This story was originally published on Jul. 19, 2016.
Several months ago, a woman I’m very close to checked herself into a hospital because she’d been having thoughts of ending her own life. Not just thoughts, actually — she had a plan. Those of us who know her truly had no idea things had gotten that bad. Sure, we knew things had been tough lately, but she’d weathered worse. She’s dealt with depression and mild bipolar disorder for much of her adult life, and has gone through some very low times, but she has always come back up before. This time was different. Thankfully, she had a potentially life-saving mental health care network in place. She had subsidized health insurance, was seeing a decent local psychotherapist who accepted her insurance, and was brave enough to be honest with that therapist about what she was thinking. Had just one of those things not been the case, she might not be alive, and I and so many others would be mourning her now. More and more Americans are being touched by the tragedy of suicide. Rates have been on the rise since 1999, especially among women. While more men than women take their own lives, the suicide rate for women age 45 to 64 grew faster than that of any other group of people, jumping 63% between 1999 and 2014, according to data released this spring from the Centers for Disease Control and Prevention. The overall suicide rate in the U.S. is 24% higher today than it was in 1999. In fact, we’re back up to levels the country hasn’t seen since its last suicide peak in 1986. Why are so many women taking their own lives? And what can we — as a country and culture — do about it? The answers are complex, and every expert with whom I dug into this topic had a slightly different take, but a few clear themes emerged. What follows is by no means a comprehensive list of the steps we must to take to start making an impact on suicide in women, but it’s a start. Destigmatize Antidepressants...Again
The last time we were able to successfully decrease suicides in this country was during the late 1980s, when rates began a steady, decade-long decline after the FDA approval of the SSRI antidepressants Prozac and Zoloft, says Christine Moutier, MD, chief medical officer for the American Foundation for Suicide Prevention. Prozac hit the market in 1987, and by 1990, 650,000 prescriptions were being written or refilled every month. It’s no coincidence, says Dr. Moutier, that self-inflicted deaths started to fall around the same time. “Suicide rates were going down quite beautifully,” she says. But in 2000, news headlines started circulating that SSRIs might be linked with an increased risk of suicide. (“While the happy drug works for many people, in a significant number it can take them to the edge of despair,” stated one particularly gleeful takedown in The Guardian that year.) Over the next few years, however, the CDC analyzed studies involving more than 100,000 subjects and concluded that the increased risk was small and that it was only statistically significant in children and adolescents. In 2004, the Food and Drug Administration issued a black-box warning for antidepressants, stating that they were linked to an increase in suicidal thoughts in kids under age 18. Unfortunately, many experts now believe this warning, while probably warranted, may have done more harm than good — and ended up confusing both patients and doctors. Research conducted since has found that use of antidepressants among adults — who were never believed to be at risk for increased suicidality on SSRIs — fell by 14% in the two years after the black-box warning was issued. Primary care doctors, feeling that they had fewer treatments to safely offer, began diagnosing depression in fewer people — and cut back on antidepressant prescriptions across the board, even in patients who were clearly clinically depressed, according to a 2010 report in the New England Journal of Medicine. “There was a media swirl that very much confused both healthcare providers and the public because the rhetoric became that antidepressants are more dangerous than they are helpful,” says Dr. Moutier. “But that’s not a true statement. Effective use of antidepressants to treat depression saves lives, and there is plenty of research to show that.”
Several months ago, a woman I’m very close to checked herself into a hospital because she’d been having thoughts of ending her own life. Not just thoughts, actually — she had a plan. Those of us who know her truly had no idea things had gotten that bad. Sure, we knew things had been tough lately, but she’d weathered worse. She’s dealt with depression and mild bipolar disorder for much of her adult life, and has gone through some very low times, but she has always come back up before. This time was different. Thankfully, she had a potentially life-saving mental health care network in place. She had subsidized health insurance, was seeing a decent local psychotherapist who accepted her insurance, and was brave enough to be honest with that therapist about what she was thinking. Had just one of those things not been the case, she might not be alive, and I and so many others would be mourning her now. More and more Americans are being touched by the tragedy of suicide. Rates have been on the rise since 1999, especially among women. While more men than women take their own lives, the suicide rate for women age 45 to 64 grew faster than that of any other group of people, jumping 63% between 1999 and 2014, according to data released this spring from the Centers for Disease Control and Prevention. The overall suicide rate in the U.S. is 24% higher today than it was in 1999. In fact, we’re back up to levels the country hasn’t seen since its last suicide peak in 1986. Why are so many women taking their own lives? And what can we — as a country and culture — do about it? The answers are complex, and every expert with whom I dug into this topic had a slightly different take, but a few clear themes emerged. What follows is by no means a comprehensive list of the steps we must to take to start making an impact on suicide in women, but it’s a start. Destigmatize Antidepressants...Again
The last time we were able to successfully decrease suicides in this country was during the late 1980s, when rates began a steady, decade-long decline after the FDA approval of the SSRI antidepressants Prozac and Zoloft, says Christine Moutier, MD, chief medical officer for the American Foundation for Suicide Prevention. Prozac hit the market in 1987, and by 1990, 650,000 prescriptions were being written or refilled every month. It’s no coincidence, says Dr. Moutier, that self-inflicted deaths started to fall around the same time. “Suicide rates were going down quite beautifully,” she says. But in 2000, news headlines started circulating that SSRIs might be linked with an increased risk of suicide. (“While the happy drug works for many people, in a significant number it can take them to the edge of despair,” stated one particularly gleeful takedown in The Guardian that year.) Over the next few years, however, the CDC analyzed studies involving more than 100,000 subjects and concluded that the increased risk was small and that it was only statistically significant in children and adolescents. In 2004, the Food and Drug Administration issued a black-box warning for antidepressants, stating that they were linked to an increase in suicidal thoughts in kids under age 18. Unfortunately, many experts now believe this warning, while probably warranted, may have done more harm than good — and ended up confusing both patients and doctors. Research conducted since has found that use of antidepressants among adults — who were never believed to be at risk for increased suicidality on SSRIs — fell by 14% in the two years after the black-box warning was issued. Primary care doctors, feeling that they had fewer treatments to safely offer, began diagnosing depression in fewer people — and cut back on antidepressant prescriptions across the board, even in patients who were clearly clinically depressed, according to a 2010 report in the New England Journal of Medicine. “There was a media swirl that very much confused both healthcare providers and the public because the rhetoric became that antidepressants are more dangerous than they are helpful,” says Dr. Moutier. “But that’s not a true statement. Effective use of antidepressants to treat depression saves lives, and there is plenty of research to show that.”
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In these days of “clean eating” and “all natural” everything, there’s also a growing resistance among women to being “medicated” in general. “I hear from a lot of people who don’t want to medicate themselves for their mental health issues,” says Natasha Tracy, 38, a mental health speaker and writer who has been dealing with the challenges of bipolar disorder for 18 years, including periods of feeling suicidal. “Some of them won’t even work with a mental health professional at all because they know that the doctor will want them to take something. They want to believe that there’s a ‘natural’ way to fix this problem. If you had a problem like a broken foot, you wouldn’t expect an herb to fix it. People think a natural remedy will work for mental illness because it’s ‘just their emotions,’ but it’s biological; it’s in your brain. The brain is an organ just like any other. The brain is a very fancy organ and does a lot of things, but just like your lungs or pancreas can get sick, your brain can get sick.”
Tracy, who survived a suicide attempt five years ago, now takes medicine for bipolar disorder and depression, but admits she has a love-hate relationship with the drugs. “The side effects are quite brutal for me much of the time,” she says. “I spent a lot of my life feeling suicidal. If it weren’t for medication, I probably wouldn’t be here today. So that’s the love part of it: I recognize that medication is important in my life, and that the positives, i.e. staying alive, far outweigh the negatives.”
Enforce Mental Health Coverage Laws That Are Already On The Books
The Mental Health Parity Act of 2008 required health plans to cover mental health conditions and treatment at the same levels that they cover medical conditions and treatment. But anyone who’s tried to get an appointment with an in-network psychiatric provider knows that doesn’t automatically translate into great mental health care. For one, all health plans do not actually comply with the parity law, a 2015 study out of Johns Hopkins found. Cognitive behavioral and dialectical therapy, for example, have both been shown effective in treating depression — but what if your insurance only covers six sessions, when even so-called “Brief CBT” therapy often requires an average of eight, plus one or two booster sessions for follow-up? Or there’s no one in-network within a hundred-mile radius of you who can provide it?
The Mental Health Parity Act of 2008 required health plans to cover mental health conditions and treatment at the same levels that they cover medical conditions and treatment. But anyone who’s tried to get an appointment with an in-network psychiatric provider knows that doesn’t automatically translate into great mental health care. For one, all health plans do not actually comply with the parity law, a 2015 study out of Johns Hopkins found. Cognitive behavioral and dialectical therapy, for example, have both been shown effective in treating depression — but what if your insurance only covers six sessions, when even so-called “Brief CBT” therapy often requires an average of eight, plus one or two booster sessions for follow-up? Or there’s no one in-network within a hundred-mile radius of you who can provide it?
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If you had a problem like a broken foot, you wouldn’t expect an herb to fix it.
Natasha Tracy
”
“The Affordable Care Act has made seeking help easier, but the demand is outweighing our mental health system's ability to catch up,” explains Jennifer Wright-Berryman, PhD, a suicide expert from the University of Cincinnati College of Allied Health Sciences. “For example, in Kentucky, there is such a demand for services that they have an agreement with some neighboring states to provide dual licensure so that they can have enough clinicians to provide services. Therefore, people may wait to get the care they need.” (However, she points out that in the case of emergencies, when someone is at risk, that person cannot be turned away from an emergency room and will receive care on the spot.)
“The Mental Health Parity Act and the Affordable Care Act are both positive steps forward to improving access to care,” says Jeffrey Borenstein, MD, president and chief executive of The Brain & Behavior Research Foundation — but these laws must be fully enforced in order to work. “This includes making sure that insurance companies have full panels of psychiatrists and other mental health professionals available to patients. Enforcement includes making sure that insurers do not have bureaucratic or payment issues, which ultimately block access to treatment.”
Slow The Flow Of Rx Painkillers
Serious mental illness such as schizophrenia, bipolar disorder, and post-traumatic stress disorder all increase the risk of suicide. But the prevalence and severity of these illnesses has not changed greatly, so underlying mental illness cannot completely account for the increase in suicides in the U.S., says Wright-Berryman. “However, certain other factors have changed in the last decade or so, and one of those has been the prevalence of opioid prescriptions,” she says. Since 1999, the amount of prescription opioids like oxycodone and hydrocodone — also known by brand names OxyContin, Percocet, and Vicodin — sold in the U.S. nearly quadrupled, according to the CDC. This is especially impactful for women, since women are more likely to attempt suicide by self-poisoning, while men are more likely to use guns. Access to highly toxic and potent medications like opioids increases the chances that a woman will die during an attempted poisoning. “A certain portion of the population has attempted suicide multiple times, and what determines the outcome is what method they used. If they now have more immediate access to toxic medication, they are less likely to survive an attempt,” says Dr. Moutier. Poisoning was the most common suicide method for women in 2014 — a change from 1999 when women were slightly more likely to use firearms.
Serious mental illness such as schizophrenia, bipolar disorder, and post-traumatic stress disorder all increase the risk of suicide. But the prevalence and severity of these illnesses has not changed greatly, so underlying mental illness cannot completely account for the increase in suicides in the U.S., says Wright-Berryman. “However, certain other factors have changed in the last decade or so, and one of those has been the prevalence of opioid prescriptions,” she says. Since 1999, the amount of prescription opioids like oxycodone and hydrocodone — also known by brand names OxyContin, Percocet, and Vicodin — sold in the U.S. nearly quadrupled, according to the CDC. This is especially impactful for women, since women are more likely to attempt suicide by self-poisoning, while men are more likely to use guns. Access to highly toxic and potent medications like opioids increases the chances that a woman will die during an attempted poisoning. “A certain portion of the population has attempted suicide multiple times, and what determines the outcome is what method they used. If they now have more immediate access to toxic medication, they are less likely to survive an attempt,” says Dr. Moutier. Poisoning was the most common suicide method for women in 2014 — a change from 1999 when women were slightly more likely to use firearms.
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Increase Genuine Connection & Community
People who attempt suicide often describe feelings of intense isolation, experts say. The way we conduct our relationships today may be adding to women’s feelings of being all alone. “I do wonder about whether there’s something changing in our social connectedness and culture [that leads to more suicides],” says Dr. Moutier. Divorce could be one factor. In a 2010 analysis published in the journal Public Health Reports, researchers noted that in 2005, unmarried middle aged women were 2.8 times more likely to die from suicide than married women, and the divorce rate in middle-aged and older people has doubled since the 1990s. Perhaps our growing reliance on technology is another. “I would like to see more attempts at connectedness,” says Wright-Berryman. “Research shows that we need to focus on increasing the protective factors that prevent suicide. When people are feeling suicidal, they feel alone, even if they have a large circle of caring friends. So whether it's women in urban or rural areas, they need to feel like they are ‘dialed in’...meaning that there is always a way to seek and receive help, love, support.” Sometimes that may be turning to a close friend or family member, but it could also mean using technology to make a genuine, helpful connection, says Wright-Berryman. “There are crisis phone apps, for example. Someone could simply tap on their phone and chat with someone about their feelings. There are community-based interventions, such as Question-Persuade-Refer (QPR) and SafeTALK. These are short trainings that any community member can take to learn how to ask the questions, know how to respond, and guide someone to help. Suicide is a community issue, and the more our community members know about how to intervene and help, the more we can collectively make an impact on suicide.”
People who attempt suicide often describe feelings of intense isolation, experts say. The way we conduct our relationships today may be adding to women’s feelings of being all alone. “I do wonder about whether there’s something changing in our social connectedness and culture [that leads to more suicides],” says Dr. Moutier. Divorce could be one factor. In a 2010 analysis published in the journal Public Health Reports, researchers noted that in 2005, unmarried middle aged women were 2.8 times more likely to die from suicide than married women, and the divorce rate in middle-aged and older people has doubled since the 1990s. Perhaps our growing reliance on technology is another. “I would like to see more attempts at connectedness,” says Wright-Berryman. “Research shows that we need to focus on increasing the protective factors that prevent suicide. When people are feeling suicidal, they feel alone, even if they have a large circle of caring friends. So whether it's women in urban or rural areas, they need to feel like they are ‘dialed in’...meaning that there is always a way to seek and receive help, love, support.” Sometimes that may be turning to a close friend or family member, but it could also mean using technology to make a genuine, helpful connection, says Wright-Berryman. “There are crisis phone apps, for example. Someone could simply tap on their phone and chat with someone about their feelings. There are community-based interventions, such as Question-Persuade-Refer (QPR) and SafeTALK. These are short trainings that any community member can take to learn how to ask the questions, know how to respond, and guide someone to help. Suicide is a community issue, and the more our community members know about how to intervene and help, the more we can collectively make an impact on suicide.”
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“
Suicide is a community issue, and the more our community members know about how to intervene and help, the more we can collectively make an impact.
Jennifer Wright-Berryman
”
I was taken by surprise when my close female friend went into the hospital — like I said, those of us who know and love her didn’t realize her pain and desperation had gotten so intense. Looking back, I realize now that most of my impressions of “how well” she was doing were from Facebook, or quick texts exchanged in between doing other things. I hadn’t seen her in person in five months, and we hadn’t talked on the phone in several weeks. So how connected were we, really? Social media and texts created the illusion that things were alright. But they weren’t. I’m not saying that regular phone calls from me or anyone else could’ve fixed her depression or kept her from feeling suicidal — I’ve had several major depressive episodes myself and know that’s not how it works. But perhaps more genuine connection and communication could help all of us feel less alone.
If you, or someone you know, is having suicidal thoughts or impulses, get help and get educated now. A few ways to do it:
• Call the confidential, 24-hour, free National Suicide Prevention Lifeline at 1-800-273-TALK (8255);
• Go to Suicide Prevention Lifeline to learn more or download the free support app called My3 (also available in all the app stores);
• Text “help” to the free Crisis Text Line at 741-741;
• Find other types of support at the American Foundation for Suicide Prevention web site.
• Call the confidential, 24-hour, free National Suicide Prevention Lifeline at 1-800-273-TALK (8255);
• Go to Suicide Prevention Lifeline to learn more or download the free support app called My3 (also available in all the app stores);
• Text “help” to the free Crisis Text Line at 741-741;
• Find other types of support at the American Foundation for Suicide Prevention web site.
Refinery29 is teaming up with Black Girls Smile Inc. in honor of Minority Mental Health Month to encourage women everywhere to lead their most mentally healthy lives. Because there is no health without mental health. Prioritize yours.