and people of the world through the exotic journeys of Anthony Bourdain, the news that the 61-year-old celebrity chef, author and storyteller had chosen to end his life hit like an emotional punch in the gut. At the time of his death, Bourdain stood atop the pinnacle of his career, documenting his globetrotting adventures on CNN’s Parts Unknown. But more than that, to the viewer whose everyday reality was far more mundane, Bourdain appeared to be alive in the best sense of the word — endlessly curious about cultures, food and the human spirit and seeming to savor each moment as he quenched his sizable appetite with engaging company in remote locales. What remained invisible to most in the general public was Bourdain’s years-long struggle with emotional pain, dark moods and suicidal tendencies.
News of Bourdain’s death, on June 8, 2018, came just three days after another global icon, fashion designer and businesswoman Kate Spade, ended her life at the age of 55. Their twin passings left millions of admirers to confront the reality that a public persona can mask private demons and that fame and fortune do not preclude individuals from sinking to such a level of despair.
Like those of other public figures before them, the deaths of Bourdain and Spade cast a harsh spotlight on suicide, sparking a national conversation on the issue in the news media and among friends, family and colleagues. But is it the right conversation? Do celebrity suicides raise much-needed awareness about the factors that drive tens of thousands of less-known people in communities across the U.S. to take their lives each year? Do such deaths point to warning signs that can be used to prevent these tragic deaths? How can we effectively address the stigma that continues to prevent many people from being forthcoming about their struggles and seeking potentially lifesaving care? Or, are we overly focused on the sensational aspects of celebrity loss while missing opportunities to engage in meaningful discussions and actions that could reduce suicide’s societal toll?
UCLA experts — including leaders of an ambitious campus-wide initiative to tackle depression and a center that is at the forefront of the national effort to address suicide among youth — say much more needs to be learned about what leads people to take their lives and how such actions can be averted. This much is clear: Suicide is on the rise. In the same week that Bourdain and Spade died, the U.S. Centers for Disease Control and Prevention (CDC) released a report showing that between 1999 and 2016, suicide rates rose in every state but one — Nevada, where the rate declined by 1 percent. In half of the country, suicide among individuals ages 10 and older increased by more than 30 percent. The CDC reported that rates are up across all age, racial and ethnic groups and among both males and females.
Suicide is now the 10th leading cause of death in the U.S. overall and the second leading cause of death among people ages 15 to 34, bringing immeasurable pain to families and communities. And for every completed suicide, there are many more attempted suicides. “This is a public health crisis,” says Joan Asarnow, PhD, professor of psychiatry and biobehavioral sciences, co-director of UCLA’s Youth Stress and Mood Program and a leading national expert on depression and suicide prevention among youth. “We are losing about 45,000 people each year to suicide in the U.S., and about a million people worldwide — and what’s alarming is that it seems to be increasing across the board.”
ACROSS THE UCLA CAMPUS, MORE THAN 100 FACULTY EXPERTS from more than two dozen departments are participating in the Depression Grand Challenge (DGC) — established in 2015 as the largest university-led grand challenge, with an anticipated budget of $525 million for the first decade of its planned 35-year duration. The centerpiece is a 100,000-person study to learn about the genetic and environmental factors contributing to depression, along with the molecular mechanisms and brain circuitry that characterize the condition. A treatment center will use innovative technologies to offer the most effective therapies based on the project findings. The grand challenge also involves a research, outreach and education program aiming to eliminate the stigma associated with the world’s leading cause of disability.
“Such a profound problem requires unprecedented solutions,” says Nelson Freimer, MD, Maggie G. Gilbert Professor of Psychiatry and director of the DGC and the UCLA Center for Neurobehavioral Genetics. “The Depression Grand Challenge is unprecedented.”
Given the strong correlation between depression and suicide, learning more about the causes of depression and how it can be more effectively treated undoubtedly would contribute to reducing the number of individuals who choose to end their lives. But many questions still would remain. For most people, depression never leads to suicide; moreover, in many suicides, clinical depression isn’t the primary factor. In fact, the CDC report found that more than half of all suicides in 27 states that use the CDC’s National Violent Death Reporting System involved people with no diagnosed mental health condition. Dr. Freimer points out that this doesn’t mean these individuals didn’t have one. “We have evidence that the majority of people with depression, for example, have never been diagnosed,” he says. Not surprisingly, the CDC report found that the group of never-diagnosed people who take their lives consists disproportionately of men and racial/ethnic minorities — groups less apt to seek mental health services than women and non-minorities.
Nonetheless, Dr. Freimer says, there are many routes to suicide beyond mental illness. Other common contributors include relationship problems, life stressors, social isolation, employment and financial trauma, substance misuse and abuse and chronic pain or illness. Risk factors can vary widely depending on age, sex and other characteristics. For example, the Suicide Prevention Resource Center notes that among LGBTQ youth, discrimination in the form of bullying, violence and family rejection is associated with high suicide risk; among middle-aged men, stress stemming from unemployment and divorce are common risk factors.
Exactly what is driving the mounting suicide rate is less apparent. “The evidence that suicide is increasing is indisputable,” Dr. Freimer says. “But I don’t think we have a good understanding of why this is occurring.”
A number of societal trends are widely believed to play a part. Michelle G. Craske, PhD, professor of psychology in the UCLA Division of Life Sciences and professor of psychiatry and biobehavioral sciences in the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, points out that depression, a leading suicide risk factor, is on the rise. “This may be partly due to people’s greater willingness to talk about it, but epidemiological studies suggest that there is an actual increase unrelated to that, and it’s not clear why,” says Dr. Craske, who directs the UCLA Anxiety and Depression Research Center and is a member of the DGC’s executive committee.
Dr. Craske cites other likely contributors, including the rise in opioid addiction. The CDC has found that suicides from opioid overdoses nearly doubled from 1999 to 2014 and that many people who were determined to have died from an unintentional opioid overdose had suicide risk factors, including depression and financial woes. Research also has found an association between economic crises and increased suicides, suggesting that the Great Recession that started a decade ago, along with growing wealth inequality and a fraying social safety net, could be factors in the increase. “There’s a terribly vicious cycle between poverty and depression, where it’s hard to improve your situation when you’re feeling depressed about it and lacking motivation or hope that anything could be different, which can lead to further stress,” Dr. Craske says.
She and other experts suspect that growing levels of social isolation and a reduced sense of community in much of the country also might be contributing, although there needs to be more research to better understand the connection, if any, and the dynamics at play. Paradoxically+, Dr. Craske notes, technology and social media could be fueling the feelings of loneliness by reducing face-to-face interactions and increasing stress, while reminding people of things they don’t have and activities or groups of which they aren’t a part.
The latter is a particular concern for the younger generation. “In general, there seems to be less community closeness and support for kids than there used to be, and I worry about the consequences of that,” says Jeanne Miranda, PhD, professor of psychiatry and biobehavioral sciences and co-director, with Dr. Asarnow, of the UCLA Youth Stress and Mood Program. “There also appears to be greater pressure on certain groups of kids to succeed, and bullying continues to be a major concern.”
Dr. Miranda also notes that the rate of suicide among sexual- and gender-minority (SGM) youth is four times greater than for non-SGM youth and two times greater among youth who are questioning their sexual identifies compared with non-SGM youth. Compared with SGM youth who did not attempt suicide, those who did had experienced higher levels of victimization due to their sexual orientation. “Problems such as negative beliefs and feelings about one’s sexual orientation that are internalized because of society’s negative views are a part of normative developmental processes for many of these youth, and suicide attempts often are associated with how identifiable the youth is as SGM, especially by parents,” Dr. Miranda says.
Suicide prevention experts also cite the proliferation of firearms as a likely factor in the rising suicide rates and point to the importance of ensuring that people who are at risk don’t have easy access to lethal means to carry out the act. The CDC report found that across all groups, the most common method used by people taking their lives involved firearms. “If someone is contemplating suicide and there’s a gun on the table, he or she is much more likely to end up dead,” Dr. Asarnow says.
WHEN SUICIDE IS IN THE NEWS, as it was following the deaths of Bourdain, Spade and other well-known individuals, the increased discourse often is a mixed bag. “Certainly it offers an opportunity both for better education of the population and the promotion of more resources for mental health and suicide prevention,” Dr. Freimer says. “But often the focus is on the grieving for the well-known individual, without addressing the factors leading to increased suicide and the need to develop effective prevention tools, including early detection and treatment. And with celebrities, because the details tend to be private, it’s hard to get an appreciation of what led to it, and so some people will think, ‘If this could happen to someone who had everything going for them, what chance do I have?’”
The heightened attention also has the potential to increase suicide risk among vulnerable populations. Researchers have documented a contagion effect, particularly among adolescents. “We know that exposure to peers who have attempted suicide or engaged in self-harm, as well as exposure through the media — including from a movie featuring suicide — has been associated with higher suicide rates or visits to emergency departments for suicidality,” Dr. Asarnow says. Her own research has found that children who make multiple suicide attempts are more likely to have known someone who died or attempted suicide.
When the Netflix drama series 13 Reasons Why — a show that depicts a teenage girl’s suicide and the events that preceded and followed the death in graphic detail — debuted last year, it was met with considerable backlash from commentators in the mental health community for its portrayal. A research letter published in JAMA Internal Medicine found that internet searches around the term “suicide” spiked in the weeks after the show first aired. Given research showing that exposure to suicide in film and the media can contribute to increased suicidal behavior, particularly in teenagers, Dr. Asarnow noted that the potential for harm could have been reduced by providing information on suicide prevention resources and encouraging teens who are suffering to reach out to their doctors, school counselors, family members or others who can support them. She noted that a group of leading experts in suicide prevention, working in collaboration with suicide prevention organizations, journalism schools and media outlets, has developed recommendations for best practices to report on suicide deaths to reduce the potential to negatively influence behavior.
Elana Premack Sandler, LCSW, MPH, an associate professor at the Simmons College School of Social Work in Boston, Massachusetts, who worked with the Suicide Prevention Resource Center on guidelines for developing suicide prevention programs, says that too often media coverage of suicides involving well-known people sensationalizes the death to the point of overshadowing the individual’s life. From the standpoint of suicide prevention, Sandler says, the best coverage avoids sensationalistic language, descriptions of methods and language such as “committed suicide” that criminalizes the act. “Focusing on the life gives a more accurate picture of mental illness and allows room for discussion of the fact that many people go through these struggles without it leading to suicide,” Sandler says. Coverage always should be accompanied by information about resources for people feeling suicidal, such as the National Suicide Prevention Lifeline, the Crisis Text Line and others, she adds.
When presented responsibly and to promote ways for people to seek help and reach out to others in need, coverage of suicide can be constructive. “In general, it’s good when suicide is being talked about and not treated as taboo,” Sandler says. “Sometimes people are afraid to bring it up, but if we normalize these issues, we can make it more accessible to seek help. By asking whether or not someone is feeling suicidal — or even saying, ‘I’m thinking about you and I care about you’ — we communicate that we are available to that person and that it’s OK to discuss it, which can be lifesaving.”
Dr. Craske believes that reducing the stigma around depression and suicidality, as UCLA’s DGC has set out to do, is a critical suicide prevention strategy. “People tend to be uncomfortable around others who are depressed or to think that depression is something a person should be able to ‘get over,’ rather than viewing it as a disease,” she says. “That stigma keeps people isolated and makes them less likely to come forward for help. As a result, many walk around with suicidal thoughts, and no one around them knows.”
“We need to use these times of national discussion not only to talk about suicide prevention, but also to increase the percentage of people who seek mental health care more broadly,” Dr. Freimer adds. “That would certainly have an impact on suicide.”
It’s not just stigma that keeps many people from coming forward. “We don’t have good access to mental health services in this country, and too many people are receiving care that is not evidence-based,” Dr. Asarnow says. “Our estimates suggest that 13-to-20 percent of children in the United States experience a mental disorder each year. There are effective treatments, but they aren’t being implemented within broad public health policies.” One goal of the UCLA Youth Stress and Mood Program is to work to bring treatments with demonstrated effectiveness into the places where people receive care in their communities.
HEALTH SYSTEMS CAN, AND SHOULD, DO MORE by ensuring that all patients are screened for depression and that health professionals routinely ask about suicide rather than waiting until patients bring it up, Dr. Freimer says. “Given the state of our knowledge right now, that’s probably the most important way we can make an impact on suicide rates,” he says. Toward that end, UCLA’s DGC has focused on assessing not just for depression and anxiety, but also for suicidality — and then ensuring that a process is in place so that when early signs are detected, patients receive the follow-up care they need.
Separately, in partnership with colleagues at Duke University, Dr. Asarnow heads the Center for Adolescent Suicide, Self-Harm & Substance Abuse Treatment and Prevention (ASAP) Center, which takes a trauma-informed approach to caring for youth who present with suicidality, self-harm and substance abuse. The ASAP Center is part of the National Child Traumatic Stress Network, funded by the U.S. Substance Abuse and Mental Health Services Administration to raise the standard of care and increase access to services for children and families who experience or witness traumatic events. The center has worked with health systems across the nation to implement initiatives designed to improve care and outcomes for this population — including a strategy for delivering an enhanced mental health intervention in emergency departments, given that as many as half of patients in these settings fail to receive follow-up outpatient treatment, Dr. Asarnow says.
When UCLA launched the Depression Grand Challenge in 2015, it was with the bold goal of cutting the burden of depression in half by 2050 and eliminating it by the end of the century. It is an ambitious task — one that requires support from many fronts.
“UCLA’s Depression Grand Challenge is an effort to try to change the world,” says donor Robina Riccitello, a member of the UCLA Depression Grand Challenge Leadership Council. “Trying to find good treatments and, eventually, a cure for depression is one of the most impactful ways UCLA can affect the lives of human beings around the world.”
The success of the Grand Challenge can have dramatic outcomes for families who have suffered the devastating — and sometimes fatal — consequences of depression, families like those of Hillary Hartman and Dana Jacobs. “If our sister Andrea was alive today, she would tell you that she suffered from depression since kindergarten,” says Hartman, a donor to the Grand Challenge. “It has been 21 years since she committed suicide. UCLA’s ambitious goal to eradicate depression gives us hope that one day, those who suffer will not turn to suicide to find relief from their pain.”
Dr. Asarnow’s group also recently received funding for a large National Institute of Mental Health clinical trial in conjunction with the national Zero Suicide Initiative, a commitment among health care systems to close gaps and ensure that suicidal patients don’t fall through the cracks. The study identifies at-risk youth within the health system and offers evidence- based care approaches commensurate with their level of risk, including technology-enhanced services. For high- and intermediate-risk patients, the treatment includes dialectical behavioral therapy (DBT) — a cognitive-behavioral therapy focusing on treatment engagement and reducing self-harm and suicide attempts by teaching skills for enhancing emotion regulation, distress tolerance and building a better life. Dr. Asarnow and her colleagues recently published the results of a randomized clinical trial, showing the first evidence of DBT’s efficacy in decreasing repeated suicide attempts in adolescents and the second demonstration that DBT is an effective treatment for reducing self-harm behaviors among high-risk adolescents.
DBT is one of several evidence-based therapies offered by the UCLA Youth Stress and Mood Program, all of which are family-centered. “Treatments for self-harming youth who have a strong family focus tend to have the greatest impact,” Dr. Asarnow says. “Parents can function as seatbelts — a buffer before the child starts to act on feelings of self-harm. We have to build a society of support for our children, including not only parents, but also schools and health care providers.”
“We work with parents on ways to tune in, notice their child’s moods and know how best to respond,” Dr. Miranda adds. “And we work with the kids to better understand their own moods, to have a safety plan for when they begin to experience thoughts of suicide or self-harm and to be open in sharing what they need from their parents at those times.”
The approaches developed and studied at the UCLA Youth and Stress Mood Program are saving lives, but Dr. Miranda is quick to point out that she and other professionals involved in suicide prevention are aiming higher. “We have effective treatments for decreasing depression and suicidality, but much more research is needed on prevention,” she says. “Ideally, we want to be able to intervene earlier, to help kids not get to that crisis point.”
Dr. Freimer notes that just as there is evidence of genetic contributions to mental health conditions such as depression, schizophrenia and autism spectrum disorder, there are suggestions of a distinct genetic contribution to suicide. Through the research efforts aiming to unravel the genetic and environmental contributors to depression, DGC researchers hope also to learn about the specifics of what leads some individuals to be at high genetic risk for suicide.
The DGC has already begun using advanced technology to continuously record sleep, social interactions, voice quality and other characteristics of at-risk research subjects. “It would be extremely helpful to our prevention efforts if we could learn more at the micro level about what’s happening biologically and psychologically that puts people over the tipping point to where they want to end their life,” Dr. Craske explains.
DGC leaders also believe the massive research effort will lead to better depression treatments — including new medications as well as new psychological and neuromodulatory approaches. That would represent a boon for the millions who don’t benefit sufficiently from current depression therapies. But when it comes to preventing suicide, Dr. Asarnow notes, it’s only one of many necessary steps.
“Depressive illness has to be treated, but we also have to go beyond depression,” she says. “The most effective suicide prevention approaches help people to build a life they want to live.”
Dan Gordon is a regular contributor to U Magazine.
“Internet Searches for Suicide Following the Release of 13 Reasons Why,” JAMA Internal Medicine, October 2017