Nathan Abse interviews Dr. Asim Shah, Chief Psychiatrist for Harris Health in Texas and a leader in public mental health for Houston's 5 million people. Shah discusses our country's rise in suicides—and how feds and their families can help stem the tide. In distress? Dial 988!
Suicide—even before COVID hit the U.S. in early 2020—was rising fast and killing nearly 50,000 people per year in our country. This brutal toll, according to sources inside and outside of the medical community, has worsened still in the more than two years since we began suffering the worst contagious disease crisis in over a century. The pandemic plays a big role—directly it has killed over a million and led to sharply rising rates of economic and mental misery, in turn priming higher rates of mortality from psychiatric illness and suicide. Just over two years ago, federal employees were spotlighting campaigns such as “Out of the Darkness” suicide awareness walks to increase concerted effort to help those in distress and lower the numbers of deaths considerably. Just before the pandemic, Nathan Abse interviewed Dr. Asim Shah, Baylor College of Medicine’s Chief of Community Psychiatry and a major public health authority. This week, Abse follows up with Shah. The doctor lays bare the worsening stresses that have brought even more suicide attempts and suicide—and offers solutions we can all help with, and ultimately save lives.
Q&A with Dr. Asim Shah
Government statistics paint a grim picture. And the estimated numbers of completed suicides has only grown since I last talked to you in 2019, right?
Shah: Yes. Unfortunately, the problem has been growing in our society—quite clearly. Just since COVID, we see there has been around a 30% rise in E.R. visits in which there is suicidal ideation. Now, the reason I'm using the word “ideation” here, specifically, is that—look, the data on “completed suicides” is two to three years behind. That’s because official completed suicide data is collected really only after an autopsy, an analysis, and that data is just not current. As you know officially just before the pandemic we were getting around 47,000 to 48,000 suicides each year. Now that data is outdated. It’s at least a couple of years behind, right? So we don’t have exact data through the pandemic. But with ideation up, it makes sense that so too are completed suicides. We do not have 2020 and 2021 exact official data. But I have to say, if you are interested in exact numbers or rates of growth for this tremendous problem, we will never have the right suicide data—ever.
Why is that, doctor? Why is the data so far behind—and even that is an undercount, as you and other experts say?
Shah: First of all because we just are behind in adding up even the imprecise numbers, as I said. And to me, as to many others in this field, it is clear that the problem is growing worse. But secondly because so many people hide the fact that a family member or friend has died because of suicide. People hide it, all the time. Because of this, even when we catch up we will always have undercounted numbers. The data is always skewed.
The suicide epidemic is horrible—that’s why so many feds and others in communities across the U.S. want to help, whatever their jobs, to fight mental illness and suicide. Why is it happening?
Shah: I work in an E.R.—an extremely busy psychiatric E.R.—and I clearly see that the numbers of people coming in with suicidal ideation has gone up tremendously since COVID hit. Of course, right now, I would say that rate is lower today than it was in 2020 and 2021. That is because COVID and the stresses along with it are, at least for now, better. But we know that the financial struggles that started with COVID are still there—look at the inflation rate! Anything that was once five dollars is suddenly seven dollars, right? So many things now are more costly. All the financial strain, and other strains, hitting people since the COVID crisis, these don’t make it easy for a normal person to just get on with living their life.
So COVID and its health, economic and family pressures led to more mental illness and suicide?
Shah: It was already bad, but, yes, that is when it really worsened even more rapidly. All the stresses did and are continuing to cause problems, and the number of depression cases has increased. Anxiety has increased. So, those are some of the factors why the suicide risk jumped. Two big factors, then: One, financial. The other, other stresses, just that rate of depression and rate of anxiety increased—the rate of PTSD increased.
Where are we with suicide then?
Shah: Well, I can tell you suicide is the number two—number two!—cause of death in the U.S. in children and young people between 10 and 24. And, unfortunately, it’s again a major cause in those 34-plus. I have given you some of the reasons. But there are even more reasons for these increases in clinical signs. I think it’s clear that fueling suicides is there are many new and dangerous illicit drugs, and some older ones in larger numbers, coming into people’s lives, into the market. These are very dangerous and make matters worse. Obviously some of the newer illicit opioids—fentanyl and other drugs—are making a big impact.
Any other factors? Some say a significant part of this kind of suicide epidemic are sort of ‘accidental suicides’?
Shah: That’s correct. A large proportion of suicides simply involves a kind of increased recklessness, leading to seemingly accidental deaths. The problem is that when you combine the immaturity of a young person—could be a 14 year old, or a 20 year old or even older—often they are still immature, and kids to me. Take that person, with the kid’s maturity issues, and you combine it with their mental and emotional problems and add substance abuse—and really soon there are more suicide deaths. Whether their drugs are alcohol, opioids, meth, or whatever. Suicide is an act of impulsivity. People must understand this. When you combine that immaturity with acts of impulsivity, what is tragically often the result? A completed suicide—that is what we call it. So, is it accidental? Is it something they planned? It might be both. But so many of those suicides whether or not they appear “accidental,” the people they involve, even in that moment, do not want to die. But because they are impulsive, and take dangerous risks, they do. And very, very often it is of course that they are under the influence of something, powerful drugs or alcohol or all of that together.
Alcohol is still common in suicides. But it’s opioid-related deaths that have doubled quickly, to over 100,000, right? Do you note a spike in Texas suicides, accidental or otherwise?
Shah: Of course, yes. But opiates—opioids—in Texas are just not as commonly the drug involved. In Vermont, New Hampshire, and the Northeast—those are some of the areas with more of the worst opioid abuse and deaths. But in Texas, we see more cocaine and meth, and just like in other states, we see alcohol and marijuana, like all over the country, right? In Houston, we see more cocaine, and in the countryside more meth. Do you know what else many doctors like me see as a big problem? Vaping.
Shah: Yes. All this nicotine, it’s very addictive and it is adding to the depression and anxiety—and so ultimately to the illnesses that are driving suicides. In the past many doctors, and we all, used to say that marijuana is often the gateway drug. Well, now vaping is that.
So whatever people—often young people—start to use to change their brains and states of consciousness and get addicted to, and now that’s vaping that they often start with?
Shah: Exactly. Yes.
Here’s the question: What can regular people and feds of all kinds do to help?
Shah: Well, your audience are in government. First thing I’d say to them is that government needs to stay involved here, to be part of regulating all these newer forms and spreading drugs. So, for example, we see marijuana and cannabis being “legalized.” But you know, that doesn’t mean we should legalize it the way it is happening many places. Look at other drugs people abuse. Like opiates? Doctors still prescribe Vicodin or Demerol and other potentially dangerous medicines—these are still legal forms of opioid, with legitimate uses, right? But if we want to use marijuana for its medicinal value—many possible indications—in theory it’s good to make marijuana legally available. But it should be regulated. Like, regulatory agencies, FDA and the like. We should not, as a country or by states, be making it legal the way it is being done now. People—including young people—are getting powerful drugs of many kinds from mom and pop shops, often for just so-called “legal” purposes. The free-for-all is in many places just adding to complete disaster.
With the spike in health problems—COVID—and suicides, do you see greater consciousness among organizations, clubs, corporations, charities—of wanting to pitch in and help somehow?
Shah: You mean compared to a couple of years ago? With some of them, yes. But with many others, no. But I do see greater awareness of mental health and suicide crisis today than even a year ago. So, though COVID has been horrible, that awareness has been good.
But it’s a terrible situation, with more suicide, suicidal ideation and mental health issues, since the pandemic—with economic and family circumstances shaken. You recommend regulation of cannabis and vaping. But what can regular people—feds or workers at companies—do?
Shah: I think people need to push their government, elected government, to do these things, and more. Government needs to help more, to be a steward of mental problems. The problems are starting before age 14. Half or more of them begin before 14. So, we all can help and intervene more at the school level. We can educate kids and families more. About substance abuse. About mental health issues. Honestly, in most schools and towns and cities we are doing nothing on substance abuse, no serious effort. This is a gem hiding, waiting to be found. We need to use these methods to go after the problem in kids before it starts. Government is a big part of that.
Focusing on suicide, are there other “gems waiting to be found,” that might help?
Shah: Yes, absolutely. But many are even more political. Starting with dealing with guns. Some gun controls. Look so many people are dying of suicide—and more than 50% of suicides now involve guns. We cannot continue to ignore this, to fail to act on this. Another problem that raises political issues: There are far too many psychiatrists and psychologists who insist on cash or its equivalent. Many got public funds and loans to get educated. We should leverage that, require them to take insurance, and less cash, in exchange for loan relief.
So with so many people dying of suicide, what should everyone know about this tragic problem?
Shah: The first thing to remember is that the number one predictor of future suicide is previous attempts, ideation of suicide. And every year, we have so many suicide survivors, because luckily, more people attempt and less people complete the suicide. People need to be aware of this. We must all focus and help, especially those people who attempt or show signs. They’re the ones who otherwise will attempt again. And one more thing. We had one very big victory this year, in July, when finally we created a universal crisis intervention number for mental health: simply dial 988. Similar to 911, but for mental health. So easy to remember—for yourself or anyone who needs help: dial 988.
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