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Duologue with Leslie Heaney
What the Warning Signs of Suicide Actually Look Like — with Mark Kaplan
00:55:53
May is Mental Health Awareness Month — and I wanted to do something that felt real rather than performative. So I called a suicidologist. His name is Mark Kaplan, and he has spent his career studying why people die by suicide: the data, the risk facto...
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- [00:03]
A
Hey everybody, it's Leslie, and you're listening to Duologue with Leslie Heaney. So May is mental health awareness month and I could think of no more important topic to discuss than suicide prevention. This past November, I lost my best friend to suicide. The grief is truly unimaginable and it's a subject specifically its causes and warning signs that so many of us do not discuss until it's too late. Today I'm talking with Dr. Mark Kaplan, who's a researcher, research professor of social welfare at UCLA. Dr. Kaplan is a suicidologist who has spent the past 20 years focused on the study of suicide. In this conversation, he and I explore in depth why people die by suicide, the data, the risk factors, and what we can hopefully do to prevent it. Losing a loved one to suicide is something that I would not wish on anyone. And I'm really hopeful that this episode will help you prevent suicide from ever touching your life. So with that, here's my conversation with Dr. Mark Kaplan. Well, Mark, thank you so much for coming on and joining the podcast. As you and I, we've spoken a bit before and I've told you this is a very personal subject for me and I really appreciate you coming on as an expert in this field to talk a little bit more about what you are seeing around suicide in the United States. You are a suicidologist, which before finding you, I must confess, I didn't know that there was this area of sort of focused area of study. Can you talk a little bit about what is a suicidologist and the focus of your work and maybe even how you got into this line of work?
- [01:50]
B
Well, thank you so much for that introduction, Leslie. I am a suicidologist and by suicidology I mean it is a field that combines multiple disciplines, including those that we often think of such as psychology and psychiatry, medicine in general, primary care, are now doing a lot of suicide related prevention work. Public health, of course, that's my background. I bring a public health focus to my studies of suicidology. Suicidology is the field that helps us better understand why people die by suicide. Now that's, that's, that's, that's, that's, that might be a little vague, but it basically more specifically deals with the, the causes, if you can, such risk factors as well as ways of preventing what are the most effective ways of preventing both suicide mortality as well as preventing suicidal behaviors including suicidal ideation, suicidal thoughts, non fatal attempts, and self harm as well. So it's a broad that covers a lot of ground, and that has grown in the last few decades. The term was first popularized in the 1960s, so it's not a new field. It was first popularized by Edwin Schneidman, who was a professor at ucla. He was a professor. I think his title was professor of death and dying. And so he came up with this term suicidology. He's considered to be the founder of the field. He helped establish the American association for Suicidology, who you probably have heard of, that some of our listeners might be familiar with, AAs and also, and this is quite important, he established the first suicide prevention centers in the United States. You know, things that we take for granted that we don't think twice about. And there's a help line and crisis line and that derive that can be traced back to the work of Professor Schneidman, who was here at ucla.
- [04:03]
A
Oh, sorry, I don't mean to interrupt you there, Marc, but that's really interesting to me. I didn't. I really thought about who was the founder, or I sort of assumed it was either a federal government program or state governments. The hotline, which is very. I think everyone listening has heard of calling the suicide hotline. It might be different numbers for different states or different areas, but how fascinating to know that that was actually spearheaded by a person who was studying this work.
- [04:33]
B
Right. Probably our listeners or viewers are familiar with the 988 suicide and crisis life, what you referred to, and you're absolutely right, the suicidology, while launched and founded by Professor Snidman, it really took federal initiatives and federal funding to get this going, including the crisis line that was funded by federal agencies. Multiple agencies have been involved. I was affiliated with the Centers for Disease Control and Prevention. Their injury prevention branch, called the national center for Injury Prevention, served for four years on the board of Scientific Counselors, which serves in an advisory capacity to the CDC on issues related to violence prevention. And one of the areas that we focused on was suicide research and prevention. So the popularity and the term has been funded. The organizations, the efforts, the work has been funded in part by the federal government as well as private organizations, too. The American foundation for Suicide Prevention, which is one of the leading organizations that has spearheaded efforts to expand prevention efforts in this country. I'm a scientific counselor to that organization, meaning that I participate in review of grants that they receive. I myself received a Distinguished Investigator award by the afsp. So as a result of the initial work by Professor Schneidman, today we have multiple organizations that deal with suicide prevention aimed at the general population. And then there's some organizations that have a more specific, narrower focus.
- [06:27]
A
Did you have a personal experience of your own that led you into this line of work, or.
- [06:33]
B
I think suicide is on everyone's plate, so to speak. And I don't mean to trivialize it, but it kind of goes along with what you said. Everyone's been indirectly or directly impacted by suicide. And I've had, you know, I've had colleagues at one of my former universities, a colleague who died by suicide. You know, as you enter the field, you know, sooner or later you come across, you know, very things that touched you very closely. So I've had experiences. Not as direct as you, but I have worked with people who died by suicide. Perhaps the one that is. That touched me the most was a young colleague who was struggling in a very silent way. She had a young child under the age of 10 and wound up taking her life. And to this day, it remains a mystery some of the factors that may have led up to that. So this happens a lot. And you and I have talked before about, you know, many suicides are silent suicides. You know, you just don't know what's. What's going on. A lot of particularly men don't want to talk about it. This is something that is indeed very, very troubling because, you know, there are no. Very few signs. Sometimes there's, you know, people will take their lives, and we're left, you know, just wondering what. What. What was going on? Why. Why did this happen? You know, books have been written. You know, we. We discussed one of the books, the suicide index, which was written. And this is probably a common story where the. The author of this book was trying. Went back to try to figure out what. What were the factors that drove her dad to end his life. So this is very common. And many of us have heard those stories beyond just that book.
- [08:31]
A
Well, Mark, when you talked about just the example of the Golden Gate Bridge and those people who had been convinced not to jump or were not successful, and then they didn't go ahead and try to do it again, to me, that is emblematic of the fact that I think people get stuck in moments, right? And we're gonna talk about other factors, like how intoxic and other things can affect people's judgment. But it's sort of. I think that's probably what it is for many. Obviously, I. You know, I'm not an expert in this space. You are, but it's sort of like you're stuck in this moment and you're not really looking at, it's just sort of whatever overtakes you in that time, it is affecting your decision making in a way that you wouldn't if you had had other influences.
- [09:17]
B
There's a element of, you know, many of those suicides might be characterized as impulsive acts.
- [09:23]
A
Right.
- [09:24]
B
Something very intense is happening to them, some crisis that they're facing and they're stuck there. And that's where, you know, we can talk a little bit about the role that alcohol plays in that. You know, to be very clear, suicide is tremendously complex. I will say to you that it is perhaps one of the most complex public health issues that I have studied. I've looked at other things over time. I haven't just studied suic, I'm primarily a behavioral scientist and I've studied other issues related to health in the population. But suicide to me is perhaps the most complex. And sometimes I get a little bit concerned about trivializing suicide, turning it into, you know, kind of oversimplifying the complex nature of the problem. And we often intervene at the tail end at the, at the all, you know, rather than go going upstream downstream, you know, we intervene at the moment. And I think we, we need to be looking for ways of moving up a little bit upstream that is both at the individual level as well as the population level, trying to understand factors that are out there that may not necessarily be connected to suicide prevention, but may improve people's communities and individuals quality of life and attenuate their, their probability of taking their lives at some point.
- [10:57]
A
Yep. Yeah. No, I know there was a young teenager who had taken his life in New York City and he was the same age as my middle child at the time, my son. And you know, reading about, you know, in the newspaper, you know, people didn't see any signs. You know, he was a very high performing student. He didn't have any background of any mental health issues. And he would kind of come in, you know, from school and go to his room, which every 12 or 13 year old boy seems to do, right? Or they're on their phones or they're playing video games or whatever it is that they're doing. And the parents didn't see these signs. And I remember it sent a shockwave of fear through me. Am I missing something? My 13 year old seems totally fine. And I read something about how people who, particularly teenagers who get out of themselves and engage in their communities can be a, you know, a helpful way for them to, you know, have sort of a More connected existence because it's natural in adolescence to kind of want to go inward. And so we started doing. My son and I started doing these volunteer projects together. And I don't know if that any. I didn't ever told him that that was why I was do those things. But you know, it just scared me because I. These parents didn't see any warning signs in their kids thought their son was absolutely healthy, 13 year old and maybe he just was stuck in a moment. Maybe he had a terrible day at school or there was a bully at school. You never know. But figuring out as people and as members of our communities what we can do to not only try to prevent that from happening in our own families and our own friends and circle, but how we can reach out beyond ourselves to help others that might be suffering. I thought it might be helpful, Mark, to kind of set the table for people listening about. You know, I know this is a subject or an area of study that's interested you because you see it as a public health crisis and it really is a public health crisis. And so can we talk about, you know, in the US how prevalent is it? How many occur every year? And I'll kind of ask, go through kind of age groups and those at highest risk.
- [13:07]
B
I think we may come back to this point, but I think you're touching on just your statement about this child. You know, there are many suicides that are silent, I call them silent. But there are many suicide profiles of individuals who die by suicide that are remarkably. You know, there aren't any indicators, any standard markers of suicidality. That's an area that's of interest to me. That's more the case with males than it is with females where there's a conspicuous absence of some of the standard markers of suicidality. There are no prior attempts, there are no serious behavioral health problems, no alcohol or drug problems. And yet they're. What, what, what these cases have in common quite often is a major crisis that, you know, that rattled that individual and caused this downward spiral leading up to that attempt. So that's an area that, that I don't think receives enough attention. We spend a lot of time looking for the proverbial needle in the haystack, you know, and yet there are out there who are at risk, who are, sigh. Whose symptoms are not shared, whose desire to end their lives is not shared with others. And those are the difficult cases to prevent. So not every case follows that standard pattern or trajectory that we often associate with people who have died by suicide.
- [14:34]
A
Yeah. So what Are the numbers, Mark, how many suicides occur in the US Every year?
- [14:41]
B
You know, fortunately or unfortunately, we have good numbers, but those numbers go back a couple years. The numbers are revised, but the most recent numbers that I have are from 2023. In 2023, there were about 50,000 suicides. Exactly 49,316. 16 suicides in 2023. Let's go back to 2021 to just give you a sense of, of, of how those numbers have grown. There were about 30,622 suicides in the year 2001. So as you can see, it's grown. Now you might ask.
- [15:15]
A
Well, I'm sorry, Mark, that's 2001 to 2021.
- [15:19]
B
Yes.
- [15:20]
A
Okay, sorry.
- [15:21]
B
30,600 to about 39, 49,300. So it's okay. Suicide remains fairly. The rate of suicide over many decades remains. This might surprise you, has remained relatively flat. We have seen, you know, there's minor fluctuations from time to time, but if you look at the long term or secular trends, they have remained, remained relatively flat. So in spite of all the advances in therapeutic approaches, in drug therapy, talk therapy, you know, putting, you know, limiting people's access to the means they use, you know, going back to the Golden Gate Bridge, they finally installed a barrier at the Golden Gate Bridge, which took decades. And my professor then was part of that movement to install a barrier. So if people attempted, there was a barrier that prevented him from falling. So in spite of all that work, the rate of suicide in the US has remained fairly flat. Suicide is the 11th mark.
- [16:24]
A
Sorry to add sorry to this is might be why I didn't do so well in the math section of the sat. But is it that because the population has gone up because you were saying it was 30,000 in 2001 and that it's 49,000 and in 2023, so that 20 years. The reason why it's sort of remained flat is because the population has increased over that period.
- [16:47]
B
Then you can adjust for population changes.
- [16:50]
A
I see.
- [16:51]
B
Okay, so that's what I was about to share with you. Okay, but before I get to that, before COVID entered our public health in this country, suicide deaths ranked mortality rate for suicide was in the top 10. It's 11th now. And homicides ranked 16th. So the rate we rank suicides ranks higher in the top 10, you know, closer to the top than, than homicide does. Suicide increased and this is getting at the rates between the year 2000 and 2023, the rate increased 41% from the year 2000 to 2023, that is, after adjusting for population changes. In other words, the rate, the rate of suicide per 100,000 population in the year 2000 was 10.4 per 100,000. By 2023, the rate had gone up to 14.7 per 100,000. So the raw numbers went up, but also the rates. And that factors in changes in population size over time so you can arrive at a valid comparison over time. So clearly the picture that I'm presenting here is that, that the suicide is high and rising in the population.
- [18:14]
A
Do you think? I mean, are people in your line of work, are they attributing that increase over this particular time period to things like social media?
- [18:23]
B
Well, I'm glad you asked that question. I have worked on various projects that tried to look at the influence of, of social media. And I must say that it's hard to isolate the effects of social media without looking at everything else. Everything in the social sciences and in behavioral sciences, you know, it's hard to remove all the noise in the background, if you know what I mean. And the noise, I mean, things that may possibly confound. So you can arrive at a clear understanding of the role that social media plays. But you know, social media is occurring in the context of a lot of other things that are going on in society, cultural factors, psychological. And so social media probably plays some role. How much of a role? I don't think we have a very good understanding on that. Okay, let me just end with more points because I think this is important. 80% of all the suicides are males. Okay. So 8 out of every 10 suicides are men. You know, that's often overlooked. And I, and I know that that might seem hard to believe, but sometimes we think of suicide and we don't do the, the appropriate separation of the, of the sexes. It could be two very different phenomenon, so to speak. Women are more likely to attempt and survive. Men are more likely to end their lives with a very lethal means such as firearms. And many suicides in this country. Over half of all suicides in this country involve the use of firearms. It's even higher among men. It's even higher among certain groups of men, such as veterans, older men. My colleagues and I published a paper in one of the JAMA journals late last year. Older men, older women, gun use. You know, there are parts of the country where over 80% of suicides among older men over the age of 65 involve the use of firearms.
- [20:28]
A
Is there any kind of psychological or study that's gone into the. You mentioned that Women are not as successful. I mean, obviously, if you're going to use a firearm, you're probably not doing it because it's a cry for help. You really are doing it to be successful. Right. So are you looking at sort of the subtleties between that? Between. I guess it's hard to tell whether it was a cry for help or whether they intended to be successful.
- [20:55]
B
You know, there's no doubt. And that's, there's no doubt about that. And earlier I did say that, you know, we, we. There's so much nuance in the data in terms of, you know, yes, some are cry for help, but others, it's not a cry for help. Across the age span, men are four times more likely to die by suicide than their female counterparts. But when you get into older age, which is quite interesting and sad at the same time, is that the rate for males to females, older males to females, is 12 times higher. So. And that goes, you know, that. Remember I said too, that the age group with the highest fraction of all suicides involving guns is in older age, where, you know, nearly 80% in some parts of the country, 90% of suicides among older men involve the use of a firearm.
- [21:53]
A
You know, I have two family friends, two people I know whose elderly fathers took their own lives with a firearm because they. One was terminally ill and the mother had just died, and they had watched their wife go through, you know, their children having to put their lives on hold to care for her. That was one, he didn't want to be a burden. And the second was the same reason he was diagnosed with dementia, and he did not want to be a burden on his daughter. And I was very surprised. You know, in both of those cases, these were very. They had families who loved them. They were engaged older people. They just didn't want to either go through an illness or be a. Be a burden to their families.
- [22:39]
B
Well, that is, that's so consistent with what we were talking about earlier that it is a way of, you know, becoming a captain of your own destiny. And what that gun represents is that, that, that freedom to basically end your life the way you want it to end. And that sounds pretty, pretty awful, but it is true. And we see this playing out over and over again. So guns do, you know, provide elderly people, especially men who are suffering with some chronic, debilitating, painful condition, who feel like they've feel abandoned, they feel like they're a burden on others. I remember seeing this with the veteran population, older men who were living in rural parts of the country who basically were frail and just could not see, you know, there wasn't much of a future that they were living a life that was worse than being dead in their minds and wound up taking their lives from a self inflicted gunshot wound.
- [23:45]
A
So how do the veteran rates compare to non veterans?
- [23:50]
B
Considerably higher even to this day. I'm glad you asked that question. Just yesterday I was on another work actually talking, being interviewed by a journalist who's writing a piece on a brand new article in the one of the, I think it's in JAMA Psychiatry, one of the JAMA journals and it's on veteran, it's on social determinants of health and suicide in veterans. And we were talking about this and I told him that, you know, we some years ago published a piece that I think to this day has not really been replicated and that is showing that veterans compared to non veterans, their odds of dying of suicide is two to three times higher than non veterans in the general population. We did a study back at the height of the Iraq, Afghanistan wars and we found that people who were veterans and others who were non veterans over 12 years to look at their and looked at those who had died and it turned out that when you compare the veterans with the non veterans the veterans had a much higher probability of dying by suicide. And that's still true today. They're more like they have a much higher suicide rate than in the general population. And going back to what I said about firearms, they're more likely to use a firearm if they complete suicide.
- [25:16]
A
How do the US rates compare to other countries?
- [25:19]
B
Well, we are probably somewhere around, you know, other countries are somewhere around a rate of 1415 per hundred thousand and we're pretty much around that globally. Some other countries have much higher rates. Korea, Japan and this might because it's been in the news lately. When we look at the Nordic countries, Greenland really stands out as being one of having one of the highest suicide rates in the among peer nations. Their rate, just for your information I looked it up is about 75.6 per 100,000. This was in 2023. So that's, that's the case and the
- [26:06]
A
group and is that a correlation? I mean I can see, you know, obviously there might be some cultural and I want to talk about the link. A lot of your research is focused on the correlation between shame and suicide and maybe certain cultures, whether it's Korea or Japan, maybe that's tapping into that. Again, I'm no scientist but Greenland are those Nordic countries. I would think our daughter is at the University of St. Andrews, and it's an amazing school. But when we dropped her off in September, I thought, this is the greatest place to be on planet Earth. And then when we went to go visit her in November, I thought, I thought, gosh, this is a little depressing when it's only light out for five hours a day.
- [26:42]
B
It is a factor. But keep in mind that that alone doesn't explain the high rate in Greenland. And I should say that other Scandinavian countries, Nordic countries have experienced a drop in suicide. So there's something about Greenland. It's very isolated, as we saw in recent months. It is very isolated, very, very difficult climate to live in. And the rate of suicide is usually those at highest risk or the suicide rate tends to peak in Greenland in adolescent and young adult. And that's not necessarily true in other industrialized countries. So there's something particularly unique about it. You might feel the harsh climate might lead to social isolation, which could be a factor. So there are a lot of issues. And it's as I've been saying all along, there rarely is just one reason for dying by suicide.
- [27:43]
A
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- [29:38]
B
Yeah. Again, I want to emphasize the fact that it's a complicated issue. It's rarely just one, one risk factor. There isn't one single factor that causes suicide or leads to suicide. Risk factors are characteristics that make it more likely that an individual consider attempts or die by suicide. But there are a whole host of factors that to be considered. That is, they include health, as we talked about in older age, there are often environmental issues. There is, you know, for instance, by environment I don't mean the climate, but there was a fascinating piece a couple weeks ago in the New York Times in the real estate section of all places. But it had to do with occupational risk of suicide. Construction workers who have a very high rate of suicide, the conditions, environmental conditions under which they work, the psychological demands, et cetera, are huge and very intense and may contribute to their risk. So when we look at occupations, we see quite a bit of variability. And I was glad to see that construction workers, which had been reported in literature, but I was pleased to see that the New York Times devoted a full page plus to that issue. But there's also, let me also say this before I get into specific factors. There's also also incorrect assumption that suicide is a risk only for those who have had some a diagnosable or a diagnosed psychiatric or mental health problem. There are many, many individuals who without a diagnosed mental health. And one of those, I was involved in one of those studies where there was no known mental health problem who also died by suicide. And that gets at. What I was saying before is that there are circumstances, circumstances precipitating circumstances, perhaps things like the loss of a job, the loss of a partner, you know, what happens to young people who basically are involved in a relationship breakup, the death of a spouse, transitions with older people, for instance, transitions into retirement. I know you're you, you have asked me about, well, what about people who experience a cognitive decline, dementia? There's, there's some research that early stages of dementia can, can lead to suicidal behavior. There's also the question of which I've been interested in. What role does, you know, being diagnosed or having, you know, having a stroke, for instance, that can be awfully, you know, change your, your, your, your life permanently. What role does that play in contributing or elevating your risk for suicide? So there's a lot that are, in a way, due to these social determinants of health that are applied to suicide. Some of the standard markers of suicide or warning, warning signs include things like, you know, a person might express a desire to die, they feel guilt or shame, they feel like they're a burden on others. I talked a little bit about that with older men. In terms of feelings that are risk factors. Feeling empty, hopeless, trapped, or having no reason to live. All these are clearly spelled out by the National Institutes of Mental Health, as well as some of these organizations, such as AAS and afsp. So other feelings include extreme sadness, anxiety, agitation, a sense of, you know, full of rage and unbearable emotional or physical pain that also can be. Can lead to suicide.
- [33:40]
A
You know, in my own experience, right. I had shared with you, you know, my best friend had, you know, you lost her job. And you mentioned, you know, it could be an event. Right. And this is not someone who has a history of mental health issues. Right. But is it the dsm? What is the psychological handbook?
- [33:59]
B
The dsm.
- [34:00]
A
Dsm, yeah. About how we look at it. Because it might. Many people are asked by their therapist, right, are you having suicidal thoughts? No. Gosh, I would never. And then three days later, they take their lives. So what changes in that three days? And I think for people that are left behind, you're beating yourself up. I am all the time about what could have done differently. But it's sort of trying to identify what those risk factors are. And you brought up behavioral changes. In her particular case, she come to stay with us in Tennessee. She hadn't slept in a week. I mean, she wasn't sleeping. I think if you have. When you have these events, if you're under a great deal of stress, you mentioned divorce or a death or a physical health problem. And you're not sleeping or you're drinking wine or you're doing these things that are impairing your judgment, you can find yourself in a situation that you didn't necessarily perhaps mean to be in.
- [35:02]
B
You're absolutely right about these changes in moods, in eating habits, in sleeping habits. In taking, you know, using drugs or, you know, increasing your intake of alcohol. All these might be signs. But and also let me just remind you that the presence of a firearm in the home is a huge factor that's been studied over and over again. A home with a gun, a home with a gun increases the probability that a suicide will happen, happen involving that firearm. This has been well established and we don't do a very good job of keeping guns, limiting access to guns among people who are, who are in crisis. You know, we do have red flag laws and we recently published a paper on red flag laws in some states and they can work remarkably well. But, you know, only about fewer than half of all states have passed red flag laws because they feel like, you know, there's been opposition to red flag laws and, but that could help.
- [36:12]
A
Mark, what is a red flag?
- [36:13]
B
Somebody, a petitioner basically says that this is an individual who is, who has access to a gun in their home and goes to a judge and petitions. It can be a, it can be a clinician, it can be a family member, it can be the, the police goes to a judge and they issue a, an order to remove the firearm from that person's possession. So that's what that does. But few states, relatively few states only, I think 21 states have, have those in, in place. Some states there are compromises. I think Maine, you may recall there was an incident a couple years involving I think a mass shooting where they had yellow flag laws which are just a watered down version of red flag laws. So it is, it has been found to be quite successful as per our. That appeared in one of the JAMA journals. But there's resistance to that. I mean, I happen to teach a course on firearm violence prevention policy and many of these policies that are well designed, empirically supported are resisted because of second amendment issues. We continue to clash with advocates of gun rights. As I said before, you know, most suicides involve guns. And when you look at the totality of gun deaths in this country, most gun deaths are suicides.
- [37:39]
A
Because our rates though are sort of on par with rates of other western countries that don't have the same access to guns that we have. Not to take away from, from what you're saying, I'm just curious about if people are determined to do it here. Even if they didn't have access to guns, they would. Guns might be easy and guns might be because they're accessible and they might be easy because they're pretty definitive. Other countries that have similar rates, those people don't have access to guns. So are they hanging? Hanging, yeah.
- [38:20]
B
Hanging has. Researchers call this the case fatality rate, which, which is the rate of mortality rate. So with guns it's about 95% and with hanging it's a little bit lower, but still the second most lethal means or violent means used. And Greenland is a country where that's the case. But the problems that guns pose is that opportunities to intervene and rescue. Think of it as a window, it's almost shut tight. There are no opportunities when there's a gun in resources. How do you rescue a person who's on about to take that gun and, and use it? So that's the problem that we don't have the means right now. And that's, that's one area that's of interest to me is from a public health point of view, how do we develop a methodology that would allow us to do that? We're not very good at making sure people have their guns locked up. We other countries do a pretty good job to own a gun. You have to have your gun locked up and you have these random inspections of your, of your home to make sure that gun is locked. We in this country rely on, you know, it's an honor system where basically we rely on people's willingness to lock up their guns. But increasingly most people own guns these days for self protection. Right? People don't own guns for any other reason, civilians at least. And the last, I think one of the things that we don't fully appreciate is the fact that most people who own a gun for self protection purposes or protection of their family have the gun ready to be used. So they want that gun, you know, loaded and ready for use as opposed to locked up, unloaded. And that is problematic. That's very challenging. And whenever there's a gun, and keep in mind we haven't talked about guns and kids, but kids increasingly are using guns. And not only that, but they're also dying of accidental deaths involving guns. In fact, there are more kids, more children dying of gun violence than of car accidents today.
- [40:27]
A
So in addition to that, you obviously, because a lot of your research does focus on the sort of recommendations around policy with restricting or coming up with guidelines around guns and gun usage in your home. But what other from a policy perspective, what else would you like to see? Would it be more access to mental health services? I mean, part of getting therapy is expensive. So is that part of it? I guess you had mentioned too that our rates, even though there's been so much more public attention about the importance of mental health, more people speaking out about mental health, Celebrities and others that are about their own struggles to sort of raise awareness. But we're still not seeing a decrease right. In the suicide rate. So maybe it's whatever. That's new. As I mentioned, there's this new movement to kind of look at how do we identify the risk factors. Right. More. I mean, now to me, like, anyone who I know who's not sleeping well or is under a lot of stress that I'm close with, I'm gonna be super vigilant. I thought I was being super vigilant before, but even more vigilant. But I. I'm wondering what else you would recommend or that you're seeing from where you sit being so close to this issue.
- [41:48]
B
That's a great question. And what would I do if I could propose major changes and had the budget to implement those. First of all, recognize that this is rarely one factor. But let's just say for a moment, moment. Guns account for gun use, accounts for the lion's share of suicides as well as gun deaths in this country. There is an organization, various organizations have assigned graded how states do on gun regulations. California does a superb job. It gets a. A rating from the Gifford organization, that is, that was founded by Gabby Gifford. G gets a terrific grade. And compared to other states like Mississippi, that get, you know, one of the lowest grades, I think they get a D or an F on how they do on gun regulations. What California has managed to do is to. Well, it again, we are not an island. So guns still come into the states and there are plenty of guns. But because of all the regulations we have in the states state, we've tamped down the fraction of suicides involving guns. So what? Why is that important? You might say, well, okay, but they might use other means. Well, as we discussed earlier, people don't always turn to other means just because they. They've lost their access to guns. This is a mess. This doesn't necessarily mean that they will subsid, find a substitution. You know, they will compensate for that. That simply doesn't happen. That's based on research that we just published. But I think what that does is that it provides us with, and this is something I'm introducing into our conversation, is a form of harm reduction. In other words, if guns, you can't rescue, remember what I said, that window is shut tight. But if people attempt with other means, there might be an opportunity there to intervene and save a life. Okay? And I think that's important on the mental health Front. Yes, I would like to see more mental health, but I would like to see more preventive prevention in mental health. Not, you know, mental. Our mental health system is really geared up for, you know, end stage issue, not end stage, but downstream issues. Right. We go to, we seek mental health when there's a crisis, but how often do we talk about, you know, a form of what used to be called salutogenesis, in other words, more prevention. You know, how do we improve people's quality of life so they don't wind up depressed and possibly suicidal later on. So we need to look more upstream in terms of mental health, not focus exclusively on people who are experiencing tremendous amount of distress that might lead to an attempt or some form of self harm. So that, that's the other thing I would do. Also important primary care. Unfortunately, we have an under resourced primary care system in this country and very few people. Just this morning on NPR was reported that only one out of three individuals in this country has access to a primary care. Primary cares are really good if they're properly trained of delivering, offering some type of primary care, that is somebody who you trust, who you consider your primary care provider, who would be, would be a great gatekeeper for this. So that's what I would do. There are other professions, you know, in the past they used to train mail carriers who worked in rural areas. And that person was perhaps one of the few individuals that people living in very isolated areas would have contact with. So there are gatekeepers, there are, there are individuals who might be able to detect and refer that person to some mental health center. But I want to emphasize the need for more prevention and that's a public health issue. And not only focus on people who are at risk, but people who are not at risk yet or may never be at risk. Unfortunately, as I said before, we spend a tremendous amount of energy on trying to find that needle in the haystack. And that's very costly. But there's something called universal approaches that cover everyone regardless of whether they're at risk or not. And I think there's so much more that we can do if we simply had a different mindset about this.
- [46:25]
A
I think that's really important. Mark, I was going to ask that question about the primary care piece and should it be just standard for people's pediatricians and general practitioners, first of all, to make sure people are having access to them and having them be kind of the first line of defense or first point of screening for people to ask those questions of them so that they can get the services that they need and then frankly, to have the services be accessible so that it's, it's an issue for, as you said, it is a public health concern in the United States. It sounds like globally it is. But what more can we do here and how can we give people access to the mental health support that they need? As you said before, it gets to the point of crisis.
- [47:14]
B
Right, exactly. And I just want to make it very clear that, you know, I like your reference to it as being the first line of defense, make that the first line of defense as opposed to the 988 suicide in crisis line, that it might be too late by that point. And not everybody calls you. We assume that people who are suicide are going to share their, you know, emotional distress with somebody who's taking their call or texting with them. But, you know, I think primary, we need an expanded primary care system. We expend in this country far less of our natural resources on the primary care. Primary. Many, you know, as there's a brand new report on this, many medical students are kind of steered in the direction of these specializations such as cardiology and radiology, as opposed to primary care, partly due to the fact that primary care providers are often underpaid relative to all these other specialties. So very few want to enter that field. But as you know, with primary care, they feel they have this calling. It's a very different type of area of practice.
- [48:22]
A
Well, Mark, that's a whole other episode I should do because I did. I've had conversations with the head of pediatrics at New York Presbyterian Cornell. She's been on Dr. Sally Parmar. We've talked about that issue with having fewer people go into pediatrics because of, you have these people that are going to medical school, they have student loans, they have all these financial concerns. And so they are directed towards areas of practice that are more lucrative. But part of that is because of insurance companies who are not reimbursing, you know, at the same levels, you know, for primary care and pediatrics as they are for specialties. And that's really, that's a big, a big, big problem.
- [49:04]
B
And this spans the. Goes across the age span because in older adulthood you're seeing the same problem. Geriatricians, there are far fewer of those because, you know, many of them are doing primary care with older adults. So it is a huge problem. But it ties into what we're talking about because I actually, many years ago we did a study with some, I worked with some gerontologists where we Were looking at how well do primary care providers manage suicidality, depression, suicidality among older patients. And there are big gaps there. And so we need better training, we need to expand the primary care system. And I know this is a health policy conversation, but I think it has ties into what we were talking about before, about more. We need to be spending far more on prevention, real prevention, upstream prevention, universal forms of prevention, as opposed to the downstream activities that we now are funding and doing, which I think have contributed very little, very little to the population level rate of suicide mortality in the United States.
- [50:15]
A
Yeah. And then for takeaways for people, Mark, who just want to make sure that they are doing all that they can do to prevent this from happening to someone that they love. You talked about behavioral changes. This phrase isn't used for this particular thing. But if you see something, say something, meaning if something doesn't seem right, be proactive.
- [50:39]
B
Exactly.
- [50:40]
A
Maybe this is my advice.
- [50:44]
B
It is, it is a very basic idea. That is, if you see significant sun changes, loss of interest in, in hobbies, in, in, in activities that were very much part of this person's life, say if they were, you know, they were, you know, they were a swimmer, they were a runner or something, and suddenly giving up on that loss of interest, especially among youth, you know, withdrawing from others, becoming more socially isolated, making a plan, researching, you know, this is common. You know, researching way of dying, how to get a hold of a gun, for instance, giving away important items that, you know, this, this, you hear this a lot. Saying, beginning to say goodbye and not picking up on those messages, becoming, as I said, losing those connections, withdrawing from social life. Also, you know, people begin to, you know, we've also seen this happen where people are engaging in extremely dangerous behaviors, as you rightly noted, loss of, you know, not sleeping well, not sleep. Hygiene is a big issue and, you know, very extreme mood swings. But again, and guns, don't forget firearms. But not everybody who has died by suicide, suicide has, has, has this profile. And that's, that's, that's the disturbing part of this. The silent suicides, those who did not have the standard markers, or shall we say, psychiatric markers of suicidality, that to me is very troubling. That's more common among men. And, you know, as we know, men just don't like to talk about their feelings.
- [52:24]
A
Yeah. And then there's the, as we mentioned, there's the event. Right. So maybe if we have people in our lives who have that big event that a death of someone close to them, a loss of a job that they really identified themselves with so strongly. There's sort of a big shift in their life. It's helpful for all of us to kind of have our eyes open in those kinds of circumstances.
- [52:52]
B
Those life events that you just mentioned can have a huge impact on people's lives. Lives on. The quality of their life may not necessarily lead to a suicide, but make. They could make them depressed. And we, in some of the work we've looked at, those are very powerful factors and are often characterized as precipitating circumstances, the ones you've just highlighted. So we need to be aware. But, you know, we do have an epidemic of loneliness. We do have a epidemic of social isolation. I think that's where social media has contributed, in spite of what. What people have argued that it's connected us. No, I think on the other hand, yeah, it's. It's minimized our, you know, that connectedness.
- [53:37]
A
It also minimizes. You look at someone's life. You know, I said this to my daughter. You know, she. There was someone she babysat for, and she said, gosh, they look, you know. Did you. She said, they. This family looks so perfect, but, you know, in their Instagram. But I babysat for them and things are a little chaotic over there. And I said, well, isn't this a great example for you that what you see on social media doesn't necessarily reflect realities? But, Mark, thank you so much. I mean, when I reached out to you, I really was looking for some direction or way to make sense of this for myself and for others who have been touched by why this most recent event for me. But I know it's something that's shared by, unfortunately, and the numbers speak to that by everyone, everyone who's a listener, whether it's directly or indirectly, and whatever we as a society can do to be more aware, be more vigilant, whether it's advocating for policy or whether it's just having your eyes open to those around you. I really appreciate you joining today and shedding important light on this issue, what we can look for and what could be possible. And thank you very much.
- [54:56]
B
Thank you so much for having me. I enjoyed this immensely.
- [55:01]
A
That brings us to the end of this episode. I want to thank Dr. Mark Kaplan for joining the podcast to shed a light on this very important subject. I hope that if there's any takeaway from this episode, it's to pay close attention to your loved ones if they're in distress, and to say something if something feels off. Also, a big thank you to our sponsor, Cozy Earth. Don't forget to visit their website for all of their amazing brush bamboo jogger sets and clogs. Run, don't walk to www.cozyearth.com and don't forget to use the promo code Duologue at checkout for 20% off. If you enjoyed this episode, please rate or review us on Apple Podcasts, Spotify, or wherever you get your podcasts. We really appreciate your support and your reviews go a long, long way. We'll release a new episode again next Wednesday. Until then, this is Leslie and thanks for listening to Duolog.