Mental Health Matters
In 2020, suicide was the 12th leading cause of death in the United States, claiming the lives of over 45,000 people. Suicide doesn't discriminate—it impacts people of different ages, races, and genders. In this episode, we talk with Dr. Arielle Sheftall, an associate professor in the Department of Psychiatry at the University of Rochester Medical Center. We learn about who is at increased risk for suicide, how it's impacting the nation's youth, and most importantly, what we're doing about this tragic and preventable issue.
ARIELLE SHEFTALL: So, for our kiddos, 5 to 9 years of age, it's the 10th leading cause of death. Just to think about that, it's quite devastating to be 100% honest, to think that a child that young could even have thoughts about suicide is very devastating, but it does happen. It's the 10th leading cause of death for that age group.
JOSHUA A. GORDON: In 2020, suicide was the 12th leading cause of death overall in the United States, claiming the lives of over 45,000 people. And suicide doesn't discriminate. It impacts people of different ages, races, and genders. The death of a loved one by suicide has profound impacts on a person's family, friends, and the larger community. Hello, and welcome to "Mental Health Matters," a National Institute of Mental Health Podcast. I'm Dr. Joshua Gordon, Director of NIMH. And today, we'll talk with Dr. Arielle Sheftall, an associate professor in the Department of Psychiatry at the University of Rochester Medical Center. We'll learn about who is at increased risk for suicide, how it's impacting the nation's youth, and most importantly, what we're doing about this tragic and preventable issue. Arielle, welcome, so glad to have you.
ARIELLE SHEFTALL: Thank you for having me.
JOSHUA A. GORDON: I'm just curious, suicide, it's a topic that can be challenging to talk about, much less devote one's career to, what made you become interested in studying suicide and suicide prevention?
ARIELLE SHEFTALL: To be 100% honest, I kind of stumbled upon suicide and suicide prevention. Originally, I thought I was going to be a medical doctor, but I realized chemistry was not my forte, so I had to change that pretty quickly. I went to Penn State for my undergrad. I studied biobehavioral health and had a minor in psychology. And I really enjoyed looking at problems from a behavioral, biological, psychological perspective. And I continued to just really enjoy that, and went on to Ohio State, and got my master's in Human Development and Family Science, and had all of this combined, and learned how mental health could be associated with different systems depending on where you are and what you're doing, and who you're interacting with. And it really opened my eyes, to be honest, about mental health. That was something that really excited me. And I happened to stumble upon Dr. Jeffery Bridge, at that time, who had just joined Nationwide Children's Hospital, and he was actually studying suicide and suicidal behavior in adolescence. And it really hit a nerve, to be honest. So, when I was 14 years of age, my mother passed away from cancer. And I started living with my grandmother. And during that time, I was starting high school, I was trying to figure out my life. You know, at 14 years old, my mom who was my best friend had passed away, and I was really lost. And I love my grandmother. I mean, I love, love, love her. And still, she's the strongest person I've ever known in my entire life. But, you know, we had a really big age gap. And I think, unfortunately, she just didn't quite understand what I was experiencing. And she was very smart, though, she actually had my older cousins check-in on me very often, because she knew that it would be better coming from my cousins at that time than from her specifically. And I went into this very deep, dark space, and started to have suicidal thoughts myself.
JOSHUA A. GORDON: Yeah.
ARIELLE SHEFTALL: So, I could relate to this study that Dr. Jeffery Bridge was doing. And I wanted to understand what was it about suicidal behavior during this stage of lifespan? How could we help individuals? How could we get the care for these adolescents so that they don't suffer? And what could we do on our end to help them to get through this space that I had, thank goodness, been able to achieve, and to be able to get through, but I had a lot of family help to get me through that really dark, dark space in my life. And some of those individuals, unfortunately, that I interacted with during that study didn't have that. And we had to be that barrier, so to speak, and getting those kids the help that they needed, and to make sure that the quality of care that they were receiving was high so that they can move on and get better.
JOSHUA A. GORDON: So, for you during your training, suicide prevention, it was professional, but also deeply personal.
ARIELLE SHEFTALL: Absolutely.
JOSHUA A. GORDON: I'd imagine that hasn't changed.
ARIELLE SHEFTALL: No, it hasn't. It really hasn't. I am very, very committed to the field. And not only because of my own personal experiences, but all the experiences that I've heard about. I've been in this field for, which is so crazy to believe, 17 years now. And I've been able to actually study suicide from different perspectives. But that's great, but hearing the stories from the families that I work with, that's even more motivation to keep going and keep striving, and keep doing better. And that is something that I take with me every single day. And if I can help one person, then I feel that I've done a good job and that I can actually keep on moving forward to help another one and another one and another one.
JOSHUA A. GORDON: Before we go any further, let's talk about language. What do we mean when we use terms like suicidal ideation or self-harm?
ARIELLE SHEFTALL: Yeah. So, suicidal ideation is just thoughts about suicide. So, those can range anywhere from something that's very passive, like just wishing you were dead, or all the way up to a thought that has a specific method in mind, with intention to actually act on that method. So, they can range, but it's really just a fancy way of saying suicidal thoughts. And then when talking about self-harm behavior, that is actually different in terms of suicidal behavior, just so everyone is aware. So, self-harm behavior, is when someone actually hurts themselves on purpose, but they do not have the intent to die. And usually, these injuries occur to help someone or a person to actually get the emotions that they're experiencing out, if that makes any sense. And some people actually indicate that they self-harm, because they feel so numb on the inside that they want to see something or feel something. Suicide attempt is when an individual will actually hurt themselves on purpose with the intent to actually die. That intent is what's really important. That intent to actually want to die has to be present for it to be a suicide attempt. And then suicide is what we would call someone that dies by suicide.
JOSHUA A. GORDON: We used to say someone committed suicide.
ARIELLE SHEFTALL: Yes.
JOSHUA A. GORDON: You use died by suicide, just then, and tell me why that's become a more preferred way of saying for either?
ARIELLE SHEFTALL: Yeah. So, back in the day, suicide was actually considered a crime. And that stigma continues to be present in our field of mental health and suicidal behavior. Like, so you commit a crime. You don't commit cancer. Like, you don't commit heart disease. People die from those things, and people die from suicide. And so, we actually have changed the language, so that we can get rid of that stigma, and actually start talking about the problem freely. And that takes the onus off of that person dying by a specific method versus them actually committing a crime and making it criminal.
JOSHUA A. GORDON: So, this something that happens to you because of an underlying illness. What are those underlying illnesses or risks? What increases the risk for suicide?
ARIELLE SHEFTALL: So, there are a ton of risks that are associated with suicide, and they vary from person to person, though some of those can be mental health concerns. So, for instance, depression, bipolar disorder, schizophrenia, and substance use disorders, but some can be chronic health concerns, like diabetes, others can be financial concerns, divorce, relationship problems. So, risks can vary greatly. They can be genetic. So, we've seen that having a familial history of suicide and suicidal behavior has been associated with an individual having a higher risk for suicidal behavior or they can be environmental. Like, experiencing bullying, or being a bully actually puts you at higher risk for having suicidal thoughts and behaviors as well.
JOSHUA A. GORDON: What about the link between suicide and depression? We often think about suicide as a potential outcome from depression. But not everyone, right, who dies by suicide is depressed. Tell me about that link.
ARIELLE SHEFTALL: So, there are individuals in this world that suffer from depression. And there are individuals that unfortunately, who have depression who died by suicide, but that's not necessarily the case that once you have depression, that is going to be your cause of death. There is a higher association, yes. But individuals that suffer from depression don't necessarily have suicidal thoughts. So, there's different risks for different individuals. But there is a higher risk, unfortunately, for those who do suffer from mental health concerns. So, I focus on youth suicide, primarily. Depression is actually not the disorder that we're seeing that's associated with suicide death. What we're seeing actually is ADHD. So, Attention Deficit Hyperactive disorder. And those are in kids, you know, 5 to 12 years of age. So, it depends again, unfortunately, on what group of youth you're speaking of, or individual that you're speaking about when looking at the association between depression and suicidal behavior.
JOSHUA A. GORDON: So, bottom line suicide, suicidal thoughts, these are seen, yes, in individuals who suffer from depression, but also in individuals who suffer from other mental illnesses and other environmental conditions.
ARIELLE SHEFTALL: Yes, absolutely. Nobody is immune. And unfortunately, if you were to do a survey from around the world, you would find that a lot of people have had thoughts about suicide. It doesn't see race. It doesn't see age. It doesn't see sex. Anybody can suffer from suicidal thoughts and behaviors. So, I think we need to change our mindset a little bit in terms of thinking about this being a public health problem for anyone.
JOSHUA A. GORDON: How many people die by suicide in the US each year?
ARIELLE SHEFTALL: Yeah. So, that's a great question. How big is the problem itself? So, in 2020, suicide was the 12th leading cause of death, and it was the cause of death for about 44,000 individuals.
JOSHUA A. GORDON: Forty-four thousand? That's a lot of people.
ARIELLE SHEFTALL: Yes, it is a lot of people. Absolutely.
JOSHUA A. GORDON: How does suicide rates in the United States compare with the rest of the world?
ARIELLE SHEFTALL: Yeah. So, when you look at the rest of the world, we are not doing well. So, the World Health Organization collects data on suicide, though, for 184 countries. There's 195 in the world, so they get majority of the countries. When you compare all 184 countries, we are actually the 32nd for adults, which is pretty high. Our rate in 2019 was 14.5 per 100,000. And then when you look at Australia, it was like 11.3, United Kingdom is even lower at 6.9. And then Israel is even lower than that at 5.2 per 100,000. And when you look at youth suicide, it's even more horrifying, to be 100% honest. For the United States, we are actually 19 when you compare all the rates. Yeah, 19.
JOSHUA A. GORDON: Nineteen per 184.
ARIELLE SHEFTALL: A hundred and eighty-four.
JOSHUA A. GORDON: So, compared to the rest of the world, we've got a lot of work to do.
ARIELLE SHEFTALL: Absolutely.
JOSHUA A. GORDON: Changes in rates that you described, are those changes happening differently for different people, for different demographic groups?
ARIELLE SHEFTALL: So, suicide does differ depending on the age group. So, for 25 to 34-year-olds, suicide is actually the second leading cause of death. And then for our 35 to 44-year-old individuals, it's actually the third leading cause of death. And this differs even more when you start looking at youth. So, for children 5 to 19 years of age, that's the primary age group that I focus my energies on, it was actually the third leading cause of death in 2020. And it touches my heart even more now. I have young kids myself. I have a 6-year-old and a 10-year-old. And to think even that those thoughts have been on their mind is devastating.
JOSHUA A. GORDON: And it's rising faster in that age group isn't it than in other age groups? Yeah.
ARIELLE SHEFTALL: Yes. So, when you look at the breakdown, so over the past 20 years, for our teenagers, 13 and 19 years of age, so we've seen from 2000 to 2020, we've actually seen a 38% increase in that age group. But for our 5 to 12-year-olds, it's actually been 107%.
JOSHUA A. GORDON: Wow, that's more than a doubling in the rate of death by suicide in young kids.
ARIELLE SHEFTALL: Five to 12. And unfortunately, another area of my research looks at black youth suicide.
JOSHUA A. GORDON: Yep.
ARIELLE SHEFTALL: And unfortunately, we've seen that rate is even more drastic. For our black youth, 5 to 12 years of age, they're approximately two times more likely to die by suicide than their white counterparts. What's happening in this age group is that suicide seems to be the leading cause of death for black girls 12 to 14 years old. A lot of research to be done, a lot of work to be done.
JOSHUA A. GORDON: Do we know why these changes are happening? And in particular, do we know why these changes are happening differently for people from different groups?
ARIELLE SHEFTALL: The research, it's still pretty young in terms of where we are when looking at minority, so youth of color, individuals of color, to be 100% honest. Back in the day, suicide was really considered to be a white male problem, because again, the rate was the highest in white middle-aged men. So, a lot of research focused in on white men or white youth. And now we're starting to see, wait a minute, we lost a lot of opportunity here because we didn't focus in on these youth of color. So, we're still in the infancy of this research. We're trying our best. I think we have gotten a lot further than what we did in the past. But we still have a lot of research to do in order to understand what are those specific risks, and how can we actually intervene appropriately for youth of color?
JOSHUA A. GORDON: It's really important this research that you are doing to try to get at the causes of suicide, particularly, in young people. Rare, as you pointed out, we know that children as young as five die by suicide, which, to me, it's just truly heartbreaking.
ARIELLE SHEFTALL: Yes.
JOSHUA A. GORDON: What do we know about suicide in children that young? And in particular, maybe you can tell us, what should parents do if their young child, their 5, 6, 7-year-old child says they're thinking about killing themselves, or they have other thoughts of self-harm?
ARIELLE SHEFTALL: Yeah. So, I would definitely say no matter the age, we should absolutely 100% make sure we're taking every disclosure of self-harm or suicide or suicidal thoughts very, very seriously. And I know that can be very hard for parents to do even, you know, at this young age to even fathom that my kid is saying these words, actually speaking these words, and they actually mean these words. Because, you know, we never think. Never, ever would have ever thought that my five-year-old would think that they want to kill themselves or hurt themselves on purpose. We have to do something about it. As a parent, this is gonna be a very scary space that you're gonna be in, but we have to make sure that we get the kids, even at this younger age, the help that they need immediately so that we can make sure that they're okay. And that they can get off of that trajectory towards self-harm behavior, or towards suicidal behavior. So, we have to take it seriously every single time.
JOSHUA A. GORDON: Your research has shown that black youth, particularly very young black youth, have a higher rate of suicide than white youth. What do we know about this? What are the circumstances in the black community that might be contributing to this difference?
ARIELLE SHEFTALL: So, I will be 100% honest, black youth suicide was something that we kind of stumbled upon with myself and my colleague, Dr. Jeffrey Bridge. He received a phone call from a media outlet that asked him about a suicide death that had occurred in an 8-year-old. When we started to break the data down by race, what we found is that for our black males, they actually had a significant increase in their suicide rate versus white males. So, we started to dig a little bit more. And he did the analysis over and over and over again because couldn't believe what he was seeing. And then he asked me to do it, and it was the same results, unfortunately. And yeah, it was just something that we weren't understanding to be 100% honest, but we knew it was important for us to report. And what we found is that for black youth, specifically, 5 to 12 years of age, they were about two times more likely to die by suicide compared to their white counterparts. So again, why? That's the big question. So, when I started to think about the problem, when I started to sit down and really do some introspective work, so to speak, I started to think, what are those risk factors that black youth may actually experience that white youth don't necessarily? Well, one of them, unfortunately, is racism, discrimination, right? And recently that has been shown to be associated with suicide, death, suicidal behavior, suicidal thoughts. So, I think that is one of the risk factors that may be playing a role when you look at suicide rates and suicidal behavior in black youth. And I think, unfortunately, the environment that we live in right now is not a safe space for black youth, specifically, or youth of color, specifically.
JOSHUA A. GORDON: Which the reason why we ask questions about why things are happening because we wanna do something about these disparities, and about suicide deaths in general. Are there ways that we know of now to reduce suicide deaths?
ARIELLE SHEFTALL: That is absolutely the reason why we ask these questions, right?
JOSHUA A. GORDON: Right.
ARIELLE SHEFTALL: We wanna do something. We want to change the trajectories that we're seeing, these trends that we're seeing, and I think unfortunately, the research is still not done to be able to say, "Oh, yeah, use this prevention program, or use that prevention program." But I do think there is hope. And I think that's why I still am in this field to this day is because I think that number one, suicide is preventable. Everybody can prevent suicide no matter who you are, no matter how old you are. But I think also there are some promising avenues for preventing suicide. I think in terms of youth suicide, there have been programs that have shown good promise. So, Signs of Suicide is one of them. And they actually, I believe, are starting to take the Signs of Suicide and bring it down to elementary school age.
JOSHUA A. GORDON: Tell us more about Signs of Suicide, what is it?
ARIELLE SHEFTALL: So, it's a school-based program, specifically. And you educate everybody from the top to the bottom within that school setting. So, it's the principals, the counselors, the teachers, the cafeteria staff, the environmental services staff, the students. You are telling them all about what are the signs that they should be looking for in any individual that they interact with that is concerning and that they should act upon. So, these things could be, you know, isolating themselves, like not answering your text messages anymore than what they used to. Acting differently, giving away possessions. Things like that that just spark, like, this isn't right, behaviors have changed. So, it educates the entire school on these behaviors. But not only that, it tells them what to do when they see these behaviors present. But it also brings the parents to the table as well. So, it educates the parents of the students also. So, you basically are creating a system of prevention within one school setting that can go outside of the school into the family setting.
JOSHUA A. GORDON: Maybe it's the fact that you've been there yourself that helps you understand that reaching out to kids and talking about suicide is a helpful thing rather than a dangerous thing. Many of us are reluctant to talk to anyone, much less children about suicide because it's a scary thing for us to think about. We worry that we're gonna cause them to think about it. We're gonna impact them that way. So, just the fact that you intuitively understand that kids wanna talk about this stuff, and they appreciate learning from you more about suicide, I mean that's powerful.
ARIELLE SHEFTALL: Yeah. And there's actually research out there that says that if we talk about suicide, that does not put the thought of suicide in a child's mind. There's research out there that supports that argument. It actually gives an opportunity for a kid to feel like, oh, I can talk about these things with you. And I can actually be very honest and open with you about not only this but other kind of risky behaviors that they might be doing or might be thinking about doing, right? So, we have to break that barrier. We have to understand that this does not put those thoughts in that child's mind. If the thought's there, the thought's already there. And us not knowing that the thought is there is what actually does more damage than good.
JOSHUA A. GORDON: You've now mentioned research several times throughout our conversation. NIMH has been supporting research now for 75 years.
ARIELLE SHEFTALL: Yes.
JOSHUA A. GORDON: A lot of that in the suicide and suicide prevention research field. What has been NIMH's role from your perspective, and how far have we come in terms of understanding or preventing suicide?
ARIELLE SHEFTALL: Number one, NIMH is the number one funder in the government world when it comes to suicide prevention and research. So, if NIMH wasn't present number one, my research couldn't be. It couldn't be. So, I'm very grateful for that. And thinking even way back in the day, where suicide was this taboo topic, where we didn't want to talk about it because again, we had all these thoughts about, well, if we talk about it, it's gonna open this big can of worms, and people will become suicidal. Well, no, I think NIMH has actually made that very clear that talking about it is necessary, and that we need to continue to have this conversation. We can't just, you know, brush it under the rug. And I think unfortunately, that's been the case for many years that we've kind of brushed it under the rug, that suicide doesn't really exist, and that we don't really wanna talk about it because it'll bring up other things. So, I think NIMH is absolutely the one that's driving the conversation, and making sure that you are all working with other institutions and other organizations to make sure that people understand that suicide is a public health concern, and we have to do something about it.
JOSHUA A. GORDON: Is there anything you think the field could do better when it comes to studying suicide and supporting the work necessary to study it?
ARIELLE SHEFTALL: So, I think engaging community, getting community organizations to be at the table to give you input about your own research ideas, to actually listen versus just talking to, and to gain insight from the community because they're the ones that are on the ground and working with these families, and working with these youth, and understand the problem probably a little bit better than what we do. And I think they are the insiders. And having their input, and being able to hear what they have to bring to the table, and to help actually form our research ideas can be extremely beneficial, and I think will play a big role in actually changing the trajectory that we're seeing. The other thing is the youth voice, which is something we haven't done in the research field. We have not done a really good job at listening to youth that have lived experience, and understanding what we can do better. And understanding what that experience was like when they did have suicidal thoughts. What were those experiences that they had prior to suicidal thoughts? What happened when they were hospitalized for a suicide attempt? What was that experience like for them? And gaining perspective from the youth themselves is something I think, again, will help us change the way that we look at the problem, and also give us some insight on where to go in terms of intervention and prevention programming.
JOSHUA A. GORDON: Have you been involved, personally, in some of this research in these kinds of evidence-based approaches?
ARIELLE SHEFTALL: Yeah. Actually, I have. And that's why I say Signs of Suicide. But there are other ones out there as well. But Signs of Suicide when I was in Columbus, Ohio, at the Abigail Flexner Research Institute, we in the center have a prevention arm, which is actually educating schools in central and southeastern Ohio. So, we actually have a whole team that was dedicated to going into schools, doing the Signs of Suicide training program, and then also implementing the program, and then training the trainer's so that they could keep the program going. So, I was actually involved in that program. And we were also involved with Boys and Girls Club. So, actually taking the Signs of Suicide program and implementing it into the Boys and Girls Club in Columbus. And trying to figure out how can we take that program and make it more community-based.
JOSHUA A. GORDON: What was that experience like for you to be involved in an effort to really develop something that can make a difference?
ARIELLE SHEFTALL: You know, that was the best feeling. It really was. And don't get me wrong, I love that NIMH funds my research. And I love that, and I love doing what I do. But getting on the ground and actually talking to kids, and talking to individuals that are talking to kids every single day, and giving them those tools to have in their tool belt to actually prevent suicide, that is like one of the best feelings in the world.
JOSHUA A. GORDON: I wish that our listeners could see your face right now, and how animated it is, but I'm sure that they can hear it in your voice. Working with kids, talking to them about suicide, it clearly drives you.
ARIELLE SHEFTALL: It does. It really does. I've been there. I've been there. And I don't want people to believe that means I know everything. That's not true. I don't know everything. This was my experience. These were my circumstances. But I don't want people to feel like they're alone in those experiences that they're having. And the more that I can do, the more that I can share my own story, the more that I can be present to give individuals ideas about what they can do for their friends and their family members. I feel that goes further than anything else I can do on the research side of the world.
JOSHUA A. GORDON: Dr. Sheftall, thank you for joining us today.
ARIELLE SHEFTALL: Thank you for having me. I'm very honored.
JOSHUA A. GORDON: This concludes this episode of Mental Health Matters. I'd like to thank our guest, Dr. Arielle Sheftall, for joining us today. And I'd like to thank you for listening. If you enjoyed this podcast, please subscribe, and tell a friend to tune in. If you'd like to know more about suicide, please visit nimh.gov. We hope you'll join us for the next podcast.