Does Robin Williams’ Suicide Represent a Larger Mental Health Crisis? Professor Dana Alonzo

When the news broke of Robin Williams' tragic death by suicide, many of us at the School of Social Work wondered what Professor Dana Alonzo would have to say. She has conducted research in the field of suicidology for over 15 years and recently received funding to engage scholars and practitioners in developing new interventions aimed at reducing suicide risk by ensuring that patients adhere to mental health treatments. Professor Alonzo kindly agreed to answer a few questions posed by the director of the School's Office of Communications.

Hi, Professor Alonzo. I know you were quoted in some of the ABC News coverage about Robin Williams’ death by suicide, as someone who felt that it highlights the rising risk of suicide in our country.
The death of beloved actor and activist Robin Williams is a tragedy for his family, friends and fans. At the same time, I think it is indicative of a larger public health crisis. Suicide rates in this country have increased dramatically over the past decade. Between 2006 and 2011, the age-adjusted death rate from suicide grew by more than 11 percent. We are now at approximately 40,000 suicides annually.

I understand that men of Williams’ age are part of that group?
Yes, although suicide has been viewed traditionally as a problem among the youth and elderly, between 1999 and 2010 the rate among middle-aged Americans rose 28 percent.

From my own reading, I see that suicide cuts across all socioeconomic groups, religions, ages, and geographic regions—but are there any particular risk factors?
Depression and substance abuse are key risk factors for suicide across all groups.

Williams had both of these factors going against him. Why didn’t he seek help?
Approximately 90 percent of individuals who die by suicide have a potentially treatable mental illness, yet very few of them seek treatment. Of those who do seek outpatient psychiatric treatment, most terminate the treatment program prematurely. In fact the majority (around 60 percent) drop out of therapy after just one week.

What makes them drop out?
Several studies have found impairment in the decision-making ability of those who attempt suicide. In addition, because suicidal individuals often view themselves and the world very negatively, they have difficulty forming accurate, adaptive mental representations of the problems they are facing and hence what action needs to be taken to improve their situation. This could account for why engaging in treatment is so difficult. Suicidal individuals are inclined to drop out of treatment because they 1) fail to identify treatment as a possible solution to their problems; 2) hold negative/biased attitudes towards treatment based on prior experiences; and 3) do not anticipate that treatment could lead to a positive outcome even when the therapist and others have identified it as a potential solution.

How good would you say our methods are of treating suicidal patients these days?
In the past ten years, as the suicide rate has been climbing, we’ve made great strides in improving the pharmacological treatment of the psychiatric disorders most often associated with suicide. We have also been pioneering evidence-based practices to reduce the likelihood of depressive episodes leading to suicide. However, to date, we have been more focused on how to reduce the number of suicide attempts when we should also be studying better ways to engage individuals with suicidal tendencies in treatment, especially given what we know about their overwhelming tendency not to seek, or adhere to, such treatment due to their impaired decision-making faculties.

When a famous person commits suicide, many people worry they should be doing more to ensure this doesn’t happen to their nearest and dearest. What would you say to them?
There is no one sign or symptom that indicates when suicidal thoughts/feelings may be present. All I can say is that if you know someone who is struggling with depression and/or substance abuse, and that person is expressing feelings of helplessness, hopelessness, or worthlessness, this is an important warning sign. Other warnings signs include extreme feelings of guilt, isolating themselves from loved ones, giving away possessions, and suddenly seeming happier or calmer. The most important advice I can give is not to feel scared to talk about suicide with your loved one because you’re afraid you might be giving them the idea. This is one of the biggest myths. Encouraging the person to talk about their thoughts and feelings serves to provide an outlet for the their fears, concerns, and emotions. Just be sure you ask the questions in a simple, caring, non-judgmental way.

What kinds of questions should you ask them?
Important questions to ask include: Have you ever felt so bad that you have thought about suicide? Have you thought about when you would do it? Have you thought about how you would do it? Do you have a plan to commit suicide or take your life right now?

What about if someone in your family has committed suicide. Do you have any advice for how to cope?
Until recently, it was thought that family survivors of suicide experienced no more difficulties than survivors of other forms of traumatic deaths, such as accidents or natural disasters. However, recent research indicates that family survivors of suicide (on average, there are six per suicide) experience heightened feelings of rejection and responsibility, and their grief process may be complicated and prolonged. They may struggle to find a reason for the action of their loved one, which gives them feelings of powerlessness and helplessness, along with depression, self-directed anger and shame for missing possible signs and/or being unable to prevent the suicide.

What do you mean when you say that families experience “heightened feelings of rejection”?
Our society imposes some stigma on families after one of their members commits suicide. Or, to put it another way: suicide-bereaved individuals receive more blame from those around them than non-suicide bereaved. They are thought of as less likeable and more blameworthy.

Finally, can you recommend any resources for those who are coping with suicidal thoughts or the death of a loved one as the result of suicide?
For individuals struggling with suicidal thoughts and feelings, concerned loved ones, and family/friend survivors of suicide, there are numerous resources that may be accessed for support and guidance. Some of them include:

• American Foundation for Suicide Prevention
• The Samaritans of New York, the only community-based organization devoted to suicide prevention in the NYC-Metropolitan area.
• Didi Hirsch Mental Health Services (Suicide Prevention Hotline): 877-727-4747
• The National Suicide Prevention Lifeline (24/7): 800-273-8255
• Crisis Text Line: Text LISTEN to 741741

Thanks so much, Professor Alonzo, for such an helpful and informative exchange. I think we've also ended up learning a great deal about your work on suicide intervention, a considerable bonus.

—Conducted and edited by ML Awanohara

All statistics cited by Professor Alonzo are from the Centers for Disease Control and Prevention. The image of Robin Williams was taken by Chad J. McNeeley, U.S. Navy (CC BY-NC-SA 4.0).

Suggested readings for social work students:

• Bailley, S.E., Kral, M.J., & Dunham, K. (1999) Survivors of suicide do grieve differently: Empirical support for a common sense proposition. Suicide and Life Threatening Behavior, 29, 256-271.
• Calhoun, L. G. & Allen, B. G. (1991). Social reactions to the survivor of a suicide in the family: A review of the literature. Omega, 32, 95-107.
• Cleiren, M. & Diekstra, R. (1995). After the loss: Bereavement after suicide and other types of death. In B. Mishara, (Ed.), The Impact of Suicide (pp.7-39). New York: Springer.
• Lawrenson R, Tyrer F, Newson R, Farmer RDT. The treatment of depression in UK general practice: Selective serotonin reuptake inhibitors and tricyclic antidepressants. Journal of Affective Disorders. 2000;59:149–157.
• Lenze E, Miller M, Dew M, Martire LM, Mutsant BH, Begley AE, Reynolds CF. Subjective health measures and acute treatment outcomes in geriatric depression. International Journal of Geriatric Psychiatry. 2001;16:1149–1155.
• Lester, D. (1993). Challenges in preventing suicide. Death Studies, 18, 623-639.
• McFarland B, Klein D. Mental health service use by patients with dysthymic disorder: Treatment use and dropout in a 7½ year naturalistic follow-up study. Comprehensive Psychiatry. 2005;46(4):246–253
• O’Brien G, Holton A, Hurren K, Watt L, Hassanyeh F. Deliberate self harm and predictors of outpatient attendance. British Journal of Psychiatry. 1987;150:246–247.
• Silverman, E., Range, L., & Overholser, J. (1994-95). Bereavement from suicide as compared to other forms of bereavement. Omega, 30, 41-51.