December 1, 2004 Regular News Suicide: The silent threat Suicide: The silent threat What you don’t know can hurt you Jim McDonough Director, Florida Office of Drug Control In the main, American society does a good job of recognizing and addressing the major threats to human life — among them illnesses such as cancer and heart disease, accidents in the work place, in the home, and on the highway, and life style risks such as obesity, unsafe sex, and smoking.Sharing information on such threats to physical well-being and undertaking public campaigns to mitigate their damage auger well for bringing down related death rates. One area, however, that is little understood and even less discussed, is suicide. Thus ignored, it constitutes a major threat to public safety.For generations, the suicide rate has remained at a near constant level, far out-stripping the murder rate in the United States (by two to one) and approximating the annual toll in traffic accidents (30,000 Americans killed themselves last year). For some age cohorts, it is a leading cause of death (third for teenagers; second for those ages 25-34). Men kill themselves at several times the rate for women, and the elderly (those 65 and older) at a rate six or more times higher than any other age group. Florida has not done well in preventing suicide, ranking in the top quartile of all states for per capita deaths by suicide.Yet virtually all experts on the subject agree that suicide is among the most preventable of life-threatening phenomena. While not directly predictable, suicide potential is often signaled by those contemplating it and can be correlated with other manifest risk factors, some quite dramatically. Over 60 percent of suicide victims, for example, evidence some degree of substance abuse; over 90 percent a mental health problem. Often, both are present. Alcohol abuse alone is a factor in 25-43 percent of all suicides. Among the estimated 13.7 million alcoholics in the United States, 2.2 to 3.4 percent are at risk for suicide for the duration of their lives. According to the National Institute of Drug Abuse (NIDA), there are approximately 4 million drug addicts in the U.S., of which 85,000 are heroin dependent. Heroin addicts die by suicide 20 times more frequently than the general population. Yet, until recently, there has been little consideration of how people serving the suicide prevention and the substance abuse treatment communities can or should collaborate to advance their mutual goals of saving lives and treating the illnesses that underlie both concerns.Substance abuse is a multi-faceted risk factor for suicide because it contributes to other significant risks complicating the understanding of the direct relationship between substance abuse and suicide. In addition to its direct relationship with suicide, substance abuse also leads to suicide via a number of indirect paths. Substance abuse exacerbates the presence of psychiatric disorders and is associated with a host of dangerous behaviors ( e.g., accidents, overdoses, impulsivity, etc.) that may be considered passive suicide attempts. Perhaps of most importance is the tendency for individuals with substance abuse disorders to lose significant relationships with loved ones as well as social support systems that serve as key protective factors against suicide.As stark as are the debilitating links between substance abuse and suicide, the mental health complications are even worse. In spite of the more than 90 percent overlap, most of those who die by suicide have never seen a mental health professional, and up to two-thirds are not receiving treatment at the time of their death. People with schizophrenia and affective disorders (including depression) have the highest suicide risk among those recently diagnosed, whereas, suicide risk for alcohol and drug dependence remains fairly stable throughout the life of the disorder. Risk of suicide greatly increases with comorbidity, the presence of two or more mental illnesses at one time.But perhaps the key missing ingredient for suicide prevention has been the reluctance to even talk about it. In many ways it remains the last taboo. People will air their most personal concerns, but suicide gets hardly a mention. Armed with such anonymity, suicide comes in under the radar screen. Without discussion, the warning signs and the appropriate responses to them are not only misunderstood, they are completely unknown to the vast majority of the public. Without an advocacy base that makes itself heard, policy leaders are loathe to take a public policy stand on what is simultaneously a complex and depressing issue. Voiceless and leaderless, the problem festers. In this case especially, what we don’t know can hurt us.Florida has determined that we can take an effective stand against suicide. Under the leadership of Gov. Jeb Bush, Florida issued a policy paper in 2002 titled Statewide Suicide Prevention Strategy, that seeks to lower the suicide rate by one-third by 2005. That paper can be accessed at www.myflorida.com/drugcontrol. A state task force continues to develop policies and programs and channel resources toward the prevention of suicide. We invite Florida’s lawyers to join us in the essential effort to reduce suicide in Florida, to help reduce substance abuse and provide adequate attention to mental health issues. This column is published under the sponsorship of the Quality of Life and Career Committee. The committee’s Website is at www.fla-lap.org/qlsm.