40,000 suicides annually, yet America simply shrugs

Standing high above the San Francisco Bay, perched on an I-beam outside the Golden Gate Bridge railing, the man dressed neatly in khakis and a button-down shirt hesitated.

Kevin Briggs stood a few feet away, imploring him not to jump. In nearly 20 years as a California Highway Patrol officer policing the famous span, Briggs had more success than failure in talking troubled souls back from the ledge.

He and two other officers persisted for nearly an hour on this day in 2007, and the man, perhaps 35 years old, seemed touched by their earnestness. He reached over three separate times to shake Briggs' hand.

Then it was suddenly over. "He said, 'Kevin, thank you very much,' " Briggs recalls quietly, "and he left."

The man plummeted to his death in the waters below.

There's a suicide in the USA every 13 minutes.

A short ride from the Golden Gate Bridge where about 1,600 of these deaths have occurred over the years, actor-comedian Robin Williams took his life at his Tiburon home in August.

Americans are far more likely to kill themselves than each other. Homicides have fallen by half since 1991, but the U.S. suicide rate keeps climbing. The nearly 40,000 American lives lost each year make suicide the nation's 10th-leading cause of death, and the second-leading killer for those ages 15-34. Each suicide costs society about $1 million in medical and lost-work expenses and emotionally victimizes an average of 10 other people.

Yet a national effort to stem this raging river of self-destruction — 90% of which occurs among Americans suffering mental illness — is in disarray.

In a series of stories this year, USA TODAY explores the human cost of allowing 10 million Americans with mental illness to languish without care. On the dark edge of that spectrum is a consuming urge to die, and those committed to understanding suicide say there are potential solutions if there is a national will to seize on them.

The country seems almost complacent with this staggering death toll. America's health care community remains mired in confusion over how to tackle suicide mostly because the public — and with it, the federal government — never gets serious about finding crucial answers.

Basic questions about whether suicide is a public health problem, whether it can be prevented on a broad scale, whether suicidal thoughts and actions are a disorder or a symptom of other disorders, remain widely debated.

Perhaps as a result of this scattered approach to what is clearly a health crisis, greater sums of money and research are devoted to curing diseases and social ills that kill far fewer Americans despite clear historical evidence that more investment translates into more lives saved.

"Is there the kind of concerted effort (for suicide) that's been made with HIV, with breast cancer, with Alzheimer's disease, with prostate cancer?" asks Christine Moutier, chief medical officer for the American Foundation for Suicide Prevention. "There's never been that kind of concerted front."

"When we invested in HIV/AIDS and breast cancer, we dramatically reduced the rates of death," says Jill Harkavy-Friedman, vice president of research for the foundation. "If we invest in suicide prevention — really invest in it — then we have a good shot at bringing it down."

The National Institutes of Health — the largest source of research money — spends a small fraction on suicide compared with diseases such as breast and prostate cancer that result in as many or fewer American lives lost. The suicide research budget for the National Institute of Mental Health (NIMH) has actually been shrinking since 2011.

The Centers for Disease Control and Prevention promotes several "winnable" priorities, among them motor vehicle injuries and HIV. Suicide, though more costly in lives than either of those categories, is not on the list.

Lawmakers' agendas are heavily influenced by public disinterest and a persistent view in the USA that anyone bent on killing themselves cannot be saved. Briggs saw the worst of this during suicide crises on the bridge when drivers passing by would yell out, "Go ahead and jump."

"If the public doesn't think you can do anything about it, they won't support it," says Alex Crosby, a CDC epidemiologist who focuses on suicide prevention.

"Can you really stop somebody who wants to kill themselves? I still hear that," says Jane Pearson, chair of the NIMH research consortium. "Changing that perspective is really critical."

Only in one area did Americans react to suicide. When soldiers started killing themselves in record numbers during two arguably unpopular wars in Iraq and Afghanistan, a groundswell from the public and Congress drove the military to respond.

The Army suicide rate tripled from 2004 and 2012 as more than 2,000 GIs took their lives. A new RAND study says that since 2005, about $230 million was poured into suicide research, more than two-thirds of it from the military.

"All the military research is likely to benefit civilians as well," says Michelle Cornette, executive director of the American Association of Suicidology.

A centerpiece effort is a $65 million study — the cost split between the Army and NIH — analyzing soldier suicides and tracking tens of thousands of troops over a period of years to understand self-destructive urges.

"The level of detail we are getting ... nobody has ever done anything on that scale in any population relating to suicide risk," says NIMH study scientist Michael Schoenbaum. "We have an enormous amount to learn."

Briggs, who retired from the CHP last year, says answers are long overdue. Promoting crisis management and suicide prevention, he says the nation must find a way to treat despair before the only resort is a police officer begging someone not to jump.

"Get them before they're up on the bridge," Briggs says, "because when you're up on that bridge, it's almost game over."

When Matthew Milam smiled, dimples on his broad face ran deep, and his cheekbones grew round and high — the infectious look of someone who could light up a room.

"As a little kid, I used to always tell him he had heart," says his mother, Debbie.

Medication was the key after he grew up. Without it, Matthew toggled emotionally between a sweet, compassionate 24-year-old who loved to cook and was terribly shy around strangers — to someone consumed with paranoia who dug his own grave in the backyard and stood outside in a lightning storm, begging God to strike him down.

"It'd be like a light bulb going off," says his father, Pat, vice president of sales for an oil field service company in New Orleans.

Those with severe mental illness such as Matthew, diagnosed with paranoid schizophrenia at 24, illustrate the gaping challenges researchers face in finding solutions to suicide. Half of those with schizophrenia, an illness marked by delusions and hearing voices, attempt suicide. One in 10 succeed.

Matthew's parents said his emotional state began to grow worse after he found his younger brother Michael dead at 18 of a heroin overdose in the family home in Harahan, La., in 2007.

Within a few years, Matthew was diagnosed with bipolar disorder and later with schizophrenia as more severe symptoms emerged.

He was institutionalized for brief periods four times in 2011, once after cutting his throat with a steak knife, according to his medical files. Each time, Matthew improved with medication and promised to stay on it. Each time after coming home, he would stop — a problem common to those suffering from bipolar disorder who believe the drugs dull their manic periods of elation.

Matthew's parents said they felt helpless to prevent their worst fears from coming true.

Equally frustrating, they said, was an inability to collaborate more closely with Matthew's doctors because of their son's privacy rights under the federal Health Insurance Portability and Accountability Act, or HIPAA. The law restricts release of personal medical information for anyone 18 and older.

"As a parent, you really don't know what else to do. You try to go to doctors and talk to them and ask them what in the hell is going on?" Pat Milam says. "The first thing they always say is 'Oh, we can't talk about it. HIPAA. HIPAA.' "

In 2011, the year Matthew's life was in crisis, suicides across America had been on a steady rise for 12 years despite modest investments in research. A private-public partnership formed in 2010 called the National Action Alliance for Suicide Prevention decided to go back to basics.

The alliance formed a task force of leading experts and published a way forward on research this year. It asked fundamental questions: Why do people commit suicide? How can they be identified? What works? Where is most research necessary?

Some of the ideas could have been drawn right from Matthew Milam's short life story — how to prevent a second suicide attempt after a first try, how to continue needed care.

The challenge in cases like Matthew's is when potential answers clash with individual rights, says Eric Caine, who assisted the alliance task force and directs the Injury Control Research Center for Suicide Prevention at the University of Rochester Medical Center.

Pat Milam says his son would be alive today if there had been a way to keep him medicated.

Some states allow for court-ordered treatment plans. No studies have been done on whether this could prevent suicides, another example of gaps in knowledge, Caine says. Such ideas, he says, lie "at the edge of what we know and what we don't know."

HIPAA restrictions, though frustrating to parent/caregivers of troubled adult children, enshrine coveted American principals of individual privacy protection, Caine says. Changing this would require substantial social debate.

The net result, he says, are many "fracture points or cracks or chasms that people can fall through." The despairing Matthews of the world "push away many, block those who would intervene and challenge our notions of individual autonomy," he says.

On Oct. 21, 2011, Matthew went into his closet and killed himself with a small homemade explosive. He fashioned it in secret. His parents were downstairs, waiting to take him to his next therapy session.

Sarah Clingan says severe depression feels like drowning, "where I can look up and see the bubbles from my nose rising toward the water's surface and am aware of every breath I can't take."

There is a profound sense of being alone, she says.

"One of the hardest things about mental illness is you can't walk into a hospital and show them you're broken," says Clingan, 30, a former preschool and kindergarten teacher who lives in Seattle.

The oldest child of a pediatrician father and a mother who is a speech therapist, Clingan grew up in Port Orchard, Wash., outside Seattle and was first diagnosed with depression during college.

The illness grew more severe after graduation when she began contemplating ways of overriding feelings of oppressive gloom whether it was through eating disorders, cutting herself or even suicide, Clingan says.

"It's wanting to escape," she says, "feeling like I had worked really hard and tried everything and knowing that my depression and mental illness was affecting the people around me that I cared about and not wanting to be a burden on them anymore."

Twice she tried to kill herself at age 26 with a medication overdose. During this period, she was finally introduced to one of the few tools validated in curbing suicides.

Known as Dialectical Behavioral Therapy or DBT, it is an intense, team-therapy treatment. In the beginning, Clingan had access to a therapist round-the-clock. During therapy, she learned ways to avoid falling into familiar patterns of anxiety and developed tools to better tolerate feelings of sadness and hopelessness.

Last month, an American Journal of Preventive Medicine edition devoted to suicide identified five other promising therapies for curbing suicide attempts or self-harm. A small number of medications have shown promise as well.

"That's how early we are in the science around the interventions for suicide," says Moutier of the American Foundation of Suicide Prevention. "People are now turning toward it. Have they turned fully? No. Are they in the process? Yes."

Clingan says her therapy continues. She's enrolled in a master's program in social work at the University of Washington and began to blog about her life this year.

"I am alive," she wrote in a moment of exhilaration last May, "and it is a grand thing."

There is a sense for some that time is short and too many are at risk. A new World Health Organization study estimates that globally, there is a suicide every 40 seconds.

Urgency is all Army Capt. Justin Fitch thinks about. Time is running out for him personally, and he says there is too much left to do to stop suicides.

The 32-year-old commander of a headquarters unit at the Army's Soldier, Research, Development and Engineering Center in Natick, Mass., nearly succumbed to suicidal urges during his first combat deployment to Iraq seven years ago.

A combination of depression, loss of sleep and combat stress left him alone one day with his M-4 rifle in his shipping-container sleeping quarters.

"It was at the point where you have a gun up to your head, you can taste the carbon of a barrel in your mouth, and the only thing that stands between me and being a statistic is 4.5 pounds of trigger pressure," he remembers.

Fitch hesitated. He later reached out to a counselor on the base, and with the help of medication and therapy, he began coping with his depression. "It took time," he says.

Today, he cannot recover from colon cancer diagnosed in 2012 that doctors declared terminal last year. In June, they said he had only months left. Faced with his own mortality, Fitch consulted his wife, Samantha Wolk, and reflected on the 22 veteran suicides occurring each day. He chose to devote his remaining time to prevent others from committing suicide.

"I've always wanted to focus on trying to leave the world a better place," he says.

This sentiment, shared by others, has fueled modest victories in the war against suicide. "In pockets, there's been progress," says Rochester University researcher Caine.

Biological research led scientists in recent years to assert that suicidal behavior is a disorder that deserves to be included in the bible on mental health illnesses — the Diagnostic and Statistical Manual of Mental Disorder — so doctors could better diagnose, identify and move into treatment those who are suicidal.

American Psychiatric Association officials who periodically revise the manual want more study.

"It's really a shift to consider it a disorder unto itself," says Maria Oquendo, a psychiatry professor at Columbia University who urged that suicidal behavior be recognized as a disorder in the manual. "They (the authors) said it's an idea that obviously needs to be considered but is not quite ready for inclusion."

One fact about suicide that research has firmly established is that reducing access to lethal means reduces suicide. The result has been a national initiative to erect barriers at sites where suicides occur, most prominently a $76 million project to build steel nets along the Golden Gate Bridge. A record 46 suicides occurred there last year.

Prevention advocates say the death of Robin Williams shocked the public and led to a national discussion about suicide.

In what time he has left, Fitch is intent on tapping into this growing awareness to raise funds for his dream: completion of a retreat for at-risk veterans and their families on a 144-acre parcel of land in Shepherdsville, Ky. Despite chemotherapy that has drained him of strength and weight, Fitch has immersed himself in fundraising through the Active Heroes organization devoted to reducing suicides in the military.

To raise money, he's led "ruck marches," in which participants carry weighted backpacks or military rucksacks on long hikes. The most recent one weeks ago left him "physically destroyed, spiritually strengthened."

"Maybe I can inspire other people," he says. "It's OK to seek help. And when they raise their hand, everything humanly possible should be done to take care of that person. Because suicide is completely preventable."

National Suicide Prevention Lifeline: 1-800-273-TALK (8255)