Science AMA Series: I'm Tyler Black, a Suicidologist and Medical Director of the CAPE Unit at BC Children's Hospital. On World Suicide Prevention Day, please ask me anything about Suicide Prevention!

Abstract

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Do you think that it is possible to get rid of persistent suicidal ideation (over 1 year) resulting from existential depression, or is it a permanent problem? Asking for a friend...

kordesii2358

Yes, it's possible, and in fact, one of the larger existential traps is the distortion that it will be there forever.

For people who get trapped in cognitive existential traps, I recommend CBT (Cognitive Behavioural Therapy), HOWEVER, and this is very important, a huge emphasis on the Behavioural part of therapy. Someone with major existential depression is already very cognitive. Learn the cognitive traps and the countermeasures, but then spend a bulk of your time learning behavioural approaches to lessen the dread of existential thought.

If anyone has a majority of the following symptoms continuously for more than 2 weeks, please see a doctor:

  • sadness such that it is difficult to enjoy any activities
  • insomnia or hypersomnolence
  • suicidal thinking
  • hopelessness about the future
  • guilt about the past
  • change in appetite
  • fatigue

Has anyone ever convinced you that suicide really is the best option for them? I'm not talking about terminally I'll people or people in serious trouble with the law or mob. Just regular depressed or hopeless people.

thicka

Thank you, it's a very interesting question, but it's a pretty nuanced answer.

I am very convinced by the people I work with (keeping in mind that my primary clinical base is children 10-17) that they are convinced that suicide is the best option for them. I am convinced that they see their problems as insurmountable or that their brain is being significantly altered by mental illness (depressive distortion, psychotic delusion, intoxicant withdrawal, etc), such that they see no other option.

But, generally, no; I also have been practicing long enough to know that even for people who go through years of chronic severe suicidal thinking, recovery happens and full, rewarding lives are achieved. Way more than 99% of people who attempt suicide do not die from suicide.

For another group, (Most suicides and attempts ) are not planned; they are impulsive. There is rarely even a convincing argument that suicide is a rational choice, and often the person who attempts impulsively will come out the gate saying "I wasn't thinking clearly."

So in a long-winded way, no. Excluding major terminal illness or major external legal event, I have never been convinced that suicide is the best option for them.

On the contrary, as someone who is in the entire field of improving quality of life, I am wholly convinced that this is possible in 100% of the people I work with.


Hello, schizophrenic here. I do not have this problem so much now, but I feel it would be good for others to know:

When I or someone else is having an episode and are momentarily suicidal, what number could a loved one call besides 911? I see all too often these days that someone who is simply mentally ill and confused are shot and killed by responding police officers due to a lack of training.

heyellsfromhischair

Great question.

The big challenge in the question is that most people who call a prevention line with psychotic thinking will be directed to 9-1-1 as part of the algorithm. I think a good work-around and the less police/emergency shooty response would be to find the local nonemergency distress line (usually police services have a system like Vancouver does ). Often police will have a non-emergency line where you can say "i'm not currently dangerous but i'm really struggling" or when calling 9-1-1 you can request ambulance service vs police service.

A big help would be, systemically, if police services would severely increase the amount of mental health training they receive.

Most people with schizophrenia struggle the most with adhering to taking medication (it has side effects, and it's hard to remember sometimes, and symptoms can still flare up even when on medication). So for all those with medical illnesses that require medical treatments, please also be as diligent as possible about working with your doctor to increase medication adherence.


Hi Tyler,

Thanks for doing this AMA on such an important topic. One element of suicidality there's a lot of confusion about is suicidal ideation. I was wondering if you could speak a little about the different types of suicidal thoughts people may have and how indicative they are of risk. Are all thoughts of suicide the same?

ImNotJesus

It's a great question, and the first time I can pull out one of the graphs I prepared!

Suicidal thinking is common, especially in young people. . Suicidal thinking is a very common event for people, and does not result in suicide for the vast majority of people who have it. For anyone with suicidal thinking, forgive yourself for having the thought (a large % of brains go there), but focus on the why you had it and who you can reach out to for help.

But, no, not all suicidal thinking is the same.

We can think about suicidal thinking as a bit of a spectrum. On one end, you have passive suicidal thinking, or a more vague "I don't want to be here anymore". This can include the most vague "I don't care what happens to me" or the most specific "I wish I could die." These thoughts cause distress but also generally have some degree of ambivalence, as there is a separation between this and "I will die." On the other end, you have active suicidal ideation, with a formed plan or specific thought.

As we move from the most vague passive to the most specific active, the risk of a major event increases.


What did you think about "13 reasons why", assuming you saw it?

armahillo

As a suicidologist who knows about imitative suicide, I loathe this show, and Netflix for releasing it. The way in which the creators and Netflix used visual media to bring this book to life included an intentional and callous disregard for all of the advice they received in reducing harm to viewers. They could have made this story just as compelling but much safer for a visual medium. I truly believe that Netflix and the shows creators likely harmed thousands of people, and I personally interviewed more than 20 young people who were hospitalized or presented to emergency department as a result of thoughts or stress caused by the show.

For the reasons why I hate "reasons why" so strongly, professionally:

  • Hannah was depicted as gaining an immense amount of power and control by her suicide
  • Help was portrayed as bumbling and ineffective (this is sufficient in itself, how many young people watching this show do you think were more inspired to seek help, the way it was portrayed?)
  • the violent and explicit presentation of her suicidal act is profoundly triggering for people with self injurious thoughts or suicidal thoughts.
  • I could go on, but honestly, it makes me angry.

The thing is, we aren't just "oh no what about the children", there is direct evidence linking irresponsible media depiction or discussion of suicide causing direct harm to susceptible people. I helped co-author a modern guideline for media depictions/reporting of suicide (pdf). As an exercise, see how many "don't"s 13 Reasons did, and how many "Do's" they didn't.

Shame on Netflix.

From a narrative perspective, I can see the dramatic nature of the show and appreciate the power of a good narrative.


Hi Tyler, and thank you for doing this AMA.

I am a moderator on several communities here at reddit, and something that has come to concern me is that I will occasionally see comments from users indicating that they are contemplating suicide - and sometimes the intent seems quite real and imminent.

What to do about these comments is something that I've struggled with. While these comments can be (and are) reported to the Reddit administrators, I have a sense that not much comes from many of these reports - in general reddit seems to lag behind other popular social media sites on reporting and handling suicidal ideation. Reddit's official policy is to not release details about how these reports are acted upon, but I have suspicions that very little action is ever taken. If an admin, or u/spez, could comment that would be great!

So my question: I was wondering if this is something you have come across in your own experience? If you see a comment indicating a strong intention to imminently commit suicide in a social media setting, what should be done? Do you think moderators have different responsibilities than regular users? What responsibility do you think reddit has?

Thanks!

SirT6

All moderators should report red-flag material, and reaching out to the person in a human way ("hey wow, this message had to be taken down but we are really worried about you, can I help you in some way?") is about all a moderator can do.

On the what to do as a moderating team:

  • remove the comment or hide it
  • message the administrators
  • immediately sticky a "if you or someone you know is having strong suicidal thoughts, please contact..." in the thread
  • message the individual to let them know you care and that you can connect them with more localized resources if they want to reach out to you
  • on reddit, maybe add a link to /r/SuicideWatch

Do you have any advice for those of us living with someone who is being treated for depression and suicidal thinking?

Orion_4o4

It's a hard thing to witness, especially if you care. You aren't depressed, and you aren't suicidal, so you can't really be there in their mindspace and get it. In fact, if you care, you very much don't want them to suffer depression or die.

Some tips:

  • suicide prevention lines exist for you too. call and ask for help and support; it is trying and taxing on you, and every prevention line is very happy to talk to concerned people about how to help those around them
  • encourage treatment; most suicidal thoughts leave, most depressions are treatable, but stigma, access, finances, and the depressive symptomatology itself prevent people from accessing treatment.
  • you dont need to be an expert in solving problems; suicide is rarely about "fixing one thing." Suicidal thinking needs a listening ear (one that doesn't even need to offer advice, just be there), help with distraction, validate the emotions (it really hurts someone with depression to be told "you have nothing to be sad about."), and a kind and genuine offer of help.
  • call emergency services if you think they may act on suicidal behaviour. it is a loving gesture, and it results in better outcomes.

What do you have to say to/about r/incels? A large percentage of posts in that sub refers to suicide as the only solution to involuntary celibacy.

Dryfter137

I think that hive-minding on reddit is a problem, and people in the r/incel community probably need to spend time learning new things, strategies, and ideas, rather than sitting in a depressive echo-chamber.

Going there to vent? OK sure. But living there? Just no.

That being said, the misogyny of r/incels is always the most disturbing aspect of it to me. As any good scientist should, I decided to head on over to r/incel and the first post I saw was incredibly ill-informed and misogynistic. That kind of sums up my feeling of the subreddit.


Hi there! I'm going to be speaking at the AFSP's Out of the Darkness walk. I'll be telling my story of my suicide attempt. I'm nervous 'coming out' to a bunch of people. How do I not sound like an ass for surviving and subsequently thriving? I feel like if I tell all these people how I managed to stop self-harming and my realization that life is worth living, they'll think about lost loved ones and be bitter. Like I'm rubbing it in. That's more frightening to me than speaking to thousands of people.

AllRebelRocker

Congratulations and thank you, you're doing an incredible thing.

Having spoken to, with, and for thousands of survivors (friends and family) of those who died by suicide, I can tell you, unequivocally: Everyone there will be proud of you and feel so rewarded knowing that there are people like you that are trying to take the stigmatic and hidden mask off of suicidal thinking and behaviours.

They will all think something akin to "this is why I'm here - I am so glad that people like /u/AllRebelRocker are here to share their story.

What you are experiencing, the survivors guilt of speaking to people who have lost loved ones, is a normal human experience and one that shows me how much you care.


What does the media generally get wrong about suicide?

EdgerAllenPoeDameron

Media likes:

  • tight narratives - "joe was bullied so he died by suicide." suicide is a very complex behaviour with often dozens of competing reasons and counter-reasons feeding into it. Joe was raised in an abusive environment, with some poverty and chaos in his neighbourhood. But he was really good at art and basketball and was having a great school semester. He recently found out that his girlfriend was cheating on him and even though he was getting over it he couldn't stop obsessing over every instagram picture she posted. It's a lot harder to single out "bullying" than media would like to believe.

  • "if it bleeds it leads" - the great majority of suicidal thoughts result in no suicide, yet the media potrays few-to-no stories of recovery.

  • romantic narratives - glorifying (rather than memorializing, which is very important but different) people who die by suicide has unintended consequences.

  • point-counterpoint - i saw a rash of articles the past 4 years talking about how media guidelines on suicide were counter-advocacy, and we were "hiding the problem". The science is clear that when reporting is necessary (and sometimes it is), there are effective and helpful ways to do so and harmful ways to do so.


What do you think about the role of ideology in suicide? I attempted suicide for a strictly ideological reason (specifically it was Christian) as a teenager but have never seen ideology addressed by professionals to that end. I wasn't asked about what I believed, nor was what I believed questioned during treatment. If someone's suicidality is strictly ideological, wouldn't it be important to question that ideology, or do you think it's best to never question someone's religious belief?

Phlox_carolina

In the last three decades, a number of studies have tied religiousity to decreased suicide rates; however I am very skeptical of that conclusion. In fact, many of the confounders that have been identified (religious coroners in more religious countries less likely to "damn someone to hell"), and the reliance on survey rather than hard data suggest that its likely the social inclusion of religion, rather than the content of religion, that is of most benefit.

I will routinely ask people i'm working with about what role faith plays in their life, because my job as a psychiatrist is first to understand them as much as possible. I make it clear that I don't do religious counselling, but understanding it is crucial.

Despite being nonreligious myself, I am always wanting to know about the social support network of the person I'm working with and their culture, as it allows me to tailor their safety planning in a way that helps them best.


Thanks for doing this!

Do risk signs change with age? As a parent, should I adjust what I'm looking for as my child ages?

firedrops

Thanks for the question! Kids are explorers and adventurers. They generally are up for fun and like to play. Withdrawal from activities is a big red flag and one that needs following up. This is true throughout life, but in adulthood its a lot harder to see because most adults don't have daily supervisors who monitor those activities.

It's really really crucially important to think about the "cascade of suicidal thought":

  • stress
  • distress
  • hopelessness
  • suicidal thinking
  • suicidal behaviour

Suicide prevention lines are at the bottom of this waterfall. But parents, teachers, and caregivers can see the top. If a child is struggling, they are at risk for suicide. Our priority when working with children should be minimizing unnecessary stress and distress, because life already gives us necessary stress (social pressures, biological pressures, school, parent-child separation and conflict, etc).


What are the worst actions or advice that people typically think helps severely depressed and possibly suicidal people but can actually cause great harm?

HermesTheMessenger

I think a common, unhelpful trap is to quickly provide a solution; it's kind of insulting to the suicidal person ("Oh wow, you think I should try and be happier? I didn't think about that!!"). Making comparative statements ("you don't have it as bad as -whoever or wherever-") is also well-meaning but just... mean.

Be a kind, receptive, non-judgmental listener. People want to be heard, and emotions, no matter where they come from, can be validated without being endorsed. "Man you are really suffering" is way better than "but you were fine yesterday"


Does "the call of the void" phenomenon happen to people with suicidal thoughts more often? Does this phenomenon ever influence someone towards an unplanned suicide?

putinsvagina

I love the philosophy of these things, so thanks for asking. In psychiatry we call "the call of the void" - "impulsive automatic thoughts". We all get them - the famous call of the void is "standing on a cliff getting a thought about jumping". Absolutely, these play into suicidal behaviours. If someone has an impulsive brain, for a host of reasons, and they get an IAT; they can act on it. It's why people who have impulsive thoughts need to be very aware of themselves and their triggers.


What therapeutic models have you found to be most effective at quickly dissipating suicidal anxiety(anxiety about suicidal thoughts that in turn strengthens the suicidal thoughts)?

misterhamtastic

Without doubt, the strongest evidence we have for dissipating suicidal ideation is a combination of the following:

  • relaxation strategies outside of the event - practicing daily relaxation and stress relieving activities
  • mindfulness meditation (you don't have to philosophically buy into some of the more mystical aspects, procedurally it is fantastic in-the-moment relaxation)
  • distraction (you have to plan this before hand. a good safety plan is like a spy's "bug out kit" - you have it ready to go for when you need it. make a list of things you know you can do that keep your brain occupied and you enjoy, and be very specific.)
  • if possible, therapy - CBT (cognitive behavioural therapy) is all-star for reducing anxiety.
  • if needed, medication. many of our most effective as-needed medications for anxiety attacks quickly resolve the anxiety'; anyone with panic attacks or anxiety attacks that cause them intense distress should speak to their doctor.

What are your thoughts on the mental health crisis? Why are mental health issues so prevalent now? Has it always been like this? Is there something environmental affecting us? Or introduction of processing agents in our food? Lack of sleep? Social media?

ravelynn

Mental health issues have not changed much over time, our ability to diagnose them has improved. The classic example is ADHD - it's not that there is a skyrocketing group of people getting ADHD, its that we now understand ADHD and can diagnose it in more subtle cases.

Processing agents in food have very little implications on mental health - even sugar and childhood hyperactivity is unrelated! I've seen some relation of a specific food dye (yellow 2 maybe? I forget) with aggressive behaviour.

Lack of sleep: DINGDINGDING - sleep is a crucial, foundational element to our mental health and wellbeing.


Hi Tyler, thank you for the work that you do and for doing this AMA. I'm a third year medical student and actually just finally admitted to myself on my fourth week of my psych rotation that I love it. I was originally thinking peds but now pediatric psych is on my radar. On that note, what would you say is the hardest part about treating teens with self harming behavior and teens who have attempted suicide? Additionally does working with the child's family make it easier or more difficult in their recovery? Also, what is the best thing we can do today to spread awareness?

cunn1ngL1ngu1st

1) if you can see yourself doing psych - do psych. it's by far the best and most flexible medical career if you are compatible with it.

2) the hardest aspect is explaining to schools, parents, and caregivers that self harming behaviour is not suicidal, and the distress and stress should be the focus, not the coping strategy.

3) i often joke that "child psychiatry" is actually "child and parent psychiatry" - i love the work I do with families but some parents are more difficult than others.

4) please remember, no matter what direction your career takes, that suicide is a pan-societal concern; its not just a 'psych thing'.


What is the correct response when people tell you they feel suicidal? Is there different response for strangers, friends and family?

I really feel the answer to this question is missing in awareness campaigns I've seen. The average Joe may do more damage by saying the wrong thing, though he/she thinks it's helping.

krazyjakee

A helpful script would be something like:

  • thank you for telling me, I really want to help you
  • is there anything you'd like me to do beyond listening?
  • who do you have right now that I can connect you to?
  • (if you are concerned, and please trust your insticts on the conservative side) I'd really like to help you get some help... lets find a number you can call / can I help you book an appointment / lets go see a doctor?

Anytime, anyplace, anywhere - call 9-1-1 and report a suicidal person if you feel they are at risk for dying.


There's this common belief that the people who talk the most about committing suicide are the least likely to actually do it, but is this at all true, or a myth?

Jungian-Slip

0.008% percent of all people who experience suicidal thinking die of suicide every year. So statistically, you can pretty much always conclude "they are unlikely to do it". But that's only population-health level. anyone who is experiencing or expressing suicidal thinking is in distress and should receive help.

However, this myth is just that; by far and away, the strongest predictor of suicide is the history of previous suicidal thinking, speaking, or behaviours.


Is there a genetic component of depression and suicidal tendencies or is it entirely environmental?

CapitalistSquid_

Highly genetic. There are specific genes being identified (chromosome 2 has a few very highly correlated genes), and we know from MZ/DZ/sibling/family studies that even adopted away, risk is substantially higher for relatives of those who die by suicide.

Suicide has hundreds of factors, which can fall into 6 categories: genetic, environmental, social, cultural, and psychological, and medical.


Two days ago, a young man jumped off the 9-story roof at my work after having a bad day and getting mad at his supervisor. Is there a difference with impulsive suicide, planned-in-advance suicide, etc? What mentally is the difference? I wonder if there is a similar mental pattern in homicides of passion or planning as well. Is there anything we could have done or said at that moment just before he jumped, that works best?

ToeSchmoe

Often impulsive suicides are just out of the blue and incredibly hard to predict. We call these "anomic suicides" - poor coping strategy in the moment of stress --> suicide. All sorts of interventions can work but they are basically at the whim of the suicidal person to be in a situation where they are amenable to them (for example, the young man maybe would have calmed down if he sought a fellow employee for a conversation).

"Fatalistic suicide" is when one plans it in advance and its still external pressure, but they've thought it through. This is much different and generally requires extensive problem solving.

Try not to get in the trap of 'what could we have done' - always remember that when someone is upset its ok to say "hey i know you're upset but we can chat about it if you like" and don't try to use hindsight to criticize yourself. Most people get upset at their supervisors without dying by suicide.


Hi Tyler

Happy Cake Day! :) I assume you signed up 3 years ago on Suicide Prevention Day to promote the importance of this important issue. Thanks for doing this AMA!

I've trained originally in psychiatry, and suicide and self-harm is a major issue, as we know, around the world, in particular in younger people, and increasingly in men. We have found that this is becoming an issue with medical trainees as well in Australia, with a few recent suicides of trainees around the country - ironically there was a cluster of psychiatry trainees last year.

One of the things we grapple with is the preventability of suicide. There are clearly cases where depression and other mental health issues are missed, or obvious psychosocial stressors, that could be prevented. But over a population basis, there appears to be a baseline level of successful suicides, which we wonder, could be seen as a the endpoint of an illness, which is basically a known fatal complication, that may not be preventable.

What is your view on this issue? I'm not talking about clusters, although that is another interesting issue which you want to touch on (having been involved in a couple of major clusters in the state I'm in, in relation to copycat suicides amongst adolescents through social media - very controversial issue, especially in relation to recent media focus on TV shows etc).

Lastly, there has been recent research published about artificial intelligence and machine learning being able to predict suicidality from patient records, with better accuracy compared to humans (who according to systematic reviews do not get better than just above 50% if I'm not mistaken). Any thoughts on the emergence and use of AI?

Just some thoughts to generate some discussion. :)

Thanks again for your participation!

mvea

If i'm reading this correctly, I'm going to re-interpret the preventability about suicide as a final action preventability, not an un-intervenable process.

The process of developing risk factors for suicide (child mistreatment, poor health and mental health education, bullying, inequality and injustice, poor health care, witnessed violence, all of the risk factors for major mental illness, increased safety around dangerous objects, access to firearms, etc) generally are all intervenable. So there are a lot of suicides in which prevention could not have looked like a suicide prevention measure, rather a child poverty measure, or an education measure.

As it pertains to impulsive suicide; truly, people can go from 0-100 really quick and I'm not sure that there is a lot we can do about that. Contrary to the mythical "95% of those who die by suicide have mental ilness" figure (and trust me, it has no basis in reality), a much smaller percentage have diagnosable and treatable mental health conditions.

It's better to look at risk factors vs protective factors. What causes heart attacks, and what protects against heart attacks? Can we stop all heart attacks? Probably not; but we can definitely try and make people as healthy as possible in the most protected situation we can.

As to machine learning - i suspect the "data input" problem will be hard to overcome. One of my colleagues at BCCH is actually working on this and i cannot wait to see the benefits of machine learning for a narrative-heavy specialty like psychiatry.


Dr. Black, you write that discussion of suicide can trigger suicidal thinking. In the military (I work in public health/preventive medicine) we have VERY frequent mandatory training (online and in person) on the topic, and it is often mentioned at our end of week formations (eg "if you or a battle buddy is thinking about hurting themselves, ask for help" etc).

(1) What are your thoughts on this with respect to our community being such a high risk group based on the criteria you list in the attachment?

(2) What does the current research suggest are the best ways to approach the topic to large groups (eg 50+ people at a time)?

abstrusey

Thank you for your military service, what an interesting position you have. Can you tell me more about your office or position?

1) Military service is stressful. If I italicized it appropriately you wouldn't be able to read the word. Training soldiers and people working with them involves an incredible amount of intentional distress and intentional stress being inflicted upon trainees; this is not to the suicide risk benefit. A significant amount of time, resource, and opportunity needs to be taken to improve relaxation, stress-relieving techniques, support systems, and other forms of military education (i'm not particularly convinced that 'militaristic training' is optimized by physically/mentally abusing people).

2) For large groups having an available mechanism for 1-on-1 support is crucial, not everyone needs it but it needs to be universally available. Then, its relaxation and behavioural traning in stress reduction and healthy coping strategies.


What research has been done on people who survive a suicide attempt? Especially with regard to the functions of their "reward" system.

86theOrigin

It's a great question - if you're referring specifically to the dopamine-reward pathway in suicide attempts I have to confess that I am pretty uninformed. As it pertains to self-injury (non-suicidal behaviours such as cutting oneself or scratching or burning), the reward system is highly activated, likely precipitated by a baseline body state that does not provide adequate response for normal stressful situations. The science of the neurobiology of self-injury is advancing incredibly; I give a whole talk on it and the science is getting really really solid.


Why should we prevent suicide when our species no longer faces any external causes of death? Shouldn't we expect a rise in suicide rates as a natural population control as predation decreases, health care improves, and scarcity subsides? Isn't it normal and acceptable to expect some rate of suicide?

beejmusic

Acceptable? It's hard to come around to that. Also, I think "our species no longer faces any external causes of death" is about the most tone-deaf statement one could make. If that's where we are as a society at some point, maybe the philosophy changes; we are nowhere, and I mean nowhere, close to that.

There may be a baseline of impulsive suicide behaviours that cannot be reduced, due to the way our brains freak out and problem solve poorly the more impuslive we are.


How would you help someone you know cope with suicidal thinking/behaviour outside of getting them psychiatric help?

ZergB0ss

  • be genuinely kind and caring to them
  • offer other forms of help "lets do <whatever> together"
  • encourage connection to others
  • encourage treatment of medical/psychological issues (you don't need to see a psychiatrist to get treated for depression!)

How do you stay positive while being completely inundated with the subject matter of your studies?

Malbranch

My whole field is dedicated to improving the outcomes of the largest cause for child death in the western world. Any improvements will have a huge effect!

I do see horrific situations and outcomes but when your whole mentality and approach is "how can i make this better" you focus on that and it really helps.

I also have a great work-life balance: video games, basketball, a loving wife, travel, and a good sense of humour.


Do you have any thoughts on how schools should deal with shows like 13 Reasons Why? Address individual students as it comes up? Blanket statement? Just address parents? Nothing? My school pretty much did nothing and I was at a bit of a loss for what to say to students when it came up. (I watched it to see what the buzz was all about and just kind of saw it as a teen drama but I'm not a teen.)

well_uh_yeah

There is a kinda counterproductive trend in schools now to having a big traumatizing event occur after a trauma. You don't need to make a big production about a suicide story, a suicide in a school, or a suicide in a movie. Just a simple "hey this is a heavy time - if anyone needs it i'm here to talk; some people need time to rest and recoup, some people want to just get back to work, but I'm here."


Hello fellow Vancouverite

I guess an important question that needs to be asked is what are common subtle/hidden clues that a person with both intent and plan to commit suicide often show that most people often miss? I've read so many stores on this site where a loved one commits suicide but the other person says they never knew or could picked up clues that the loved one was ever going to do so.

wazabee

Unfortunately, this is referring to the impulsive suicide - basically undetectable even by professionals. There is no real code to crack - we want to reduce stressors and suicide risk factors whenever and wherever possible and improve protective factors whenever and wherever possible.

I know that's a disappointing answer, but it's the truth about suicide risk. Survivors of suicide victims need to work very hard not to blame themselves for missed signs, because there weren't any, often.


I'm curious to know: how does stress factor into or directly cause Suicide? I've heard quite a few stories about how the suicide rate is high in Japan because of the incredible stress that comes from the extremely high expectations set for the students.

RedSephy

Stress is to suicide as rivers are to waterfalls. It is a direct feed and contribution. Basically the cascade of suicide is:

Stress --> Distress --> Hopelessness --> Suicidal Thoughts --> Suicidal behaviours

For the very impulsive, this can happen in seconds.


What is the effectiveness of passive offers of help such as "thoughts and prayers" for a person considering suicide versus active offers of help such as producing tangible results for the suicidal person who truly wishes to attain a better quality of life that would make them feel not so suicidal?

socialliability

I always appreciate caring sentiments; but it has to be genuine.

What generally happens after something serious occupies your "thoughts and prayers"? A: YOU DO SOMETHING.

Nobody has a serious thought that worries or concerns them and thinks "yeah, imma do nothing about t hat" and thinks its a good thing. You can always do something. "I might have left the stove on" --> CHECK THE STOVE. You can't tell someone "i care" genuinely without demonstrating that you actually care.


Hi Tyler,

What are the biggest reasons for suicide and what should one do if he is in that situation?

One problem I've seen is that being depressed is seeing as being "cool", how can we stop that?

What can a common person do to help with suicide prevention ?

What should one do if a close friend or family member is in this situation?

What age groups and social classes are more vulnerable to be suicidal?

What movies/songs/tv shows/books etc do you suggest to help people calm down.

Also what are your thoughts on media that idealizes suicides?

Thanks for your time and that warning is appreciated.

superboyk

So many questions! Haha I'll try:

1) mental illness, external stress, abuse, and illicit substance use would account for the majority of suicides, though there are hundreds of factors

2) "Emo" stopped being cool a while ago, being depressed can be trendy but only in a subculture. I'd like to see depressed more become a medical state rather than a stigmatized or judged thing. How cool is diabetes? How cool is cancer?

3) be a kind and courteous person, and care about the distress and stress of your friends, colleagues, and fellow humans

4) https://www.reddit.com/r/science/comments/6z87lv/science_ama_series_im_tyler_black_a_suicidologist/dmtmf38/

5) suicide risk starts at age 10, increases to a high rate at 24 - 60, comes down a bit, and then for men it takes off again while women continue to see a decline

6) anything you enjoy :)

7) https://www.reddit.com/r/science/comments/6z87lv/science_ama_series_im_tyler_black_a_suicidologist/dmti0sv/


What are your personal feelings about suicide being a prevalent theme in popular culture?

KickingAround

I mean, it's dramatic. It's final. I can understand the narrative appeal.

I am not a fan of suicide being a plot device for shocking sake.


How can medical professionals, ie residents, help prevent this from happening in the first place? Is there a further certification I can bring to my residency program or personally?

DoctorNeuro

No certification that I particularly value - but one of the best pieces of advice i can give to doctors is:

  • it took us a while, but now doctors routinely ask all of our patients naturally uncomfortable questions about sexual health
  • we did that because of the importance of HIV/STDs
  • suicide kills 7.5x more people than HIV and its related diseases
  • we have to get comfortable with asking all of our patients about stress in their lives, distress, hopelessness, and suicidal thinking.

Hi I was wondering with your work in hospitals and the etc what your opinions on assisted suicide or euthanasia as whilst we do try and prevent suicide in those who are mentally ill and have potential to move on assisted suicide is seen more harshly and I personally believe is ethical for people who are terminally ill and have no possible chance of recovery. I learned the story of a man who developed locked in syndrome and was left completely dependent on others and could no longer communicate without a board and eye movements. He wanted to be able to have his wife and children help him to bring peace to them all and end his suffering but she would be legally charged for taking him to the available places. He needed up having to starve himself to be able to give his family a chance to be happy and free again and to end his pain. What talks with hospitals etc have you had about this topic and what are your thoughts from your research?

Unicornucopia3

I support dying with dignity for terminal conditions for which quality of life is severely impaired and treatment is not possible.

In the field of mental health, I work with people with largely treatable conditions, and young people, so this is rarely an issue for me. But if refractory severe mental illness with no more treatment recourse available is an issue, I would support it there too.

I kinda struggle with people who don't support it.


TIL Suicidologist is a thing.

SaitoPrecise7

person. Suicidology is a thing :)


What role do you think gender inequality issues play in the difference in suicide rates between men and women?

OompaLoompacalypse

I think that when we look at a graph like this:

http://www.bcmj.org/sites/default/files/BCMJ_53Vol10_suicide_fig1.JPG

We should be very cautious to remember that an 80 year old female on this graph is probably significantly different than an 80 year old woman will be 80 years from now.

In general (without wanting to go too far down the gender stereotype pathway), in Western societies female gender is associated with increased social role, connection to others, and emotional expression. Male gender is associated with increased productivity role, being a solo rock, and emotional concealment.

Men are also WAY MORE impulsive than women, especially in youth, which likely accounts for some of the gender gap as well.


What is the percentage of suicides that are relatable to the economy and financial problems of each individual?

jreb99

The average of the 4 years pre-collapse of 2007-8 the rate of suicide in the working population (25-64) in the US was 17.4/100,000 per year. Post-collaps the 4-year average was 19.1/100,000 per year. This is correlational stuff but i suspect economic stress certainly increases suicide risk, and the economy goes through periods of severe stress.

All stress matters to the individual, economic included.


Is there any reason, evolutionarily speaking or along those lines, for why suicide occurs?

I get the emotions, and I've dealt with it myself, but it seems like an odd thing to have evolved and not been weeded out.

Voodoo_Templar

Anything largely post-reproductive (the peak of suicide risk is age 45) is rarely significantly affected by evolutionary pressures.

Our brains are complex, fantastic machines. But they evolved with a developmental progression and unfortunately one of the last parts of the brain to "cook" is the problem solving areas - the frontal and prefrontal cortex - as late as 25. So many impulsive suicides are likely worsened by biological impulsivity


What are some of the bigger questions suicidology is trying to answer now? What do you think are some of the biggest factors preventing us from understanding suicide better than we do today?

blackdog6621

The biggest question right now is the value of stratification. Increasing evidence shows that identifying someone as "high risk" clinically is of little value when the absolute risk is low such that most "high risk" people do not die of suicide. This leads to complacency for "high risk" patients and ultimately a slippage of appropriate intervention. On top of this, those labelled "low risk" are misinterpreted as "no risk" and almost completely ignored, despite the fact that thousands of low risk people die by suicide world wide each year.

I'm increasingly becoming an advocate of whole-society suicide awareness and support mechanisms, vs the "if you're worried call 9-1-1" - certainly appropriate when it applies, but that doesn't mean we shouldn't worry about silent sufferers.


Thanks for doing this Tyler,

 

I once called a suicide hotline on behalf of a friend I was worried about. That person told me that they were having suicidal thoughts but struggling against them, and didn't want help and didn't want to talk. The hotline told me that there was nothing I could or should say to this person because they would need to (edit: have to, want to) seek help themselves to be able to be helped by someone. Is that true? The best they did for me was say if something did happen it wouldn't be my fault. I was flabbergasted, I can see how you can't force treatment on someone who isn't an imminent threat to themselves but surely they should have given me better more specific advice. What should one say or do in that situation?

 

I have a second question, how to you feel about that David Foster Wallace suicide quote about feeling suicidal is like being in a burning building? Is that a reasonable way of thinking about it?

Throwaway_2-1

There was a true sentiment there, but what a horrible way to convey it. You can't force help kindly - sometimes the best you can do is 'i get you don't want to talk but i'm here for you and there is some reason you told me'. Sometimes you can get a little bit challenging (to help!) 'come on, you can't tell me this and expect not to talk... lets try talking about it to see how it goes'.

I am just stunned that the professional couldn't see that by sharing with you, they wanted you to help. Their words said 'i don't want help' but their behaviour showed an ambivalence. A good portion of my career is navigating that ambivalence so the person can see that they actually do want help and want to stop feeling bad. Sorry you went through that.

Re: Wallace - its very hard for me to read his work because 20 years of depression with refractory recurrence is about as dire as it gets. There is serious truth to people, when in suicidal crisis, are truly in that moment where the problem they are struggling against is WAY MORE powerful than the fear of dying.The part I struggle with, is that in the vast vast majority of those times, the problem leaves, we get better handling it, or it improves, and we only get one life.


Hi Tyler, I currently work inside and Emergency Psychiatry unit as well in the US. What sensory items and other resources do you have available to you in your ED to help with crisis patients? Also our average time spent for an child / adolescent waiting for a bed is 7.5 days, how does your department compare.

Tycoonkoz

We keep things very low stim but have NDS/xbox/dvd players available to the kids. 50% of our kids are discharged within 1-2 days, so we focus on accommodating the family's needs as soon as possible and preparing for discharge. If they need a longer stay, our low-stim, low activity unit becomes counterproductive so we try and move them to a more therapeutic unit as quickly as possible.


Do you have any plans to change your name to Seth Rollins?

unhappygounlucky

he's the whole reason i registered "tylerblack.com" :D


Hey Tyler,

I am gay and I can not get over it, especially because my whole family is Russian. My suicidal thoughts ( never attempted tho ) are getting worse and tbh I don't see any reason to live anymore. I mean sure... people with mental illnesses "have something in their brain that doesn't work properly" ( oh god this must sound so wrong to you, I am sorry ) but being gay isn't something you can treat. I wish I was born into a much more supportive family. Everything would've been fine because I would be able to cope with it. Living with a homophobe family is different. They are everything I have and letting them know the truth about me will let them disown me. I am 21 and never had any gf ( thanks cap. Obvious ) and my parents are constantly asking me why. I guess I have 2 options :

  1. I'll cut every contact to them because they'll get to know of my sexual orientation ( thanks life ) and live a life without a family isn't something I think I am capable of ( they mean a lot to me) -> which could lead to option 2.

  2. Suicide

I know that it's very hard to "discuss" (?) specific cases and that's something you didn't intend with your AMA in first place but I'd like to know whether you think suicide in my case is justified or not. In the end I am nothing more than a dysfunctional human being in the eyes of my parents because they'll never get a biological grandson/granddaughter from me. ( but hey, at least they have my brother ) It's not only that. I don't think I can live in a closet for ever, especially when I know that every person I meet/know might hate me for reasons I can not control. Being hetero is my biggest wish I ever had from the moment I knew I was gay. It's only a "small" percentage of people who are gay but lucky me had to win the genetic lottery...

EDIT: grammar and stuff

ImLeeTheBee

Feeling validated and accepted for who you are is a crucial component of suicide prevention. I'm so sorry you don't have that at your home. There are groups of people worldwide who would accept you for who you are. I wish it could be your parents.

I'd encourage you to seek out a LGBT group in person or online to share your struggles. The "it gets better project" (you can Google it) is full of stories of people whose lives got better when they found a validating environment.

I would never want someone to die by suicide because they are gay and their family is not gay supportive. so please, reach out, find a community of support, and recognize your parents' faults as just that.


I often hear about the connection between mental illness and suicide. Could you elaborate on other connections? For instance economical or other health related causes.

flekkzo

Mental illness is not the sole determinant, and unfortunately many suicide prevention/MH advocates wrongly cite the poorly-scientific numbers that "90% of suicide victims had a major mental illness" all the time.

Anything that causes stress or distress can increase suicide risk, and anything that relieves stress or distress can improve it.

About health causes - man... Chronic illness is horrific. It can straight up lead to suicidal thinking and I worry a lot about the pendulum away from opioids in response to the crisis causing more people to suffer in pain. Having medical illness is very taxing and can contribute to suicide risk.


What do you think should i look for in a person to determine if he's suicidal or not?

avenger27

Though very generic, I like "IS PATH WARM" as a mnemonic.

https://en.wikipedia.org/wiki/IS_PATH_WARM


What's the best way to seek help?

There's a general theme in these sorts of things of 'seek help' but the process is rarely explained. As someone with pretty severe anxiety to compound everything else the very act of 'seeking' the help seems daunting.

Dr_Dippy

Usually the biggest barrier for internalizing problems (anxiety, depression), is the sense of isolation and difficulty in reaching out. Because there are countering anxious thoughts, or countering depressive thoughts, the person ends up feeling like they can't. So usually seeking help starts with a conversation with a trusted person - coworker, friend, parent, aunt, teacher, counsellor, nurse, family doctor. It doesn't have to be deep. "I've really been struggling with stress lately." "I'm pretty sure I need some help, but I don't know where to go from here", that kind of thing.

Not everyone will handle it perfectly, but a great place to start is by reaching out to a therapeutic space - https://www.reddit.com/r/SuicideWatch/wiki/hotlines

There is a subreddit full of people who maybe can connect on the anonymity of reddit: /r/SuicideWatch

Most importantly - any severe anxiety should be a part of treatment. Treatment comes in a variety of places, but it starts with reaching out.


Hey three questions, sorry if they've already been asked but:

1) You have a warning about discussion on suicide increasing suicidal thoughts - does this apply to suicidal intent ie "putting ideas in people's heads"?

2) Is suicidal ideation (both passive and active) an indication of suicidal intention, even if the individual claims they have no intention?

3) What pathways did you take to become a Suicidologist? I'm going to be finishing up my undergrad in psychology soon, and suicide is an area I'm particularly interested in.

AuraMire

1) there is an effect called the Werther Effect - reading or hearing or learning about or watching information on suicide can trigger suicidal thinking and risk in susceptible people.

2) intention and ideation are completely separate - but active ideation is much closer to intention than passive. intention is "what was the goal of my behaviour" ideation is "what can my brain think of".

3) pharmacology B.Sc --> med school --> psych residency --> child psych specialty ; lots of ways its a huge field! The biggest thing is to really stand on the shoulders of giants - read as much science as you can on suicidology - i have a weekly pubmed blast with a whole bunch of terms being fired to me.


How important is it that the focus of mental disorders shifts from being seen as something that can't be fixed to something that can possibly be fixed with help. As in- there are a large number of people who are not affected by mental health and are terrified of those with a disorder, or have had one in the past. How do we defeat the stigma?

Also what's considered "cutting edge" in suicide prevention and how can we best, as everyday people without suicidal thoughts, prevent them from finding a way into our own thoughts in the future? Is there a way?

WRXboost212

Stigma requires serious institutional change, plus informed and helpful advocacy - stories of recovery, networks of support, our social support of those with invisible illnesses and disabilities, etc.

Not sure how cutting edge it is, but the impact of active relaxation in improving mood and outcome is really coming to the forefront in terms of evidence. I think having good relaxation strategies and life balance is important for preventing future suicidal thinking; believing youre immune from stress is really dangerous - figure out what destresses you, use it regularly, and stay connected to people you care about.


Thanks for coming to talk with us today! I'm interim chair of the school of interactive computing at Georgia Tech, and a number of our faculty are doing work on social media and mental health including suicidal ideation. They are doing things like tracking people to see if they can identify problems. They are collaborating with mental health professionals in this work. The problem that I'm concerned about is: are they prepared enough to deal with positive cases that might be detected? We are moving to a model where all participants are pro-actively given information on mental health and suicide prevention resources. Ie (paraphrasing), "If you agree to be part of this study, we are going to ask you about some pretty personal stuff, so we want you to know if you ever feel sad there are resources available to you...." My question is, what are best practices here? They are asking people "are you depressed" and also detecting that from social media, and some folks are going to say "yes".... My concern is both for the research subjects and for the computer science grad student who may detect something amiss at a weird hour of the night and need a clear plan on what to do.....

asbruckman

Very cool! I'm always worried about the "garbage in" problem of the "computing results" when it comes to this - but man; think of all the ways we can use machine learning to identify language and posting queues of suicide risk!

I think we can be prepared - tier-based approach to suicide concern is possible and robust systems can be implemented to handle triaging of cases.

Anyone, in any capacity, who is worried about the wellbeing of another is within their rights (confidentiality does not apply in life or death situations) to contact an authority, to reach out, or to seek help. Programs like the one you are describing can certainly build this into their protocol.


Hi Dr. Tyler Black, Happy Cake Day!

I am beginning my Masters of Social Work and intend to become certified in CBT. I volunteer as a trainer on a crisis line. In my personal life I have had an immediate family member attempt suicide, I have other friends that have discussed ideation. I am always there for friends encouraging them to seek help and adamant that I will be there for them in whatever way I can. Obviously this is a concept that is extremely important to me so I have a few questions:

  • How do you feel about Canada's new laws for assisted suicide?

  • What is your best advise for supporters of those with ideation?

  • What do you do for self-care in such an intense field?

Thank you for such an awesome AMA!

lucky_penny89

Good luck on your studies!

  • its tricky; i generally see most mental health illnesses as treatable but the exclusion of all mental illnesses seems cruel and unconstitutional. after the "is it ok" comes the "so who does it and how" which is even more tricky.

  • i think what you're doing is what should be done - to the limits of civility be there and present for people and be genuine in your interest for their wellbeing. also, patient - crises can be taxing but they pass

  • i'm hugely into video games, basketball, travel, photography - i try and keep it balanced! But i love my intense field too - two ways to look at what i do: "so many sad cases" vs "i have so much opportunity to help" - i choose the latter and it really works for me.


My main problem is that I find it very difficult to take things in life seriously. Especially when things seem futile, like not enjoying life or not having the money to enjoy life, and it sets me on a thought patten about the futility of life and how nothing really matters unless we make it matter. Is this something that you see occurring frequently in those who suffer from suicide ideation? How does one confront and change these thought patterns?

summerwasting

https://www.reddit.com/r/science/comments/6z87lv/science_ama_series_im_tyler_black_a_suicidologist/dmtgboc/

Mostly answered here, I think.

Existential stuff is dangerous to go down if you overthink it. A little more behavioural relaxation/change as opposed to thinking.


Not sure if this was asked since I'm on my phone but what do you think cause Chester Bennington from Linkin Park to suicide? He was on top of the world with a new album just released. He didn't seem like he was in the position to end his life the way he did. Just want to get a professional view. Thank you

fmp398

I can't professionally speak about specific cases at all, sorry :( It's always tragic when a life is lost to suicide, particularly someone who brought beautiful art into the world.


At what age did you know you wanted to be a Suicidologist?

newsocksanddraws

Doctor at 13. Psychiatrist at 25. Suicidologist at 27. Child psychiatrist at 29.


What does the best science today have to say as the reason that 3.5x as many men commit suicide as women?

cmumford

https://www.reddit.com/r/science/comments/6z87lv/science_ama_series_im_tyler_black_a_suicidologist/dmtolc6/

Like all things with respect to suicide risk, the answer likely comes in a mixture of the social, biological, and psychological.


Is suicide an increasing phenomenon? Or are we just more aware of it. I work in a rural hospital and it seems like we have one, two or more admitted for sducidal ideations, self harm or overdose. It can be quite the burden on a small hospital since we hold them until a facility can take them. I have seen them homed in the ER for days waiting.

Hamptastic75

10 to 15 percent increase in the US over the past 10 years . Rural communities have higher rates. The highest rise is in rural female populations.


Do you differentiate between suicidal tendencies due to psychological reasons and those due to hormonal imbalances/ deficiencies of nutrients like vitamin b12?

jgmdb

Certainly in terms of treatment; i'm not sure i've ever seen the latter and we do tons of medical screening with our kids (400+ a year for 10 years).


Is there a term for someone who doesn't want to hurt themselves, but would rather have someone/something else do it?

kittytax

This is called passive suicidal ideation.


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