Suicide Prevention and Intervention

Editor's note: This second of two related articles features information and discourse on suicide. Please use discretion with regard to reading and sharing the story. Anyone showing warning signs for suicide or observing those signs in another person can call the National Suicide Prevention Lifeline 24/7 at 800-273-TALK (8255) or access the Lifeline Chat to connect with a crisis counselor online, 24/7.

The COVID-19 pandemic provided the late Paul Baltimore, who worked as a history professor in the Los Rios Community College District in Sacramento, California, with "something tangible" to talk about, a diversion from his primary source of suffering, according to his mother, Patricia. At one point, her son sequestered himself in his room and came out only for meals and a Christmas gathering.

"He was diverting his real pain, and the real pain was the working conditions," Pat Baltimore said about her son, who took his own life in 2021, just prior to his 50th birthday.

Before ending his life, Baltimore made an effort to transform the systemic work-related issues within his institution of higher education. He joined the faculty union and advocated on behalf of his fellow part-time instructors, the contingent educators who are often called "adjunct professors" or "adjuncts." They work off the tenure track and are frequently hired at the last minute on short-term contracts without benefits for appreciably less pay than their tenured and tenure-line colleagues.

"There was a problem to be solved," Baltimore said about her son and his position in higher ed's two-tier system. "There were inequities to be dealt with. And that was his focus. I think the work-related issues were the final straw that broke his back."

During the last month and a half of her son's life, she said she was "grasping at straws," and his friends weren't sure what they could do or where they could go for guidance to help him.

Preventive research and practice

The Suicide Prevention Research Program in the Division of Services and Intervention Research at the National Institute of Mental Health (NIMH) has worked to improve the ability to identify people at risk for suicide and to develop and improve efforts to address suicide.

"NIMH recommends the use of evidence-based screening, assessment and treatment strategies to help reduce the risk of suicide across the life span," explained the program chief, Stephen O'Connor, Ph.D., who facilitated a workshop on advancing training in suicide prevention clinical care in November 2021.

Promising outcomes from the program's work thus far include two studies, one that demonstrated a significant reduction in suicide risk attempts among adults who seek treatment in an emergency setting and are provided screening, brief therapy and follow-up contacts, and another that demonstrated the effectiveness of dialectical behavior therapy (DBT) in terms of decreasing attempted suicide and self-injury among adolescents.

The relationship between suicide and mental health

The NIMH has a page of online resources to aid people in finding help for mental health.

O'Connor noted that research has shown treatments intended to reduce the incidence of suicide prove most effective when factors contributing to suicidal thoughts and experiences are prioritized.

"For example, it is possible for people who are depressed to resolve their suicide ideation and reduce their suicide risk while still experiencing depression," he explained. "This is what makes the suicide-specific treatments unique from those treatments that address mental disorders more generally."

In addition to identifying improvement in the "continuity of care" offered by service providers as critical to addressing suicide risk, O'Connor identified safety planning, follow-up phone calls and psychotherapies—cognitive behavioral therapy (CBT), for example—as approaches capable of lessening the risk of attempted suicide.

The precise connection between mental illness and suicide is not easy to unpack in every case, acknowledged Mark Mayfield, Ph.D., a licensed professional counselor who founded counseling centers in Colorado and is the author of "Help! My Teen is Self-Injuring: A Crisis Manual for Parents." Nonetheless, he noted the National Alliance on Mental Illness—which boasts some 650 state organizations and affiliates across the United States—remains a useful resource for connecting individuals, as well as their families and friends, with support for severe and persistent mental health problems.

A focus on socioeconomic and work-related pressure

As Mayfield emphasized, many people don't have access to adequate mental health services based on race and socioeconomic status.

"It angers me, and it's part of the stuff that we're working to reverse," he said, noting some insurance companies still don't cover mental health costs, and coverage for mental health care can be lacking with Medicaid, a federal and state insurance program for people below a certain income level.

In mid-April 2022, Richard Wolff, Ph.D., professor emeritus of economics at the University of Massachusetts, Amherst, drew attention on his YouTube program to a spate of suicides among nurses, stressing the root of what manifests as, or is interpreted as, a mental health crisis.

"Nurses are committing suicide in record numbers, and they have been now for a year, year and a half," Wolff said on the program, likening the situation to a previous wave of suicides at Chinese factories, such as those owned by the Taiwanese company Foxconn. In those factories, Apple products are assembled and an estimated 40 percent of all consumer electronics are manufactured in high-pressure environments where workers labor for excessively long hours for extremely modest pay.

"But I'm happy to report that the nurses are now organizing and trying to do something," Wolff said. "I want to say something about their situation, so it's understood. Some of the media accounts refer to the fact—I kid you not—that there's a mental health care crisis among the nurses. I would like, respectfully, to disagree. No, no, no. There's nothing wrong with the mental health of our nurses. What we have is a level of stress that no one should be subjected to."

Wolff noted that clinics should have been ready and adequately staffed with properly paid personnel to deal with expected viral outbreaks such as COVID-19.

"That's a system failure, not a nurse failure, not a mental health problem," he explained.

Changes are happening

A study published in April 2021 in JAMA Psychiatry found a significantly increased rate of suicide among female nurses in the United States during 2017-2018 compared to women in the general population. Among men, the suicide incidence rate was about the same for nurses and those in the general population.

Michael Odell, 27, a critical care nurse, started working at Stanford Health Care in California as the COVID-19 omicron variant surged. After he left work mid-shift around 4:30 a.m. one day in January 2022 and soon after ended his life, his friends and other nurses called for structural change. They're seeking support for medical workers affected by the increased and incessant exposure to illness and death during the pandemic, improved access to mental health care and less stressful work environments.

Several banded together to create "Don't Clock Out," a project to advocate for nurses with mental illness. The project also functions as an online crisis intervention platform and a resiliency network to help people in the nursing community who are considering suicide.

Similarly, Pat Baltimore is in the process of putting together the Dr. Paul Reed Baltimore Memorial Fund to honor her son and help educators who are stuck in precarious part-time positions and having trouble with expenses, as first reported by EdSource. She felt the impetus to do so immediately after learning about her son's death.

"The first thought that came to my head was, 'I can't let his pain or his loss be for nothing,' and I decided that day that I was going to, in some way, help other part-timers who were having struggles," Baltimore said.

She also calls the fund "Paul's Peeps," after the name of the messenger group formed by her son's supportive friends and because her son advocated on behalf of other part-time professors he regarded as his "peeps." The fund will promote suicide awareness while simultaneously highlighting the issue of abject working conditions. With Paul's Peeps, she wants to advocate alongside teachers' unions and professional organizations to secure equity and respect for the part-time community, according to the fund's mission statement draft.

In collective bargaining, the labor union representing nurses where Odell worked, the Committee for Recognition of Nursing Achievement, is seeking funds so nurses can spend $2,000 a year on mental health costs. It is also trying to address the staffing shortages that exacerbated burnout as the pandemic raged. The union's vice president, Kathy Stomberg, told NPR that Odell "had to have been suffering a lot to get to the point where not only wanting to take his own life but reaching the point where he abandoned his job in the middle of a shift."

Apropos of the socioeconomic challenges Baltimore faced as a college instructor and Odell dealt with as a nurse, BongKyoo Choi, M.P.H., Sc.D., authored a longitudinal study published in 2018 that indicated job strain and long work hours can be associated with moderate to severe suicidal ideation.

Choi, an assistant professor at the University of California, Irvine, School of Medicine, concluded that enhancing employee control at work (as advocates of system change continue to champion) and ensuring an optimal level of work demands, including 40 hours or fewer per week, may be an important strategy for the prevention of suicide in working populations.

Approaches to intervention

The Didi Hirsch Suicide Prevention Center in Los Angeles County offers specialized training for first responders, medical training for health professionals, clinical training for therapists, counselors, social workers and psychologists, and community training for adults and adolescents—and more.

"In partnership with the Los Angeles mayor's crisis response team, our suicide response team will go to the scene of suicide to provide immediate comfort or support," said Lyn Morris, L.M.F.T., who served as the senior vice president of clinical operations for Didi Hirsch Mental Health Services before becoming the chief operating officer during the summer of 2020.

Mayfield said the area in Colorado where he lives has a crisis response team, separate from law enforcement, which assigns a therapist to a unit to check on individuals who might be intending to harm themselves, an approach to police-free harm reduction that appears to be gaining traction elsewhere.

Anyone who is contemplating suicide or knows someone who is thinking about suicide can call the National Suicide Prevention Lifeline 24/7 at 800-273-TALK (8255) to obtain free emotional consolation from a live human being. By July 16, no matter where you are in the U.S., you'll be able to reach the lifeline by dialing only three digits: 988, a number that will then be available to call or to text. The Crisis Text Line, which can be reached by texting HOME to 741741, currently connects individuals undergoing painful emotional experiences and anyone who needs support with a trained crisis counselor who will text back.

The lifeline is not a single national call center. It's a network of state- and locally funded crisis centers, including 13 in California, Morris noted.

"Didi Hirsch's multilingual 24/7 Crisis Line is a leading member of the National Suicide Prevention Lifeline and Crisis Chat networks," she explained.

From 6 p.m. to 10 p.m. Pacific time, teens can talk to teenage counselors on the national Teen Line at 800-852-8336. Outside of those hours, Didi Hirsch crisis counselors adept at talking to teenagers take those calls, with an additional number, 310-855-4673. Individuals with web access who are unable to make a phone call can use Didi Hirsch's confidential online Crisis Chat to connect with a counselor.

If someone shows warning signs, Morris recommended first asking the person about their thoughts and then asking whether they have a plan.

"Listen fully, without judgment, and acknowledge their suffering," she advised. "Don't try to belittle it or act like it's not a big deal."

Morris also advised individuals not to leave a distressed person who is exhibiting warning signs alone and to encourage them—without coercing, it's worth qualifying—to reach out to a therapist or psychiatrist. If danger appears imminent, she recommended getting help via call, text or chat using the numbers or links above.

"Don't let them brush it off," Baltimore said.

She also urged people in need to accept help from friends, family and others who express concern. Baltimore wants individuals facing hardship and insecurities as her son did—whether it's an inability to take care of yourself, pay for food and rent, or find employment—to know they can communicate with someone, such as a counselor committed to empathizing with and helping people in crisis, and get through them.

"Somewhere in either your family or your group of friends, there is someone who cares and someone who will understand," Baltimore said. "Open up and reach out to them. Don't go through this alone."

Anyone showing warning signs for suicide or observing those signs in another person can call the National Suicide Prevention Lifeline 24/7 at 800-273-TALK (8255) or access the Lifeline Chat to connect with a crisis counselor online, 24/7.