If you or someone you know is contemplating suicide, please call the National Suicide Prevention Lifeline at 1-800-273-8255 or text TALK to the Crisis Text Line at 741-741.

In April 2019, a classroom at the University of North Carolina, Charlotte, was the site of a shooting that claimed 2 lives and injured 4 people.1 This scenario has become a common occurrence in the United States, with an average of 1 shooting every 12 days in grades kindergarten through 12 schools alone.2 In March 2019, over the span of 1 week, 3 people affected by other school shootings died by suicide, including 2 teens who survived the 2018 shooting at Marjory Stoneman Douglas High School in Parkland, Florida, and the father of a child who died in the 2012 Sandy Hook Elementary School shooting.

These deaths by suicide highlighted the ongoing ripple effects of violence and sparked reports that a phenomenon called “suicide contagion” may have been a contributing factor in these incidents.3 Psychiatry Advisor reached out to experts for an in-depth discussion about this topic: Caroline Abbott, a researcher and doctoral student in clinical psychology at the University of Delaware in Maryland; Michael D. Anestis, PhD, Associate Professor in the School of Psychology and Director of the Suicide and Emotion Dysregulation Lab at the University of Southern Mississippi in Hattiesburg and the co-chair of the American Association of Suicidology’s Firearms and Suicide Committee; Jason R. Randall, PhD, a research associate in the Injury Prevention Centre at the University of Alberta, Edmonton, Canada.

Psychiatry Advisor: What does the available evidence show thus far about “suicide contagion,” and is it suspected that this may have played a role in the recent deaths of the Parkland survivors and the father of the Sandy Hook victim?

Ms Caroline Abbott: Suicide contagion is the exposure to a death by suicide that can increase the risk for suicide in another. This can be true within indirect (such as media or online) or direct (such as family and friends) exposure. For example, studies of suicide contagion in the [United States] have shown that suicide rates increase in the months following publicized suicides.4 This is especially true for repeated media coverage and in the case of high-profile suicides. Suicide contagion is also present within social groups such as schools, families, and military units — known as “clusters” of suicides. Adolescents and young adults are particularly vulnerable to suicide contagion.4, 5, 6

Michael Anestis, PhD: The data on suicide contagion are mixed, and “contagion” is likely not the best word. Being exposed to suicide does not cause suicide to come out of nowhere, but there are a couple of ways that research suggests exposure — like we recently saw with Parkland — could play a role in risk. First, losing social support through the death of a loved one, peer, or even acquaintance can increase other factors related to suicide, such as depression and hopelessness.

Also, E. David Klonsky, PhD [psychology professor and researcher at the University of British Columbia, Vancouver, Canada], and others have suggested that hearing about someone you relate to dying by suicide may temporarily increase one’s sense that suicide is a viable option for them. It’s important to remember that suicide is extremely difficult, which is one of the reasons that most who think about it never make an attempt, no matter how badly they want to do so. Simple exposure is unlikely to prompt the entire process, but for some vulnerable individuals, it may temporarily increase the likelihood that they may act on already existing suicidal thoughts.

In terms of the Parkland students and the Sandy Hook [parent], I do not think it would be appropriate to make assumptions regarding whether or not contagion was the issue here. We do not know enough about what they were experiencing, and I think that folks at times rush to judgment with a narrative that makes sense to them from afar, but which does not necessarily apply to a specific individual or group.

Jason Randall, PhD: I think a relevant point for this issue is that [suicide] contagion appears to be more likely in people who identify with the individual involved in the first death or attempt. This is relevant to this case because these individuals all experienced an extremely rare event and therefore identify much more strongly with each other. These individuals likely developed very strong empathy for survivors of violent events, which then makes sympathizing with the decision to attempt suicide much more likely. Combined with other risk factors, this may lead people to consider attempting suicide.

It is important to note that suicidal behaviors are very multifactorial — they are hard to understand and predict because so many risk and protective factors are involved. In this instance, there were a lot of people affected by these 2 shootings, but thankfully most people are not at high risk for suicide and make it through these events.

Psychiatry Advisor: What are the treatment implications of these findings for clinicians?

Ms Abbott: One treatment implication is to be aware of this heightened risk for suicide following exposure to suicide in real life or in the media. Individuals are more likely to die by suicide if the person is similar to them, if details of the method are known, or if the individual is a celebrity or has high status. Individuals bereaving a loss to suicide should be evaluated for risk for suicide by a mental health professional. However, it is important to note that suicides rarely “come out of the blue” and it is unlikely that hearing of a suicide would cause suicidal thoughts in an otherwise non-suicidal individual. Clinicians should be especially attuned to the risk for suicide contagion in those already at risk for suicide, such as those with a history of suicidality, mental disorders, and/or a family history of suicide.

Dr Anestis: A few things are important to remember. First, it is not always obvious who will consider themselves a loss survivor and who will be impacted by a suicide death, so take everyone’s words seriously. Second, we often do not “see it coming” when individuals die by suicide, so rather than waiting for risk to be obvious, take preventative measures and do your best to limit ready access to methods for suicide, particularly highly lethal ones such as firearms.

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Dr Randall: There is still a lot of research needed on treating suicidal ideation and preventing suicide in general. How best to counter the occurrence of suicide contagion is even less well understood. I think that preventing the effects of contagion is not well enough understood to really discuss how to address it, specifically. [The media can help by adhering to] the various guidelines written around the reporting of suicide in the media.7

However, since contagion tends to affect individuals with pre-existing risk factors, then general suicide prevention and treatment methods can reduce the effect of contagion by reducing the number of individuals who are at high risk. This would mean encouraging people to seek treatment for mental health and suicidal ideation, screening patients for these when they are seen by physicians — including family physicians and other non-mental health practitioners — and engaging in best practices for those individuals with mental illnesses and other risk factors.

Psychiatry Advisor: What are other ways in which mental health clinicians can support survivors of gun violence and suicide, including both in the clinical setting and in terms of advocacy?

Ms Abbott: Death by violence and suicide can be particularly difficult to process and grieve, especially when the deceased is a child. These violent and unexpected deaths can increase existential concerns including hopelessness and powerlessness. While some survivors may be able to process and recover from these painful experiences with time, some will likely go on to develop complicated grief or posttraumatic stress disorder (PTSD). Mental health clinicians can support survivors of traumatic loss with evidence-based treatments for these disorders. Mental health providers should be particularly sensitive to feelings of guilt, shame, and hopelessness. Survivors of traumatic loss should be screened for mental health concerns and suicidality. Individuals at heightened risk for suicide should be referred to mental health services.

Dr Anestis: Do not let suicide be the silent majority in gun death discussions. This means that clinicians should be aware that exposure to traumatic events can increase suicide risk but also that exposure to firearms can do the same.8

Dr Randall: In terms of advocacy, there should be increased awareness of the long-term effects of exposure to traumatic events and PTSD in particular. Clinicians can help people who have been exposed to psychological traumas with therapy and medication, but clinicians are limited with the amount of time they can devote to 1 patient. Therefore, we need to strengthen community support for individuals with these traumatic experiences. Friends and family are key pillars of support, and we should give them the knowledge about what they can do after these events. Clinicians should familiarize themselves with the support networks in their community. Clinicians can also consider engaging in group therapy with those who experience these traumas and their friends and family to help create a supportive environment and provide the knowledge and tools necessary for the support group.

Psychiatry Advisor: What are additional needs in this area in terms of research, clinician education, or otherwise?

Ms Abbott: One need is to better understand the role of the media in suicide contagion, given the increased risk associated with media reports of suicide. Although contagion may create fear of talking about suicide, this silence can actually limit help-seeking and increase stigma and isolation. Further, the media can have a positive impact on suicide by spreading messages of hope, destigmatizing mental health, and providing suicide hotlines and other clinical resources. However, we need more research on how portrayals of suicide in the media influence contagion. At the very least, media coverage of suicide can be improved by making sure the information is accurate, concise, and always includes mental health resources. The increase in suicide deaths in the United States in recent times highlights the need for more research and dedication to suicide prevention.

Dr Anestis: It would be helpful to know whether gun violence exposure increases risk for firearm suicide in particular, which aspects of gun violence exposure increase which aspects of suicide risk and for whom, and the extent to which specific policy shifts could decrease risk for both exposure to gun violence and vulnerability to firearm suicide.

Dr Randall: In terms of research, I think continued investigation around suicide risk factors and treatments is needed. I think any research that produces a reduction in the risk factors that occur in the general population would ultimately result in fewer suicides as a result of suicide contagion. For victims of traumatic events, there is still much work to be done in improving treatment for acute stress disorders and PTSD. More research on community-based support for survivors and family may also prove very helpful.

Clinician education is not my particular area of knowledge, but I think there is still room for more emphasis on clinicians — particularly non-mental health clinicians —bringing up issues of mental health during routine medical assessments. There are people that might feel uncomfortable bringing up these issues by themselves, but an empathetic clinician might be able to start the discussion and ultimately prevent mental health issues from progressing into self-harm. One of the recent victims [the father of the Sandy Hook student] — was a middle-age man, and this group is at particularly high risk for death from suicide. One factor that is believed to contribute to this is a lack of help-seeking in men. Clinician education on monitoring mental health might be able to get through to people who ordinarily might avoid discussing these issues.

References

  1. Border G, O’Brien B. Slain North Carolina college student confronted gunman, saved lives. Reuters. May 1, 2019.
    https://www.reuters.com/article/us-north-carolina-shooting/university-of-north-carolina-identifies-victims-in-deadly-shooting-idUSKCN1S73DC. Assessed May 24, 2019.
  2. Griggs B, Walker C. In the year since Parkland there’s been a school shooting, on average, every 12 days. CNN. February 14, 2019. https://www.cnn.com/2019/02/14/us/school-shootings-since-parkland-trnd/index.html. Accessed May 24, 2019.
  3. Perez M. Suicide contagion: what you can do to help following deaths of parkland students. Newsweek. March 25, 2019. https://www.newsweek.com/suicide-contagion-cause-death-shooting-victims-epdemiologist-1374693. Accessed May 24, 2019.
  4. Abrutyn S, Mueller AS. Are suicidal behaviors contagious in adolescence?: using longitudinal data to examine suicide suggestion. Am Sociol Rev. 2014;79(2):211–227.
  5. Abbott CH, Zakriski AL. Grief and attitudes toward suicide in peers affected by a cluster of suicides as adolescents. Suicide Life Threat Behav. 2014; 44:668-681.
  6. Randall JR, Nickel NC, Colman I. Contagion from peer suicidal behavior in a representative sample of American adolescents. J Affect Disord. 2015; 186:219-225.
  7. American Academy of Suicidology. Recommendations for reporting on suicide. www.suicidology.org/Resources/Recommendations-for-Reporting-on-Suicide Accessed on May 2, 2019.
  8. Brady Against Gun Violence. Brady and American Association of Suicidology raise awareness of link between access to guns and suicide fatality. www.bradyunited.org/press-releases/brady-and-american-association-of-suicidology-raise-awareness-of-link-between-access-to-guns-and-suicide-fatality Accessed on May 2, 2019.