Mental Health: Suicide Prevention

We're continuing the conversation with Gianna, who shares her experiences with depression, anxiety, and a suicide attempt, and Dr. Joshi, a child and adolescent psychiatrist at Stanford University Medical Center.

May 8, 2018

Rebecca: Hi there and welcome to In My Words, Jumo’s podcast series that brings the experiences of real patients directly to you. At Jumo, we provide resources for children and families to understand, manage, and own their health.

Hi, it’s Rebecca again, and we’re back with part 2 of our Mental Health Awareness month edition of In My Words. This is near and dear to our hearts here at Jumo Health. Why? While we aim to provide helpful resources across any and all conditions, and a mental health condition is something for which every person is at risk.

As common as they are, mental health issues - even just talking about them - can carry an extreme amount of stigma in our society. They are sometimes seen as someone’s fault or as a consequence of negative behavior; rather than an illness that stems from genetics or biological factors such as asthma or breast cancer. While every month should be mental health awareness month, May is a perfect time to rally together to start a conversation around our body’s most important organ - the brain.


Gianna: So I first started experiencing symptoms at the age of, I would say, 13.


Rebecca: That’s Gianna, again. As you’ll remember from our last episode, she is a teenager who has lived with anxiety and depression from a young age. As we’ve learned - this is not uncommon. Gianna struggled for years; she noticed toward the end of her eighth grade year that she was feeling down and extremely stressed about the prospect of going to high school. Her freshman year was a very difficult time; she struggled with sad thoughts, getting out of bed, and even showing basic emotions she knew were expected of her.


Gianna: and this trend continued for most of eighth grade and freshman year and there was somewhat of a breaking point in my freshman year, especially because my mother and I weren’t on the same page about a lot of things. And so my home environment and school was piling up on me and so, I would say around April to June it was probably, like, the worst time of my life for the most part. That was when I was having suicidal thoughts, attempted suicide, had a string of panic attacks and then that's when I reached out to my parents for help.


Rebecca: Realizing and admitting you need help can be a major barrier to getting the support you need.


Gianna: I did discuss with my parents. My mom and I got into a giant argument, I think in April. And so a couple of weeks afterwards, I approached her and I apologized for how we've been acting. I told her that I've been feeling sad, that I'm having suicidal thoughts, and I do want help. It kind of came to the turning point where I was just really tired of going back and forth with my mom, because I just yelled at her and [would] fight with her for maybe attention - like, it was me asking her to notice that something's wrong. And so her response was kind of the breaking point for me. My parents are very religious and they didn't know how to deal with a depressed kid that was struggling with these things. And so my mom's first response was that maybe I should go to a priest or I should go to church, and that kind of bothered me because it felt like she was just pushing aside my feelings and bringing a simple solution. Like I wish the solution was that simple, but it wasn't. And then that's when I probably started spiraling out even more. That's when things got really bad, and that's right around when I tried to attempt suicide. No, I did attempt suicide. Sorry for the wording. Yeah it was in May. So after April with discussion with my mom that's when I decided that I wanted to end my life.


Rebecca: As Gianna admits, seeking help can be harder than it sounds; but it’s important not to give up. In our last episode we discussed  the importance of identifying trusted people in your life with whom you can speak, including parents, adults, friends, teachers and doctors. Admitting that you need help is not a weakness and Gianna spreads this key message on to her peers.


Gianna: Well you know I of course tell them to seek help you know to talk to an adult. But it's maybe hard for some people to jump straight into talking to an adult or wanting to do it because for me I had to maybe admit to myself that you know it's okay for me to ask for help and I'm not worth any less because I need or want help. And so for the most part I told them of course seek help but then I tell them they can always talk to me. You know I give them a list of resources - hotlines, of course - if they need anything.

And then I always ask them how their home environment is, because a lot of people don't understand that maybe kids don't have an adult that they feel safe talking to and like your home life isn't the greatest. And a lot of people like have you told your parents and if they say no that's kind of where the conversation ends. But just because you know your parents aren't supportive doesn't mean you should stop seeking help.


Rebecca: Thankfully, GIanna’s suicide attempt was non-fatal, and she can look retrospectively on her experience and provide sound advice to her peers. We asked her about what happened after, how she began to receive treatment and the help she needed.


Gianna: Well it was kind of strange, but after my attempt wasn't successful I kind of realized like I do want to live and I'll push through it. And so it wasn't until, I would say, the beginning of August that I got treatment because my dad didn't know apparently about any of this. My mom hadn't expressed it to him and I hadn't expressed it to him, because he works a lot. He's an engineer, so he only comes home around 9 p.m. and that's when I'd be going to bed after school. So when my father saw me have a break down in front of him, he was the one to book an appointment with a therapist. And my mom and my dad came along with me for about a month and a half worth of treatment.


Rebecca: To hear Gianna speak of her experiences with depression and anxiety, makes what can seem like an abstract concept - something that is, in fact, very real. For those who are fortunate enough not to have been impacted by suicide, it can seem like something that only happens on TV or to celebrities.

But on average, there are 123 suicides per day in the US. The rate of suicide among teens and young adults has increased in recent years; and suicide is now the second leading cause of death for those 5 to 24 years old.

To get a better understanding of what’s going on, we’re back again with Dr. Shashank Joshi, child and adolescent psychiatrist at Stanford University. Dr. Joshi directs school mental health services at Stanford and runs the training program for child and adolescent psychiatrists of the future.


Dr. Joshi: Yes well it's great to be with you.


Rebecca: Dr. Joshi, what are the risk factors for suicide in children, teens and young adults? Do societal factors play a role?


Dr. Joshi: Well, you mentioned increased rates - that's actually true. We have seen the rates go up in the last 10 to 20 years. And in our section of the world in Northern California, there's actually been some formal study looking at what some of the factors might be. As a field, we think about suicide and suicidal risks as having multiple contributors. So you mentioned societal risks - yes, societal factors can contribute, but there are almost always more factors to be considered. There are almost always things like biological risks - like depression or other mood disorders - anxiety, substance abuse, or severe mental health conditions, like schizophrenia or other kinds of mental health issues. We also understand that in addition to societal factors there are other environmental factors: psychological factors, social factors regarding where you live, where you come from, your cultural background. It's another area of interest of ours in our program. Cultural factors associated with help seeking, stigma reduction as well as barriers to getting help for oneself or for a friend. So we always look at risks in the context of who the person is, where they come from, how old they are, where they go to school, where they live, etc.


Rebecca: Let’s talk about culture a bit more. In our last episode, Gianna talked about her school environment as one of high stress and competition. What are some of the cultural factors associated with help seeking and stigma? How are these barriers to getting help?


Dr. Joshi: Well culture is a very interesting paradigm. Everything we do in our program has a cultural lens, if you will. And so we want to make sure that whenever we are meeting with a young person or consulting with a school or meeting with a teacher, that we're always taking the cultural context into account. So one example of cultural context has to do with how a school thinks about mental health.

So if a particular high school that we work with sees mental health as part of overall health and that kids have to be healthy enough to learn in order to do their best work or in order to perform on the basketball court or in the piano recital hall then that is a cultural milieu that we would say values the idea that children and teens don't just come packaged in terms of the grades they're getting or their performance, but their mental health is taken care of and attended to. They're going to be happier, better able to participate in school, better able to participate in their life. And if they're not doing so well, they will then have the ability to reach out for help because in their school, for example, they may have courses on: what is stress and what is normal; what is not; how do I know when to worry about myself or about a friend or about a parent; what's the difference between stress and distress; What's how does stress develop into distress or desperation; how is stress different from depression.

And so the cultural milieu is going to be a place that we look at in order to understand how easy is it for this person to get help if they need it. If the normal everyday stress that they're dealing with is too much for them to handle on their own.


Rebecca: We talked a bit last time about the risk factors for anxiety and depression. These conditions themselves are then the risk factors for suicidal thoughts and actions. What are other risk factors that we should be aware of?


Dr. Joshi: Depression and anxiety are not the only two but they're two of the leading causes. And then when you combine them with some of the environmental and psychosocial stressors and cultural issues, like let's say you go to a school where there has been a suicidal loss in the community - well, that can increase your risk because then, in a way, suicide is in the water. And so what is it about this environment that might have predisposed this person to suicide?

I think a common misconception is, well the school must be doing something to create the conditions for suicide. We know that somewhere between 65 and 90 percent of people who die by suicide have a mental health condition or mental illness that has been diagnosed at the time the person completes a suicide or has had a mental health condition diagnosed in the past. And so  that's a very important item I want to highlight - is that schools do not cause the risks to go up as a school. What happens is there are a number of factors that might be associated with a school that might help hopefully promote the conditions of wellness and not just increase the risk of depression. But depression and anxiety are also are often the things that we see. And then there are other things like substance use which is an associated factor or a history of being a victim of bullying or being a victim of abuse, for example. All of those can increase your risk factors.


Rebecca: You mentioned the concept of “suicide being in the water” - that if a suicide has happened at a school, other students are then more at risk. This phenomenon of suicide “contagion” has had some attention in the media lately. Can you tell us a bit more about it?


Dr. Joshi: Yes. So contagion is the concept that if someone dies by suicide another person will also die by suicide. And in some communities around the country we have seen that phenomenon where within a defined period of time more than one death occurs by a similar method, at a similar place, and a similar result. And so teens in particular are the most susceptible to this concept of contagion or cluster where you have more than two suicide deaths in a particular locale over a period of time. This may be something that gets aided by the way suicide is portrayed in the media through certain popular social media portals or television or online series where suicide may be unwittingly glorified by the way it's depicted. There are several resources now for that are science based about how to depict suicide in a way that is more helpful versus less helpful, ways that can enhance education and discussion about mental health and help seeking and stigma reduction and not try to ascribe some simple reason why someone died. You know they died because of another person bullying them and that was the single event; or they had a fight with their boyfriend or girlfriend, and that's why they took their life. Or, you know, something bad happened in the community, it was too much for them to deal with. And so now anything that is relatively single-cause and simplistic is usually not the case it's usually way more complicated than that.

And there are usually several factors involved and there is almost always some sort of a mental health condition or mental illness - mental health symptoms - that may not have been diagnosed yet but for which the person may be struggling.

I think the other concept to keep in mind about contagion is any community that has had a death by suicide whether it's been by a teen or an adult depending on how it's depicted in the media and how well known it is that will automatically increase the risk of a community particularly in a school setting and how the community deals with it - how they talk about it, how they educate about mental health and the fact that suicide is very complicated and not simplistic, and how one can get help for a friend or for oneself either on school campus or through the primary care office or through some other way. Through a faith based organization, for example; many churches and temples and synagogues have ways that you can reach out for help through a youth organization for example. If that's the framework of the discussion that connection will be very helpful in reducing the risk of suicide contagion. On the other hand if a suicide is sensationalized by being depicted in a certain way - typically simplistic explanations or having a picture of the young person who died or the method that they died by and not including resources, not having a discussion about mental health, having a big headline with the word suicide in it. Those are some of the factors that the CDC study in Santa Clara County highlighted as a very unhelpful and potentially increasing the risk for contagion because of the way the media covered the story, describe the story, and may have inadvertently sensationalized what happened.


Rebecca: Suicide has been a topic of discussion in the media as of late, following the release of the Netflix series 13 Reasons Why last year, as well as celebrity suicides, such as Avicii. Dr. Joshi mentioned media portrayal as something that can, perhaps unintentionally, glorify suicide, promote copycat behavior and perpetuate stigma. With constant connectivity to social media, teens and young adults are particularly attuned to what is going on in the world around them. We asked Gianna her thoughts.


Gianna: So I didn't...I opted out of the whole 13 reasons why trend. I didn't want to watch it because of what it depicted, because I struggle through it... I didn't... at the time I really didn't want to watch someone else go through it at the same time because, you know, there's the term "trigger" but - you know, high schoolers make fun of that word now - but there really is like a trigger to seeing that. And I didn't want to be reminded of you know my suicidal thoughts. So I opted out of the show because apparently it also wasn't being depicted properly. There's some things that weren't... I've heard a lot about it, and so the things that I've heard didn't seem like it's the greatest show to represent you know mental health in general. But songs like Logic's 1-800-273-8255 gets people talking because the number itself, like if you search up the song you're going to have to figure out what the number means and what it stands for, which brings people to... brings the whole suicide hotline to light. And also like it was done in a very tasteful way because he said in an interview that he wrote it because his fan told him how, "oh you saved my life," and he thought you know if I'm saving someone's life without even trying to what if I made a song to remind people that like you're not alone. It gets better and you can work through this.

And that's the type of thing that I would like to see more of, because if it's done in a tasteful way it makes people talk about it and discuss it more because like when the song comes on the radio a lot of people like ask, "oh what's this? What is it about? What's with the title of the song?" And so that just gets discussion going, as well. And then you know there's I think there's a new movie that's coming out about anorexia and it's been yeah it's been highly criticized because of the way this person is being like I think Lily Collins is the actress. She suffered from anorexia herself - I believe she did, yeah - and so you know the movie just came out so I can't really speak on it, but it's already been accused of glamorizing it. And I think it's understandable because like it happens so often. Like this morning I woke up to an article about a schizophrenic man that killed three people. But the problem was he didn't kill them because he's schizophrenic, it was a drug deal gone wrong. But in the title it says "Schizophrenic Man Kills Three People" and it's like OK it's like it's like it has nothing to do with the problem. It's like saying, oh girl eats cupcake then dies. Of course it's Hollywood so they want to have drama to it. But there's a tasteful way to do things and hopefully, you know 13 Reasons Why it's having a season 2; hopefully they take the criticism in stride and you know make adjustments to the show to make it you know maybe a little bit more legitimate.


Rebecca: As we stressed in our last episode, mental illnesses - depression, anxiety, and others, like bipolar disorder and schizophrenia, are just that: illnesses. Illnesses that can be treated. It is not a weakness found in an individual; that person did not do something wrong. Think about conditions such as diabetes, heart disease, multiple sclerosis -- something happens in our cells to make them malfunction, creating a ripple effect in our bodies that affects its functioning, and ultimately, our behavior, thoughts, and feelings.

It's certainly not a sign of weakness it's not an inability to cope but it's really a brain condition. It can happen to anyone at any time. It doesn't discriminate based on gender or cultural background or parenting practice. It's not a hit on your character or who your friends are, what kind of music you listen to. Depression is a brain based condition. It's a medical condition.

The language we use to discuss mental illness and suicide, can go a long way in combating the misconceptions often associated with mental health - while at the same time,  it can perpetuate the stigma, allowing it to sink its teeth further into our society and prevent us from having the conversations desperately needed to save lives.


Dr. Joshi: So the first thing is, we need to talk about it because it is the second leading cause of death in young people in the U.S. but it has to be thought about and talked about in a helpful way. And so some of the terms that can be useful and and you can learn all about this at the American Foundation of Suicide Prevention website which is wonderful and has a lot of good resources particularly for those who are trying to help a friend. But also for those who may have lost a friend or family member. So the idea of dying by suicide ought to be talked about as that rather than committed suicide. Commit implies a crime; died of suicide talks of a references the idea that there was a death and in this case it was due to a brain illness and the brain illness might have been depression, or might have been anxiety, schizophrenia, might have been in the context of some other condition. But thinking about it as a death from a brain condition can be helpful in understanding it and destigmatizing it.

In a suicidal state, the way we think - our thought process - becomes distorted and this could be from biology, from psychological stressors, from social reasons, from environmental reasons, for situational reasons, for cultural reasons and all of them play together; it's not a single cause. It's usually a very complicated set of contributors that ultimately lead to an attempt that may either be fatal or non-fatal. People who are suicidal are not thinking clearly. They're struggling with almost a kind of illness in their thinking process. So because suicide is no longer seen as a crime or a sin but is recognized to be the result of a mental health condition with a medically treatable cause, we, as I said, try to stay away from the term commit which implies a crime. And then we use the term someone with "lived experience," so a person with lived experience maybe someone who has struggled with suicidal thoughts or who may have had an attempt - they may be an attempt survivor - or they may have had a family member who might have tried to take their life by suicide. So if we change the way we talk about suicide we can change the way we think about it.


Rebecca: How should we talk about suicide?


Dr. Joshi: In general the language used for any other illness-based death or sudden loss, like a heart attack or a car accident, can be a guiding principle. So as I said a person with lived experience of suicide has struggled with thoughts or behaviors of suicide and resilience is a skill that can be developed. So if you struggled with these but you bounce back, you can actually get stronger. So one is not permanently fragile when they are an attempt survivor and in many cases they are much stronger and they've developed some coping skills that they can then share with others who might be going through a similar experience and they might have a sense of connection that others might not have. Someone who's "bereaved by suicide" is someone who's been exposed to the suicide of another person and has a high level of either social or psychological distress for a considerable length of time. We often call them a "loss survivor" and so you'll see a lot of events and organizations that center around lost survivors and AFSP and AAS which is the American Association of Suicidology have a lot of events and ways for people to connect after a suicide. The AFSP has combined with the Suicide Prevention Resource Center to create a tool kit called after a suicide and particularly in school settings.

When there is a loss, people are at risk for PTSD. So in communities where we have lost teenagers, for example, we have seen PTSD not only in the peers of those teens but also in the teachers and other people in the community. If say there's a second death it can reactivate those feelings and they might experience symptoms of PTSD from that. So complicated grief patterns as a result of someone dying or the memory of someone dying who you were close to. So everyone grieves differently and on their own timeline and someone who's bereaved by suicide has been exposed to the death of another person. And then we talk about a fatal or non-fatal attempt. Instead of saying it was a successful or a failed suicide we talk about a fatal attempt or a non-fatal attempt. And that allows us to stay away from stigmatizing language.

Rebecca: Starting the conversation and continuing it in the right way is critical in changing the way we think about mental health. The good news - there are organizations out there dedicated to this cause. In our next episode, we’ll be talking with Leanne Loughran from BringChange2Mind. Their mission: To end the stigma and discrimination surrounding mental illness. See you next time.


For resources and information on mental health and suicide prevention, visit The JED Foundation exists to protect emotional health and prevent suicide for our nation's teens and young adults. To learn how to start a conversation around mental health and stop the stigma, visit Links to these resources can be found in the show notes of this episode.

This podcast and the information provided is not to replace clinical therapy and treatment. If you are in a crisis and need immediate help,

  • Call 911 or go to the nearest emergency room
  • Text “START” to 741-741 or Call 1-800-273-TALK (8255), available 24 hours a day, 7 days a week, confidential, free of charge
  • Go to your local healthcare provider or school’s counseling center (during business hours) or call campus security or the emergency number provided

Rebecca: Thanks for listening! Interested in hearing something special - or want us to help share your story? Reach out to us, we’d love to hear from you! See you next time!

The health information contained in this Podcast is provided for educational purposes only and is not intended to replace discussions with a health care provider.

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