The Last Word On Nothing

Note: This post is about suicide, so please skip it if you’re not up for that right now. 

Last month we lost a friend of ours, a seventeen year-old girl. My first impulse when I got the call was to clean our house. I didn’t know what else to do. There was nothing to do, except make some room for the grief that would be moving in and staying for a while. 

Natalie is the third teenager in our small community to die by suicide in as many years. To my husband Pete, her kayaking coach, she was like a goofy little sister. She was gutsy and competitive, the fastest runner on her track team. Her absence has settled over our lives like wildfire smoke, changing the light and air. The grief counselor said we shouldn’t blame ourselves, or anyone. It’s no one’s fault. But it is hard – impossible, really – not to wonder if there was anything we could have done differently, or better.

As a neuroscience reporter, I have interviewed dozens of researchers who study suicide. Since Natalie died I have been rereading some of those transcripts to see if they can help me understand what happened. They don’t tell me much. The number of researchers studying suicide in teenagers has exploded in recent years, probably in response to a steep rise in suicide deaths since the mid-2000s, but it’s still a young field. 

One well-established fact is that suicide increases sharply all over the world when puberty hits. It is relatively rare in children, but at around age 11 it increases “precipitously, not just in the United States, but in literally every country in the world,” clinical psychologist Adam Miller, of the University of North Carolina, told me. There’s no comparable pattern for adult suicide, which varies quite a bit between countries and cultural contexts and can strike at any age, he said. 

The spike in suicidal thoughts, attempts, and deaths may have to do with changes in brain regions that regulate our hormonal responses to stress, and social stress in particular. During puberty teenagers develop an exquisite sensitivity to social rewards and punishments, like being praised or shunned. All of that happens before the neural circuits that help us temper those feelings and keep them in some kind of reasonable perspective are fully developed. Maybe you know the feelings I’m talking about. Those excruciating, crawl-out-of-your-skin, things will never be ok feelings.

Miller’s lab sounds like my worst high school nightmare. To test their responses to social stress, he and his colleagues ask kids to do things like give impromptu speeches about their social lives in front of stony-faced judges, or be evaluated by a hidden (purely fictional) peer who watches them silently from another room then decides whether or not they want to hang out. The invisible peer invariably rejects them, swiping left. Miller has found that the teenagers who struggle to regulate their emotions after this kind of rejection have abnormal hormonal stress responses, and are at higher risk of suicidal thoughts and self-injury.

Many of the risk factors for suicide are clear-cut, like depression, access to weapons, or a previous suicide attempt. Others are only tenuously linked to teen suicide, like hyper-critical parents. The challenge for people who want to know which kids need help is that nearly all of these risk factors for suicide have quite small effects. Even among kids who have made a previous suicide attempt, one of the most potent risk factors, very few die.

Natalie was a high-risk kid. She’d been struggling with depression for at least a year and had made several previous suicide attempts. We knew her mental health problems were severe, but still thought she had a good shot at recovery. She had lots of the protective factors that are supposed to help: therapy, medication, adults and friends who cared about her. She was smart and well-liked, and did the activities she loved, like baking, kayaking, and running, with gusto. In the weeks leading up to her death, most people she interacted with said she seemed happy. Her friends and mentors, Pete included, thought she was getting better. 

A few days after Pete left for an out-of-service trip in July, I found out she had died. Over the next days and weeks, our friends came over and we sat on the floor, eating bowls of chocolate ice cream and lasagna. We forgot what we were saying mid-sentence and left our keys in weird places. Some of us couldn’t sleep or slept too much, had nightmares. We encouraged each other to focus on the basics – sleep, food, exercise – and tried to function normally at school and work. It was strange and kind of eerie, we all agreed, how relentlessly life kept going.

We probably won’t ever know why she died. Miller says that when teenagers hurt themselves, it’s often when they’re experiencing more stress than usual, and don’t have the skills to regulate their emotions or impulses. What matters is not how stressful the experience is, or whether anyone else would find it stressful– some teenagers attempt suicide after failing a quiz, while for others the trigger might be sexual assault, he said. The stress just has to exceed a teen’s ability to cope in the moment.

But emotional regulation techniques can be learned. Miller thinks that if we could teach at-risk teens skills that help them tolerate seemingly intolerable moments, it would prevent at least some deaths. He and other researchers want to develop smartphone apps that can monitor teens’ stress levels through indicators like their social interactions, the tone of their voices, and the shape of their pupils. The apps could alert family members or doctors when teenagers are at higher risk of hurting themselves, and guide them through moments of crisis. Frankly, I have a hard time imagining any teenager agreeing to that level of surveillance, including Natalie. But Miller says that in his experience, nearly all teens who are really suffering from suicidal thoughts feel relieved to tell someone about them. 

We don’t know much about what else Natalie was dealing with in addition to her depression, or if she had another diagnosis. We don’t know what happened on the day or the moments before she died, or if anything  –  a text from a friend, a phone app alert, anything – could have made a difference. Many researchers are (understandably) wary of studying teen suicide because they are reluctant to assume the ethical responsiblity for vulnerable teenagers’ welfare if they can’t provide adequate mental health care or follow-up. But it’s good that more scientists are starting to study it more, because they have learned a number of important things.

One is that it is possible to lower the rate of teenage suicide in schools. A school program called Signs of Suicide (SOS), for example, pairs education about mental illness and suicide with a questionaire that screens for suicidal thoughts and behaviors. It has been evaluated in studies involving thousands of kids in schools across the country, and in some cases has reduced teen suicide attempts by 40-60 percent. 

Another is that it is not enough to “raise awareness” about suicide. To reduce deaths, most experts agree that we need to ask kids whether they’ve had suicidal thoughts or attempts through some kind of screening. Researchers have debated whether screening for suicidal thoughts and behaviors might actually increase them. But the studies that have been done so far suggest that they don’t, and universal suicide screening for teenagers has now been recommended by a number of groups, including the American Academy of Pediatrics.

Some teenagers won’t answer screening questionnaires truthfully, but others will. One in five teenagers told the CDC they’d contemplated suicide during the pandemic. Most of them won’t die of suicide, or attempt it, so the next important question is how to figure out what proportion of that groups needs immediate mental health care and make sure they get it. This is especially difficult right now, with the shortage of therapists and psychiatrists. But there are some promising ideas for how to triage at-risk teenagers. One is a new machine learning-based tool called CASSY that was designed for use in emergency rooms as a way to assess how likely adolescents who had attempted suicide are to try again. In clinical trials, CASSY accurately identified more than 80 percent of teens who went on to attempt suicide in the next three months, rating their risk on a scale of 0-100. The tool could help ER doctors decide which teenagers can safely be sent home, and which ones need immediate treatment and careful monitoring.

In August, we attended the river version of a surfer’s farewell for Natalie, tossing yellow roses onto the water while people made a circle with their boats. I had a hard time participating in the ceremony, which was meant to be a “celebration of life” instead of a funeral. It didn’t feel celebratory, just unbearably sad. Later we learned that Natalie wrote down detailed instructions for distributing all her favorite possessions. She left Pete her kayak.

Since Natalie’s death, I’ve been trying to think of ways to show up for the teenagers in my life, even though I’m not a medical professional or parent. One is to celebrate the good stuff with them more often: barbecues, new babies, music. Rather than focusing on the catastrophes the world is facing, maybe I’ll talk more about all the reasons a teenager might want to survive them. 

Here are some other, more practical ideas.

-Tutor, mentor or coach at a local high school, club, or youth shelter – that CDC study found that kids who felt connected to someone at school or elsewhere were much less likely to attempt suicide than those who felt alone.

-Get certified in Mental Health First Aid, and learn about interventions for managing suicidal crises from organizations like the American Foundation for Suicide Prevention.

-Walk with others who’ve lost friends and family members during National Suicide Prevention Week, starting on September 4th.

-Tell people about the new, three-digit suicide hotline, 9-8-8. If you’ve never called a suicide hotline, and you need help or know someone who does, I highly recommend trying – you can call them just to get advice.

I hope you’ll share your own ideas in the comments.