Suicide is not an easy topic to discuss. It’s emotionally charged. It’s stigmatized.
It’s misunderstood by many, even those experiencing suicidal thinking. With the need to acknowledge the difficulty of the subject up front, I want to encourage the reader to use these publicly available resources if you or anyone you know are currently experiencing suicidal thinking, depression or any other emotional difficulty.
The American Psychological Association provides a free publicly available locator of licensed psychologists by geographic location and a host of other identifiers. Also, there are free support services in the forms of a national phone (call 1-800-273-Talk) and text (text “Hello” to 741741) line. Support is available. Please use it.
With that said, I was recently asked to provide a less political, more public health education perspective. Not only because of my professional background, but because of the clear importance of the topic, I thought suicide would be the best place to start.
Suicide is still a national problem, with a recent American Association of Suicidology (AAS) report noting that about 44,000 suicides occurred in 2014. After about a decade of decline, the past few years have seen a slight increase in deaths by suicide. According to the same AAS summary report, by rate, or number of people per 100,000 citizens, Virginia actually ranks 33rd highest of the 50 states and D.C.
Hampton Roads cities with publicly available suicide rate data actually fair pretty well on the whole as well. The following rates for each city are: Chesapeake (12.5), Hampton (5.9), Newport News (11.7), Norfolk (10.3), Portsmouth (6.3), Suffolk (16.5), and Virginia Beach (14.5). By way of comparison, the rate for the entire Commonwealth is 13.5, and the national rate is 13.4. In all, the seven cities have higher and lower rates compared to state and national averages. These numbers mirror the national trend of rural areas generally having higher suicide rates than urban ones.
What do the numbers mean? And why should we care? First, as is the case for the U.S. as a whole, suicide is still a pressing problem in the seven cities. Second, Hampton Roads possesses several characteristics that both place our community at elevated risk, yet also provide a pivotal opportunity to enhance suicide (and related mental health) prevention and care.
In order to understand the unique qualities of Hampton Roads with regard to suicide, we first must define several basic concepts. Public and mental health fields design prevention efforts around the ideas of risk and protective factors. And really, these are easy concepts to grasp. A risk factor is any variable that increases the chance of something happening. A protective factor (think buffer) is just the opposite – it’s any variable that decreases the chances of an outcome. I think we all get the idea of a heart attack. Risk factors? Smoking, bad diet, family history, and so on. Protective factors? Exercise, healthy diet, and so forth.
Suicide science has articulated many risk and protective factors. In many cases, you may already be aware of some: depression, drug use and stress, for example, are strong general risk factors, whereas social support, coping skills and optimism are protective factors. Luckily, we have reader-friendly summaries of the key lists. These publicly available resources include, for instance, the CDC, Suicide Prevention Resource Center, and American Foundation for Suicide Prevention. So, I will not focus on the general trends. On the contrary, I am chiefly concerned with helping you understand the uniqueness of Hampton Roads, both positive and negative, in terms of suicide risk.
The CDC provides a helpful tool to organize risk and protective factors for any public health issue (e.g., HIV, violence), which I also think can help frame a few unique factors in Hampton Roads. In short, CDC’s multi-level model lists factors at four levels (in top down order): societal, community, relational, and individual. Societal level factors include big-picture content such as laws and social norms. Community factors are those unique to a potential region such as healthcare, school and other entities. Relational pertains to interpersonal issues such as social support. Finally, individual factors are characteristics of each individual person such as demographics, attitudes, and beliefs. If you are interested in further reading on this framework, I recommend going here.
The CDC societal and community levels have the most direct bearing on the uniqueness of Hampton Roads as a community in terms of suicide risk and prevention. Specifically, I see at least three societal or community characteristics that are documented risk factors for suicide.
Those key risk factors for Hampton Roads are:
1. Military profession and associated exposure
It is no secret that our service men and women are at elevated risk for suicide. Having the largest naval port in the world, coupled with various other military installations in the region, amplifies the risk in Hampton Roads. The reasons why military personnel, both veterans and current service members, are at enhanced risk are numerous. They include exposure to combat and violence in general (which can increase one’s ability to attempt suicide), development of PTSD & depression, and experiences of traumatic brain injury. A great resource for cutting edge research and information on these issues is the Military Suicide Research Consortium.
Homelessness is also a well-documented risk factor for suicide and an array of other mental health concerns. It is important, however, to note that the relationship may be a two-way street. That is, those who experience mental illness and suicide may be predisposed to homelessness, and vice versa. Recent informative 2016 time point data is available for Hampton Roads areas such as Chesapeake and Norfolk. Although this data does not fully capture the entire homeless population in the region, it is informative for several reasons, not the least of which that it highlights critical characteristics associated with homelessness in the region, especially mental illness, substance abuse, domestic violence survivorship, military veteran status, and youth. Combined with what we know from the general homelessness literature (e.g., LGBTQ youth tend to see elevated rates), we can begin to dissect the nuance of homelessness in the region as it may influence suicide risk.
3. Firearm culture
I am not trying to take away your guns! Please, disarm yourself of this belief. I am a very ardent supporter of firearm ownership and enjoy target shooting. I do, however, need to highlight the unambiguous risk for suicide associated with firearms, both at individual and community levels. A 2014 published review and synthesis of firearm-suicide research suggests that ownership or access to a firearm lends one to be about three times more likely to die by suicide, although estimates in the literature are sometime higher. However, merely owning a gun does not necessarily equate to dying by suicide – it’s not that simple. Research also shows that issues such as improper storage and keeping firearms loaded heighten the suicide risk. At the community level, subcultures that endorse overly zealous or loose firearm attitudes, or where firearm laws are less restrictive, tend to see elevated suicide attempts and completion rates as well (see sample review here). We do need to recognize the inherent dangers of such a prevalent firearm culture in Hampton Roads.
Fortunately, the picture is not all bad! Hampton Roads possesses great potential infrastructure in moving toward buffering suicide risk and building community prevention.
Two particular themes in protective factors I have observed are:
1. Presence of healthcare infrastructure
A 2006 national level analysis showed that the presence of medical and mental healthcare infrastructure was associated with lesser suicide rates. From my perspective, this is a promising premise. Hampton Roads has a large medical campus in Norfolk, several regional medical systems (e.g., CHKD, Sentara), and several colleges and universities. Collectively, these entities can provide the necessary infrastructure – inclusive of knowledge, personnel, outreach, and facilities – to build toward prevention programming in the region. Adopting a community-engaged approach, academic, training and healthcare facilities can also partner with community entities, which brings me to the second potential protective factor I see.
2. Community resilience and involvement
The extent to which a region or culture develops collective resiliency and involvement with one another, suicide risk is reduced. On a simple level, this is because building resilience and involvement strengthens the single best protective factor we have against all mental health concerns: social support. In other words, if we come together in any organized, collective way, there is great potential to lighten the suicide burden. A great beginning effort in this area consists of a series of January 2017 professional trainings and community-engaged forums and events put on at Work Release in Norfolk (see schedule here). These events draw on best available social and health science to begin to make a dent in violence and mental health problems in the region.
I hope these protective factors are the first steps in a community-based approach to suicide prevention and mental health enhancement in Hampton Roads. In coming pieces, I will provide more thoughts on where we may be able to go from here in order to move toward these important goals.