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Dangerous shifting narratives around suicide

The suicide of Princeton economist Alan Krueger last weekend is a reminder that self-harm remains an American health crisis and that professional success in no way insulates people from the danger. Krueger, after all, had served as chairman of the Council of Economic Advisers under Barack Obama and was widely viewed as one of the leading labour economists of his or any generation.

The data suggests that white and middle-aged Americans are the demographic groups most at risk for suicide. So, in one sense, Krueger’s tragedy fits the prevailing pattern — as did the deaths last year of celebrity chef Anthony Bourdain and fashion designer Kate Spade. In general, suicide rates among whites are about three times higher than for blacks and Latinos.

Between 1999 and 2017, American suicide rates increased by 45 per cent for men aged 45 to 64 and by 62 per cent for women in that age group. As a result, that cohort surged ahead of the 65-plus age group in absolute terms, with a suicide rate of 19.6 per 100,000 — producing, in effect, a new epidemiology of suicide.

There are many reasons for this rise, all of them important. But one undiscussed explanation is the subtle loosening of taboos around suicide. Surveys suggest that Americans in recent years are more likely to view it as an acceptable reaction not just to terminal illness, but also to life setbacks that are emotionally brutal but survivable. (That doesn’t mean these attitudes played a part in any specific recent suicide.)

Other trends have been more broadly reported. The media attention given to the deaths of high-profile people should not distract from rising rates of suicide occurring disproportionately among working-class and less-educated Americans. In 2014, the most recent year from which such breakdowns of data are available, men with only a high school diploma were twice as likely to die by suicide as men with a college degree. And although middle-aged men of all educational groups experienced rising suicide rates during the Great Recession, 2007 to 2010, since then rates for college-educated men have slightly declined, while those for men with only a high school diploma have continued to rise.

One much discussed explanation for the rise in working-class white suicide holds that this group has been hit especially hard by changes in the economic landscape: less-stable employment, growing inequality, and the disappearance of well-paying blue-collar jobs because of globalisation and automation. (Krueger himself sounded the alarm, too, on the effects of economic shifts in the United States.)

Dairy farmers in the Northeast and coalminers in the Midwest — two groups that experienced upticks in suicides in recent years — have seen their expectations for prosperity and stability change for the worse. Members of minority groups are hurt by inequality, too, of course, but one theory is that these economic shifts are more jarring for white men, who had long enjoyed a more stable societal perch.

Yet, the possible cultural component of the suicide epidemic demands close attention, too. Research suggests that Americans are becoming more tolerant and accepting of the practice. In some contexts, many Americans may find this tolerance benign — as with suicide, or even assisted suicide, in the end stages of a fatal disease — although that practice has strong critics, too.

Other attitudinal shifts may be more plainly troubling. One way to track these views is through the General Social Survey, which, since its inception in 1972, has asked a nationally representative sample of Americans about their attitudes towards suicide. In an analysis of changes in attitudes from the 1982-86 period to the 2010-16 period, Tony Yi, now a medical student at SUNY Downstate College of Medicine, and I found that the share of Americans aged 18 or older who said people have the right to end their lives in the case of an incurable disease rose from 46.9 per cent to 61.4 per cent. The percentage who said that being “tired of living and ready to die” was a reasonable rationale for suicide jumped from 13.7 per cent to 19.1 per cent. And roughly 11 per cent of Americans in the later period said that suicide was acceptable during a financial bankruptcy or if one had “dishonoured” one’s family — up from about 7 per cent, in both cases.

We know that attitudes towards suicide affect behaviour. Elizabeth Luth, of Cornell’s medical school, and I examined some 30 years of data on GSS respondents — about 35 per cent of whom had died since their interviews — and found that expressions of suicide acceptability were predictive of subsequent death by suicide. Beliefs that suicide is acceptable under certain social circumstances — family dishonour and bankruptcy — had the strongest effects on mortality.

Reducing stigma around suicide can be positive — if it means that distressed people become more likely to seek help, for instance. But when and if the belief spreads that the act is acceptable under some conditions, even terminal illness, that may have ramifications we don’t fully understand. We need more research to figure out what messages destigmatise suicide in the good sense, opening the doors to life-saving conversations, and which ones “normalise” it as a response to crisis, with deadly consequences.

Much essential academic and prevention work on suicide is focused on biological and psychiatric explanations. Indeed, mental illness underlies the vast majority of suicides. Yet, larger social and cultural forces are at work, too, and, so far, the major funding agencies that support the study of suicide have paid less attention to these factors. Part of our national conversation on this difficult topic must confront the fact that an increasing number of Americans think suicide is a reasonable remedy when extreme, but common, financial or emotional problems arise.

Julie Phillips is a professor and chairwoman of the sociology department at Rutgers University