This Issue

Suicide: Out of the darkness

The tough road for those left behind

A preventable loss of life

Q & A

Need more information?

What puts a person at risk for suicide?

  • Depression or other mental health disorders

  • Substance abuse

  • Family history of mental disorder or substance abuse

  • Family violence, including physical or sexual abuse

  • Firearms in the home

  • Family history of suicide

  • Exposure to suicide of family members, peers or celebrities

  • Gender — occurs in almost four times as many males as females

  • Race — more common in American Indians and whites, but the number is increasing among blacks

  • Age — more common in people under the age of 24 and 65 and older

  • Incarceration

  • Previous attempts

Suicide is not a normal response to these risks and can often be prevented by appropriate treatment for the mental or substance abuse disorder.

What puts a person at risk for suicide?

Don’t keep it to yourself!
If you or someone you know is contemplating suicide,
make a call instead.
Telephone Number Organization Hours of Availability
800-273-TALK (8255) Nat’l Suicide Prevention Lifeline 24 hours a day
800-981-HELP (4357) Boston Emergency Service Team 24 hours a day
800-784-2433 Nat’l Suicide Prevention Lifeline 24 hours a day
617-247-0220 Samaritans 24 hours a day
877-870-HOPE (4673) Samaritans 24 hours a day
800-252-TEEN (8336) Samaritans – for teens 24 hours a day
866-508-HELP (4357) Massachusetts Suicide Prevention Lifeline 8 AM to 11 PM

Pay attention to the warning signs!
  • Threatening to hurt or kill oneself or talking about wanting to hurt or kill oneself

  • Looking for ways to kill oneself by seeking access to firearms, available pills or other means

  • Talking or writing about death, dying or suicide

  • Feeling hopeless

  • Feeling rage or uncontrolled anger or seeking revenge

  • Acting reckless or engaging in risky activities — seemingly without thinking

  • Feeling trapped — like there’s no way out

  • Increasing alcohol or drug use

  • Withdrawing from friends, family and society

  • Feeling anxious, agitated or unable to sleep or sleeping all the time

  • Experiencing dramatic mood changes

  • Giving away belongings or getting affairs in order

  • Seeing no reason for living or having no sense of purpose in life

Source: Substance Abuse and Mental Health Services Administration (SAMHSA).

Pay attention to the warning signs!

Don’t keep it to yourself!

What should you do if you think
someone is thinking of suicide?
  • Take the threat seriously

  • Let the person know you care

  • Ask questions

    Are you thinking about killing yourself?
    Do you think you might hurt yourself today?
    Have you thought of ways that you might hurt yourself?
    Do you have pills or weapons in the house?

  • Do not leave him or her alone

  • Remove potential tools for suicide

  • Tell him or her that you will get help

  • Call 911 or go to the nearest emergency room

  • Call 800-273-TALK — the National Suicide Prevention Lifeline

What should you do if you think
someone is thinking of suicide?

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Need more information?

It’s a call or click away …

American Foundation for Suicide Prevention • 888-333-AFSP (2377)

National Organization for People of
Color against Suicide • 202-549-6039

American Association of Suicidology • 202-237-2280

Suicide Prevention Action Network
(SPAN) USA • 202-449-3600

Centers for Disease Control and Prevention
800-232-4636 (CDC-INFO)

The tough road for those left behind

Since her husband’s suicide in 2007 Nepherterra Estrada (left) participates in the Out of the Darkness Overnight, an 18-mile walk sponsored by the American Foundation for Suicide Prevention. (Photo courtesy of the American Foundation for Suicide Prevention)

Life was good for Nepherterra Estrada. Married to a well-respected pediatrician, Estrada had recently launched her own public relations firm and the couple lived in a distinguished section of Milwaukee.

All of that came to a sudden halt. With little or no warning, Dr. Martin Luther Skala killed himself.

It’s been three years since her husband’s death and Estrada is doing the best she can. “I thought my life was over,” she said. “I wanted to crawl into a closet and die.”

She compared herself to Hester Prynne, a character in Nathaniel Hawthorne’s “A Scarlet Letter,” who was forced to bear the letter “A” for adultery. “I felt as a widow, there was a big ‘S’ [for suicide] on my chest.”

Of all the leading causes of death, suicide is considered to be the least understood and least publicly discussed.

But the numbers are astonishing. An estimated 91 suicides occur every day — or one every 15 minutes. In Massachusetts alone, there are about three suicides for every one homicide.

That ratio mirrors national statistics. While homicides in 2006 accounted for more than 18,000 deaths, the U.S. Centers for Disease Control and Prevention (CDC) reported that the number of suicides was almost double at 33,000.

More troubling is that suicide is the eleventh most common cause of death for all ages. But for those between the ages of 15 and 24 years old, it is the third.

And those numbers are for those who actually kill themselves. The number of failed attempts is equally significant. For every one suicide, there are as many as about 25 failed attempts. In 2007 almost 400,000 people across the country were treated in emergency rooms; an additional 166,000 people were hospitalized for self-inflicted injuries.

Though the rate of suicide in blacks is roughly half that of whites, recent statistics demonstrate a troubling trend. For reasons not fully understood, during a 15-year period between 1980 and 1995, the suicide rates for black youths ages 10 to 19 years old increased 114 percent, the CDC reported.

The youngest were hit hardest. For blacks between the ages of 10 and 15, the suicide rate increased 233 percent. That is compared to a 120 percent jump in whites of the same age range.

Though the suicide rate for young black males has leveled off in recent years, they remain at high risk. Black high school students fared poorly in the recent Youth Risk Behavior Survey. Almost eight percent had made a suicide attempt, 10 percent had made a suicide plan, and 12 percent seriously considered attempting suicide. In all categories, females reported higher rates than males.

Sean Joe, Ph.D., LMSW, an associate professor of social work at the University of Michigan Ann Arbor, admits little is known about black suicide. Because of the low numbers in comparison to American Indians and whites, the suicide rate among African Americans has generated scant interest in medical journals and scholarly publications.

In a 40-year span between 1938 and 1978, when national medical journals published scores of articles on suicide among white teenagers, Joe says he was able to find only 13 data-driven published articles on suicide in blacks.

Sean Joe, Ph.D., L.M.S.W.
Associate Professor of Social Work
Director, Emerging Scholars Interdisciplinary Network
University of Michigan, Ann Arbor
Fortunately, Joe and a few other scientists added to the medical literature when they published the results of their study on black suicide in the Journal of the American Medical Association in 2006.

The study included an analysis of more than 5,000 African American and Caribbean adults 18 and older on their suicide attempts or thoughts about committing suicide.

The results are troubling. Almost 12 percent had considered suicide; roughly a third of those said they had made a plan. Four percent made actual attempts.

Caribbean men and African American women were more likely to attempt suicide, while African American men and Caribbean women displayed the lowest numbers. Of those who made attempts, 36 percent tried more than once.

Equally disturbing is the longevity of ideation — the thought of killing oneself. Although almost 80 percent made an attempt with the first year of ideation, those with a plan continued to make initial suicide attempts for up to 35 years. This finding is significant since it gives blacks a 4.1 percent prevalence of suicide attempts — very close to the general population of 4.6 percent.

One factor that may contribute to suicides in blacks is the under-treatment for depressive and anxiety disorders. The study by Joe confirms this. He determined that respondents with a diagnosed mental disorder were almost five times more likely to consider suicide, and the risk increased with the number of disorders. Yet, a large percentage of those who attempted or considered suicide never sought treatment for their emotional disorder.

Such was the case with Skala.

As far as Estrada knew, her husband had never attempted suicide before. Nor was she aware that doctors have the highest suicide rate of any profession.

But there were hints. Every now and then, her husband would say something like “I should just kill myself …”

She says she didn’t give those statements any credibility — or alarm — largely because she uttered similar statements of frustration, statements like “Kill me now.”

“But I know I don’t mean them,” she said.

It’s clear now that Skala was at least thinking about taking his own life. It’s also clear that Estrada was in the dark on the symptoms of depression. “You don’t know what to look for,” she said. “It can be very subtle.”

As a result, she dismissed the sleepless nights and the erratic behavior as simply “a temporary phase.”

“He’s going through something,” she told herself. “There were challenges, but I don’t think they were anything others have not gone through.”

That “something” proved to be depression, which even he eventually recognized. To his credit, Skala had sought psychological help. But two months after he had begun treatment, he was gone.

For those left behind after a suicide, the problems just begin.

Experts estimated that for every suicide there are at least six survivors, a number that may total in the millions across the country. The loss of a loved one brings with it overwhelming emotion — shock, guilt, anger, denial and pain.

Edwin Shneidman, Ph.D., founding president of the American Association of Suicidology (AAS), said that survivors of suicide represent “the largest mental health casualties related to suicide.”

An even greater difficulty is dealing with the stigma attached to suicide. Shame and embarrassment can prevent the survivors from reaching out for help.

Estrada refused to surrender. Knowing she needed help, she summoned an army of support that included her parents, siblings, friends and church groups. She found a therapist whose insight she said has been immeasurable. Writing has also helped and has allowed her to put on paper her thoughts and feelings.

She recognizes that she has come a long way, but still has a long way to go. “I have not come to terms with it,” she said. “But you get through it. It’s up to me to connect the dots.”

The recriminating emotions — guilt and anger — linger. A lot of questions go unanswered. She said she has wondered if it would have been better if her husband had been murdered. At least, she explained, murder doesn’t come with stigma of suicide.

Now she’s more attuned and recently completed training in QPR, which stands for Question, Persuade and Refer — three steps to help save a life from suicide.

The QPR Institute, headquartered in Spokane, Wash., developed the training in response to the U.S. Surgeon General’s 1991 national strategy for suicide prevention.

The institute’s goal is for QPR to become as recognized as CPR, the life-saving technique for heart attack victims.

Her radar on depression and suicidal thoughts is now on high alert. “Now I take it very seriously,” Estrada said. “I want to remove the stigma of suicide. It’s like a secret society.”