In Search of a Solution to Suicide
The first time Samantha Nadler was hospitalized for suicidal thoughts was in 2001. She was 12.
“I told my school psychologist I didn’t want to be here anymore,” said Nadler. “He called my dad, and I was admitted to the hospital for five days. That kickstarted a series of many hospitalizations to come.”
At 14, she attempted suicide for the first time. The following two years, she was admitted to 10 inpatient and partial hospitalization programs across her hometown of New York City, averaging only two or three months between each admittance.
In 2005, she was sent to Nashville to join a program for troubled teens, where she spent two years in an unfamiliar community, contributing to her feelings of isolation and giving her a skewed look at how receiving help for mental health might look.
By the time she turned 19, she had attempted suicide eight times, with her final attempt resulting in three days in the Intensive Care Unit at Vanderbilt University Medical Center.
“That was my most lethal and most serious attempt, and the experience made me pause for future attempts. When I was in the emergency room before being transferred to Vanderbilt, they told me they weren’t sure if I was going to make it,” said Nadler, now 30. “I don’t remember a lot about that visit, but that’s something that sticks with you.”
Though she believes she had a genetic predisposition to mental illness and has struggled with lifelong anxiety, Nadler feels much of her suicidality was triggered by her home environment.
She was in counseling prior to her hospitalizations while her parents were divorcing. Her mom lost custody of Nadler and her sisters. Being around certain family members suddenly became a source of trauma and pain.
“I’ve since found out that my sisters struggled in a similar capacity, but I didn’t have that insight back then. I thought I was the only one, and that compounded my hopelessness,” said Nadler. “I felt like something was wrong with me and that I needed to be fixed.”
Nadler, now a Licensed Master Social Worker and head of supervision at Crisis Text Line, first felt a sense of healing when she began volunteering at a crisis call center and connected with others who cared about suicidality.
Her personal journey gives her a unique, ground-level perspective on the mental health care system and accessing resources.
“There’s an expectation that when you share your personal experience with suicidality, you have to be the ‘good survivor.’ You have to advocate for the typical course of treatment and say, ‘I took my medications, went to psychiatry, and now I’m doing great.’ That’s not how it happened for me,” said Nadler, who left the health care system entirely in the years following her final suicide attempt. “My story acknowledges that this could pop up again and that our system could be improved.”
Among the experiences that stuck with Nadler through her journey were waning empathy she received during each subsequent hospitalization and suicide attempt, being involuntarily admitted at times when she wasn’t suicidal, and facing stigma from those with little training on how to communicate with individuals in crisis.
“I’m still accessing the system, and I still think we could be doing better,” said Nadler. “We aren’t handling suicide well, but we are working on it.”
In 2017 more than 47,000 Americans died by suicide, and an estimated 1.4 million attempted suicide. There is an average of 129 suicides in the United States per day, with Tennessee accounting for a higher-than-average rate of one suicide every eight hours.
Suicide is the 10th leading cause of death in the U.S., but it hasn’t always been that way. The Centers for Disease Control and Prevention (CDC) reported a 30% increase in suicides in the U.S. from 2000 to 2016, with rates consistently increasing across all age groups.
“Suicide rates are always significantly higher than homicide rates, which you might not expect given the state of the news media. In the last 18 years, there has been this rise, and it’s hard to say why,” said Nathaniel Clark, MD, chief medical officer of Vanderbilt Behavioral Health and chief of staff of Vanderbilt Psychiatric Hospital. “People speculate there might be some link to access to mental health care, increasing rates of substance use or the state of the economy. It’s interesting because in other parts of the world the rates are falling.”
Though suicide affects all populations, rates are highest among middle-age Americans, individuals older than 85 and adolescents. Past CDC data shows particularly worrisome increases among teen girls, for whom the suicide rate rose by roughly 70% between 2010 and 2016.
While rate increases have drawn significant attention to enhancing mental health care, increasing resources and recognizing warning signs, suicide remains a difficult problem to study and an even tougher problem to solve. Longstanding stigma prevents many individuals from seeking treatment or coming forward after a suicide attempt, and attempts are typically self-reported, making them difficult to define and track.
Most research trials explicitly exclude subjects deemed at risk of suicide, making randomized studies virtually useless. Studies also don’t last long enough to determine outcomes regarding who dies by suicide.
“When we talk about suicide, we tend to only talk about those who have died. But, for every death from suicide, there is an average of 25 attempts,” said Nadler. “I know of researchers who believe it’s too risky or that there are too many liabilities to work with people who are suicidal, but it’s challenging to learn and be better if we’re afraid to approach it.”
Access to mental health care has improved for medium-range mental health interventions, said Clark, but services for individuals with severe mental illness are becoming increasingly utilized and scarce, including availability of acute care beds. Many of the individuals who need care most are not receiving it.
“There has been a lot of national work to make mental health care easier to access,” said Clark. “The question is, ‘Is it getting to all the right people, and is it being delivered in a way that makes an impact?’”
INDICATORS OF DESPAIR
Across Vanderbilt, work is being done to better understand suicide, its causes and how to identify suicidal thoughts before they turn into behavior.
Lauren Gaydosh, PhD, assistant professor of Medicine, Health and Society and Public Policy Studies at Vanderbilt University, has centered a portion of her research around indicators of despair, or factors that may precede deaths from suicide, drug overdose and alcohol-related liver disease — all of which may be caused by an underlying feeling of hopelessness and reflect self-destructive behaviors.
Potential precursors to these “deaths of despair” include binge drinking, depression, suicidal thoughts and use of substances such as marijuana, opioids and prescription drugs.
“I’m a demographer, so I’m interested in life expectancy, and the fact that it has been declining is really disturbing,” said Gaydosh.
The average life expectancy in the U.S. increased by nearly 10 years over the last half century, but it plateaued after 2010 and began reversing in 2014, dropping for three consecutive years. Meanwhile, other high-income countries have continued to show a steady increase in life expectancy.
Gaydosh’s research utilized the National Longitudinal Study of Adolescent to Adult Health, which tracked the mental and physical health of thousands of Americans born between 1974 and 1983 (Generation X) from adolescence through their late 30s and early 40s, or their current ages. She examined patterns of mental health symptoms, drinking and drug use and found these indicators of despair are rising — a finding that could mean deaths of despair frequently observed among middle-age Baby Boomers (born 1946-1964) may impact members of Generation X more broadly in the next few years.
“It’s really troubling to think what this may mean as these individuals age into their 50s. The fact that peoples’ health behaviors are getting worse as they are aging is worrisome in terms of what we might expect from them in the next 10 years, especially given that there’s evidence at a population level that our life expectancy is declining,” said Gaydosh.
Her research leaves Gaydosh questioning whether increases in indicators of despair are specific to her study population or age range, whether indicators can be clustered together or are separate phenomena, and whether the opioid crisis plays a role. She plans to study predictors of the indicators of despair to better understand potential causes.
“Things like the labor market conditions, unemployment and family dissolution have been proposed as potential underlying societal explanations, so now we want to look at the data to see if we find any evidence,” said Gaydosh.
CHILDREN AND ADOLESCENTS
Suicide is the second leading cause of death for Americans age 10-24, preceded only by unintentional injuries. A 2018 Vanderbilt-led study published in Pediatrics showed the number of school-age children and adolescents hospitalized nationwide for suicidal thoughts or attempts has more than doubled since 2008, with seasonal spikes occurring in line with the academic school year. Encounters peaked in the fall and spring and were lowest in the summer.
Increased academic pressures serve as one theory for rising suicide rates among children and adolescents, said Gregory Plemmons, MD, associate professor of Clinical Pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt and lead author for the study.
“Suicide is a complex topic, so there are a lot of theories about why rates might be rising,” he said.
There’s a large focus on social media, said Plemmons, noting that the slow increase in suicide rates among youth has been linked to the year more than half of the population began using smartphones.
“There are more opportunities for children to be cyberbullied, and there are more images being shared that depict the ‘perfect life’ and the ‘perfect profile,’ and I think that’s part of it,” said Plemmons.
Another theory revolves around puberty, of which the average age of onset is lower than it used to be. Depression has shown to rise in puberty.
To more effectively identify those at high risk of suicide, both the Children’s Hospital and Vanderbilt University Adult Hospital have implemented universal screenings for suicide in the Emergency Department and on inpatient units, asking all patients a series of questions that puts them in high- or low-risk categories for suicide. If patients are deemed at-risk, they’re connected with resources based on their personal risk level and medical history.
Plemmons hopes the approach will help destigmatize mental illness and place emphasis on mental wellness as part of a child’s overall health.
Children’s Hospital also implemented lethal means counseling for patients who are at risk of suicide.
“While there has been a large focus on why this is happening, the other focus has been on how we can reduce suicide completion in the interim. We’re having more discussions about access to firearms and prescription medicines on the front end,” said Plemmons, who noted the greatest risk of a recurrent suicide attempt is within the first month following an attempt.
“There’s really interesting data that shows children know where the firearms are in their home. Parents may not know that their child is aware of the gun or where it is, but there’s a big discrepancy in what children know and what parents think they know. We’re trying to reduce that gap.”
SUICIDE RISK ALGORITHMS
As an internist, Colin Walsh, MD, MA, is interested in every health condition his patients experience from head to toe, and mental health is no exception.
In 2015, his interest led him to combine forces with two VUMC psychologists to develop data-driven approaches to identify signals of suicide risk from routinely collected electronic health records. The team developed a set of algorithms to scan patient records for hints of suicide attempt or self-harm using data such as diagnostic codes, medications, visit types and basic demographics.
“We knew this was a complex problem and that it could pop up in any clinical setting, often at an unexpected time. It’s hindered by the fact that we know underreporting symptoms in suicidality and mental illness is a big problem, and even when symptoms are reported and documented in a clinical note, they don’t always make it to the structured diagnostic codes we rely on for a lot of our applications,” said Walsh, assistant professor of Biomedical Informatics, Medicine and Psychiatry and Behavioral Sciences.
Walsh’s team read clinical notes for more than 7,000 medical charts and found 42% of the time, a diagnostic code for self-injury showed no evidence of suicidal intent. If this gap had been left undiscovered, algorithms trained on self-injury, which is easy to find in structured data, would have misidentified many people as having suicidal intent.
Because of the difficulty of finding the signals of suicidal intent in structured data, Walsh and his collaborator, Douglas Ruderfer, PhD, MS, assistant professor in VUMC’s Division of Genetic Medicine, were recently awarded a five-year, $2.7 million grant from the National Institute of Mental Health to use natural language processing to improve their chances of accurately characterizing suicidal thoughts and attempts documented in clinical notes.
Other challenges in creating an accurate machine learning algorithm included accounting for known health disparities between demographic groups, capturing data on medical visits that took place outside of Vanderbilt and creating an algorithm that would be scalable for other institutions, which may not have the ability to sift through clinical notes. Walsh has a related study with the Tennessee Department of Health to identify patterns in statewide hospital discharge data and prescription drug management program data to understand how often patients seen at Vanderbilt present elsewhere with suicidal behaviors or opioid overdose.
“We can talk a long time about the challenges in developing an algorithm, but prediction is not prevention. The best algorithm in the world can’t help anyone if it’s not linked to the right people and the right clinical process,” said Walsh, whose team is currently focused on care delivery and how to alert a provider when a patient is found to be at risk.
Walsh is working to develop a clinical process that will take place when providers are alerted, which may include personalized guidance that involves a safety plan tailored to each patient. Guidance may also suggest lethal means counseling, a discussion of triggers to impulsive thoughts and establishing the patient’s support network.
Additionally, the team has studied time points from seven days to two years following a report of suicidal thoughts to examine the best time for intervention.
“We don’t want to just say, ‘Here’s risk information so you can worry more.’ We want to say, ‘Here’s risk information and some steps you can take to reduce risk in this individual,’” said Walsh.
His team is also mindful of avoiding extra steps for busy providers.
“What we really hope to do is combine what humans do best with what machines do best. What machines do best is sifting through lots of data very quickly. What people do best is connect with people, absorb data from our environment and develop insight,” said Walsh. “Our goal is to give human providers as many tools as possible to do their job.”
While the system will never be perfect, Walsh considers it successful even if it saves only one life.
“When someone is lost to suicide, people around them are often asking the question, ‘What could we have done?’” said Walsh. “Our goal is simply to give them the opportunity to instead say, ‘What can we do?’”
HOPE, HELP AND HEALING
While work is being done to better understand, detect and prevent suicide, VUMC researchers and clinicians agree that more effort, brains and resources are needed to combat rising rates and to reach those who are struggling — and that responsibility lies on everyone.
“We all have a role to play in this epidemic. We either know someone at risk or someone who has acted on that risk,” said Walsh. “It may be our family member, friend or co-worker. It may be somebody we drove past on the way to work today. We are all involved — whether we care to do anything about it is a different question.”
It’s important to also be realistic, VUMC experts say, and to acknowledge the problem is multifaceted and requires a crossroads of health care, policy and society.
“We’ve eradicated measles and a lot of really awful things that I saw in my training just 20 years ago, but this is something much more complex,” said Plemmons. “There’s not a vaccine you can produce or a medicine to fix it. It’s not going to happen overnight.”
Nadler — who is now happily married and has a thriving support system and a career she loves — stresses the importance for all physicians to receive training on communicating with individuals who may be suicidal, as symptoms can arise at any time in any clinical setting.
“You may be the first line of contact for someone who is seeking help, so you may be their first impression of what getting help for mental health looks like,” said Nadler. “It needs to be handled correctly and compassionately, or they may not continue to seek it.”
For those who may be struggling with thoughts of suicide, Nadler offers a reminder that suicidal thoughts are just that — thoughts — and they don’t have to be acted upon.
“I know now where my suicidality comes from. I’m able to tell myself that those thoughts come along when my anxiety is through the roof and that they’re probably related to a specific, temporary stressor in my life,” said Nadler.
“This is a passing moment. Lean on your supports to get you through it. You’re not alone, even if it’s not talked about. There’s a whole community of people who have been through it. There are so many of us.”
If you are experiencing suicidal thoughts, call the 24/7 National Suicide Prevention Lifeline at 1-800-273-8255 (TALK) or text HELLO to 741741 to connect with a trained crisis counselor through Crisis Text Line. Help is confidential and free.