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Melanie Cole: Everyone can feel down at times. However, if you suffer from depression, without the proper treatment, your feelings of despair can become so severe that you consider taking your own life. My guest today is Dr. Rachel Shmuts. She's a psychiatrist at Our Lady of Lourdes Medical Center. Welcome to the show. Who is at greatest risk of suicide? We’re hearing so much about this in the media now. Who is at the greatest risk?

Rachel Shmuts, DO: Those at the greatest risk of suicide actually are people who find themselves isolated and also suffer from a mental illness. We think of suicide as its own entity, but really, it's a symptom of other diseases identified as what we consider are the affective disorders or the psychotic disorders. The one we talk about most is depression. There are different kinds of depression. There's unipolar depression, which is what we describe as "clinical depression," and then there's bipolar depression, which is very difficult to treat and has a very high suicide rate compared to other disorders. People who have lost touch with reality in other illnesses like schizophrenia, there's also a higher suicide rate than in the general population. Anybody who suffers from these disorders, especially if they've had a history in their past of either having thoughts about wanting to end their life or even trying to end their life before unsuccessfully, aren't definitely at a higher risk. We find the fastest growing rate of suicide is among older men who tend to be Caucasian and either widowed or divorced. They tend to be very isolated, they tend to have lost their social group and with the high rates of depression in that population, there's also a corresponding increasing rate of suicide. Other things that will contribute to suicidality is having a substance use disorder. We really see higher rates either by accidental overdose or purposeful overdose in those who are using substances as well.

Melanie: Is there any genetic component if a family member has committed suicide? Does that make it more likely that you're in that high-risk group?

Dr. Shmuts: Absolutely. We’re not necessarily sure if it’s truly a genetic component or it’s something that’s a learned behavior, but any person who has completed suicide in a first degree relative, within their immediate family, a mother, father, sister or brother, the risk of suicide in that person is certainly higher than the general population. There may be a genetic component that’s related to the underlying disease state, but also it might be something that’s ‘mom did it so I can do it too’ type of thing. It’s complex, but yes, absolutely first degree relatives. The risk is lower than it is if you have a second degree relative like a grandmother or grandfather or aunt or uncle who has committed suicide, but the risk is still higher if there is that relationship than the general population or another person who doesn't have the suicide in the family.

Melanie: As far as warning signs, is it possible to predict? Nowadays, we’re seeing people posting suicidal messages on social media or if people tell you we’ve been hearing take it seriously. Tell us about some of the warning signs and red flags you really want people to pay attention to.

Dr. Shmuts: I will definitely tell you the warning signs, and I really love the question about prediction. The thing is I want to answer that quickly first and then I’ll get to the warning signs. We as psychiatrists in the mental health field are the ones that are supposed to “predict” or be able to determine whether someone is going to act in such a way or not. The thing is that we are actually very bad at predicting who’s going to end up killing themselves and who is not. That’s because the people who actually really want to do it are the ones that are not going to reach out for help. We don’t actually always see those patients, so they don’t get evaluated. They don’t get to talk to anybody necessarily about it because why would they want to be stopped if they're that determined to do it. It's very difficult for any given person to predict. Of course, we have warning signs and risk factors that we use to predict when we're doing our evaluations. Friends and family members can be aware of these as well and we do our best to try to intervene at these warning signs and mitigate these symptoms, and certainly we can prevent suicide or we can change someone's mind, but it's very hard to predict in the end if person A is going to do it and person B is going to do it if their profile looks very similar or different. Things to be aware of, if somebody seems depressed, sad, down, if they say things like life isn't worth living or I'm not a good person, they have an internal sense of worthlessness or hopelessness, they just seem off, suicidal thoughts can arise after certain life events that can be very devastating, like after major losses.

In the presence of using a substance when their judgment is impaired, if they carry a diagnosis of depression or undiagnosed but they seem down and they seem sad, they’re using cocaine, it’s going to make them more impulsive to act on their negative thoughts. Being alone, isolated, pulling away from friends and family, especially now we’re looking at teenagers and I know suicide has been very discussed in the media over the last year and I know the show 13 Reasons Why examines it from the context of teenagers and adolescence. Grades slipping in school for no reason, pulling away from friends or not having friends or having had friends and now not having friends, staying in the house a lot, not really communicating, being very quiet and withdrawn, these are all scary things that if a parent starts to identify these in their children, it’s important for them to talk about and try to bring them out in a welcoming and nonjudgmental sort of way. Like you brought up before, first-degree relative or even second-degree relative, but if there's a suicide history in the family, the number one risk factor for attempting suicide is having had an attempt before. If you know a person that has tried to have killed themselves before or who have indicated that they wanted to and didn't succeed, their risk is very high for another try. These are things to look out for if there's a loved one or someone in your life that you're concerned about. These are things that you need to try to intervene or try to talk to them about and draw them out of their shell so they don't feel alone.

It’s hard to tell sometimes because like I said, people who really want to kill themselves sometimes end up doing it because they don’t want that help, they don’t ask for that help. In order for someone to commit suicide, I had a mentor tell me this and it really made a lot of sense to me. I was actually in the context of when Robin Williams killed himself that for somebody to actually take their own life, they must be in complete and utterly intractable emotional pain and they must also be completely hopeless that there's just no possibility to them that life can get any better. If any loved ones or even if you're a healthcare provider, if you have a patient who seems to be suffering from either one of these things or both, definitely warning signs to act on.

To address your question about social media, it’s hard. It really depends on each individual case because sometimes we’re in a world where everything gets posted online and it’s hard to know with adolescents especially how much they're putting on there and how much of it is just attention seeking because that’s a normal behavior in adolescents and teenagerhood to want people to pay attention to you whether for negative or positive attention can be on equal ground or if it’s a real call for help, it’s very hard to know. I think the threshold should be low that if anything is identified on social media as being worrisome, the proper authority figures whether it be the school or family or the actual authority should act on it to prevent anything from happening. Like I said, we’re not great at predicting who’s going to do these things. Posting on social media makes it easy to be anonymous too or to be more verbal about things that you may not know is serious or not, so low threshold to act on those things because we can look back at some of the cases in the media and the news, the one at Ruckers was one of the first people that was cyberbullied and posted online that things where not good for him and it just never got picked up. We have to have a low threshold to respond and to help whoever is posting on these matters.

Melanie: You’ve mentioned talking to people, getting them help. How do you talk to somebody who has made these kinds of statements? People are afraid that sometimes if you bring it up or talk to them that you’re putting that idea into their head. What do you want people to know about what they should do when they sense those warning signs?

Dr. Shmuts: It’s actually a little bit of a myth that when these things are bought up, if you want to talk to somebody about suicide, but they don’t say or mention it outright and you use the word or use the concept with them that that will put the idea in their heads. Studies have shown some of that is not the case actually. By asking about it, it does not induce the increased possibility that behavior will happen. What the studies have found is that when people who are suffering and thinking about killing themselves are asked about it directly or are asked about it in a very nonjudgmental way, they get almost a sense of relief because in some way they get that somebody is understanding how they feel without them having to express it directly. It almost gives them permission to talk about it, but not always, but that’s what we find. Talking about it directly in a nonjudgmental way does not induce the behavior. We used to think that, but that’s not true. I think that people used to not bring it up because of that and it shouldn’t be. If someone wants to help another person whom they suspect wants to kill themselves or who is really not doing well, it’s important to talk to them, to let them know they're not alone, that they can get help and that person will help them get help. I think a lot of people don’t come forward with their feelings and their thoughts, especially if they're focusing on their own death, because they're afraid of the stigma that if they say they're going to kill themselves, they're going to automatically be locked in a mental health unit. I would say institution, but that’s outdated, but we don’t really have those anymore, where they're going to be locked up and called crazy. That’s actually not the case either. Now in some cases, it may be depending on how dangerous the suicidality is and also how much insight the person has into their mental illness. For instance, when somebody is psychotic, they're hearing voices, they're delusional and they're suicidal, they're not always able to consent. That’s a different story, but when they're really depressed and they want help, just because they're feeling suicidal doesn't mean they're going to be “locked up.”

They may need a brief inpatient stay to deescalate their feelings a little bit, getting to thinking a little bit more clearly, or they might just need to be in therapy. It really depends on what the thoughts are on how close there are to acting on them if they want to act on them at all because a lot of people walk around with thoughts in their head about wanting to die or kill themselves, but they never try or never do it, yet they're still suffering. There's different degrees of how people suffering from suicidality and then there would be different degrees and intensities of treatment. I think that’s important for somebody who is intervening for a loved one or trying to get them to talk about it to let them know I'm here for you, I'm not alone, you can get better, I will help you and you won't have to be in the hospital, there's other ways, there's other things we can do and I’ll be there for you every step of the way. That’s the way you approach it and not say you're crazy, you want to kill yourself, how can you want to kill yourself – that doesn't help. Say I understand why you feel so terrible, let's see what we can do about it together, you don’t have to suffer alone. I think that can go a long way.

Melanie: That's great advice. Wrap it up for us. To speak about this type of mental illness that still has a bit of a stigma around it and if you can really change a person's mind, can they be stopped? Wrap it up with your best advice as a psychiatrist and with the suicide helpline what you want people to know.

Dr. Shmuts: I want people to know and I think in the context of what's been going on in the media particularly with Kate Spade and Anthony Bourdain, we all kind of felt connected to them, that anyone can suffer from mental illness, just like anyone can suffer from diabetes, anybody can suffer from heart disease. It doesn't discriminate and neither does mental illness, depression, anxiety, bipolar disorder, schizophrenia – any one of us are susceptible to it, some more than others based on genetic risk, but it shouldn’t be stigmatized because it’s no different than any other medical illness. Suicidality is a symptom of these illnesses and much like diabetes, much like heart disease, it can be chronic but it can be treatable and it could be curable in some cases. There are treatments that we have out there with many different modalities and as the years go by and more research, there are new things that come up. There are medications, there are a million different types of therapies, there are groups, there are all sorts of psychoeducational materials that could be helpful. It's a horrible disease to suffer from, it's very internal, it's very personalized, but with the proper help, with the proper support, it can be treated and people can recover from suicidality and the underlying diseases that it stems from.

Melanie: Thank you so much for being with us today and sharing your expertise on this topic of such great importance and the National Suicide Prevention Lifeline is 1-800-273-8255. That’s 1-800-273-TALK or you can text TALK to 74171. You're listening to Lourdes Healthtalk. For more information, you can go to lourdesnet.org. This is Melanie Cole. Thanks for listening.