The Contagion Effect

Earlier this month, the Associated Press reported a grim statistic: the number of military suicides rose to 349 in 2012, with suicides substantially exceeding the number of combat deaths. The military suicide rate has gone up greatly over the last decade: in the Army, the suicide rate is now roughly 30 per 100,000, almost triple the rate of suicide in the population as a whole.

Media stories paint a picture of crisis: military suicide is at "record highs," an "out of control" "epidemic" that’s spreading "like an airborne disease." It can certainly feel that way at times. During a recent weekend at Fort Carson, for instance, one young soldier attempted suicide, another took his own life, and a third threatened to kill himself, but was eventually persuaded to give up his weapon.

All this within a single brigade — and though it was a rough weekend, it wasn’t entirely atypical. For every suicide in the military, there are several other service members who attempt suicide, threaten it, or tell friends or superiors they’re contemplating it. The result is a grim litany of "serious incident reports" moving up the military chain of command, documenting a phenomenon that is as baffling as it is tragic.

There’s no dearth of suicide prevention programs in the military. In recent years, DOD has launched or reinvigorated an ambitious and wide-ranging array of programs: there are suicide prevention stand-down days, suicide hotlines, "mental fitness" programs, and programs aimed at reducing the perceived stigma of seeking mental health help. In June 2012, Secretary Panetta noted that DOD had increased the number of behavioral health experts by 35 percent over three years, and suicide prevention has become a preoccupation at every level in the chain of command. Yet despite all these efforts, the military suicide rate remains stubbornly high, and keeps getting higher.

Is it possible that many of our well-intentioned efforts to prevent suicides in the military are actually having the opposite effect?

The phenomenon of "suicide contagion" or "imitative suicide" has been recognized for years. The most famous (though possibly apocryphal) example dates back to 1774, when 24-year-old Johann Wolfgang von Goethe published The Sorrows of Young Werther.

The story chronicles an unhappy love affair that culminates in the suicide of the protagonist. "See, Charlotte, I do not shudder to take the cold and fatal cup….With cold, unflinching hand I knock at the brazen portals of Death," proclaims Werther, having decided that death is the only honorable solution to his love for a married woman.

A classic of early German romanticism, the book was an immediate sensation when it was published in 1774. Rather too much of a sensation: throughout Europe, "Werther Fever" broke out, and young men and women dressed like Werther and swapped pirated copies of the slender volume. According to legend, the book also led to an outbreak of Werther-inspired suicides — so many that authorities in Leipzig and Copenhagen banned the book altogether.

Historians are still debating the evidence of a Werther-inspired European suicide epidemic. But though we may never know how many suicides were truly inspired by Goethe’s morbid little melodrama, we know today that the phenomenon of "suicide contagion" is real. Numerous studies have demonstrated that one suicide within a community can spark others.

The mechanisms of suicide contagion are not well understood, but there’s substantial evidence that the media plays a major role as a suicide vector. A 2008 World Health Organization report is unequivocal: "Over 50 investigations into imitative suicides have been conducted. Systematic reviews of these studies have consistently drawn the same conclusion: media reporting of suicide can lead to imitative suicidal behaviours."

This does not mean that the media should not report on suicide, of course. Suicide — and changes in suicide rates within particular subgroups — is legitimately of interest to the public, and it would be irresponsible for media outlets not to report on military suicide rates. But studies suggest that a great deal depends on just how suicide is covered.

According to the World Health Organization, the likelihood of imitative suicides resulting from media coverage varies, depending in part on "the amount and prominence of coverage, with repeated coverage and ‘high impact’ stories being most strongly associated with imitative behaviours. It is accentuated when the person described in the story and the reader or viewer are similar in some way….Particular subgroups in the population (e.g., young people, people suffering from depression) may be especially vulnerable to engaging in imitative suicidal behaviours… [and] overt description of suicide by a particular method may lead to increases in suicidal behaviour employing that method."

The plenitude of studies documenting a media version of "the Werther effect" have led many organizations to promulgate "best practices" for media reporting on suicide. The National Institute for Mental Health (NIMH), for instance, urges media organizations to avoid "Big or sensationalistic headlines, or prominent placement" of stories about suicide, and avoid using such terms as "epidemic," "skyrocketing," and so on when discussing suicide trends. Similarly, the World Health Organization warns that "Prominent placement and undue repetition of stories about suicide are more likely to lead to imitative behaviours than more subtle presentations."

NIMH also urges media to avoid "Including photos/videos of the location or method of death, grieving family, friends, memorials or funerals," since this can both lead others to identify more with the suicide victim — thus increasing the likelihood of copycat behavior — or lead people to focus on the idea that suicide will lead to positive attention ("After I’m gone, they’ll finally appreciate me…"). The CDC concurs, noting that "News coverage is less likely to contribute to suicide contagion when reports of community expressions of grief (e.g., public eulogies, flying flags at half-mast, and erecting permanent public memorials) are minimized. Such actions may contribute to suicide contagion by suggesting to susceptible persons that society is honoring the suicidal behavior of the deceased person…"

So, how’s the U.S. news media doing when it comes to reporting on suicide in the military?

Not so good.

Take this recent National Public Radio story. It flies in the face of the recommended best practices, offering details on the how and where (a soldier "was found dead in a west Tennessee motel room with a self-inflicted gunshot wound to the head") and highlighting his relatives’ ongoing displays of devotion ("I wear his dog tags every day," his widow is quoted as saying).

Or consider this lurid piece from The Colorado Springs Gazette, which quotes extensively from the Facebook suicide messages of a Fort Carson soldier who appears to have died in a self-inflicted vehicle crash. Or this piece from the Minneapolis Star Tribune, also quoting extensively from the victim’s suicide notes, and suggesting the victim was "driven" to suicide by disciplinary action taken against him by his superiors.

There are many responsible news stories about military suicide too, but you get the idea. Even as media stories suggest that DOD is "not doing enough" to prevent suicides, many of those very same media outlets are reporting on suicide in a way that may make the problem worse.

But let’s take this a step further. Just as it seems reasonable to ask whether intensive media coverage could be a contributing factor in rising military suicide rates, it also seems worth considering whether DOD’s own intensive focus on suicide prevention might be having have a similarly unintended effect.

On Fort Carson, for instance, as it any other large military installation, it’s hard to get through a day without seeing the word "suicide" over and over. News of suicide prevention stand-down days is posted on bulletin boards and written up in newsletters; posters highlight suicide prevention resources. At Fort Carson’s main gate, a neon sign flashes the word "SUICIDE" in foot-high red letters. (I’m pretty sure the sign said "Prevention Week" in smaller letters down below the word "suicide," but even driving past at a sedate 15 miles an hour, "suicide" was the only word that registered.)

I spoke to Commander Steven Bartell, Deputy Director of DOD’s Suicide Prevention Office, and asked if he was concerned about the potential for imitative suicides. "There are a lot of precipitating factors" for suicide, he said, and "it’s hard to say what are the major contributing causes…. But all that being said, is there a potential for contagion? The obvious answer is yes."

In practice, it’s virtually impossible to assess whether any "contagion effect" resulting from suicide prevention programs themselves is negligible or substantial. But in theory, said Bartell, "Even trying to raise awareness can put a thought there that wasn’t there before….It’s a challenge."

It is indeed. How do you raise awareness of suicide prevention resources when talking about suicide may, in and of itself, increase the prevalence of suicide? "There may be a Catch-22 here," Commander Bartell observes ruefully.

Is there any way out of that Catch-22? I don’t know, and the experts don’t know, either. But here are a few ideas.

For one thing, the media could do a better job of self-policing when it comes to stories on suicide, and DOD could do a better job of ensuring that reporters are aware of public health guidelines on suicide reporting. DOD public affairs officials say that though they conduct internal training on how to discuss suicide responsibly, concerns about being perceived as trying to stifle press freedom mean they don’t systematically push such information out to reporters.

I think that’s a mistake: there’s nothing in the First Amendment that says DOD can’t hand out copies of the World Health Organization’s recommended media guidelines to reporters asking about suicide in the military. Some media outlets will ignore the recommendations, but at the moment, many reporters are unaware that there’s even an issue.

DOD could also do more to increase awareness of suicide contagion within the military, perhaps developing internal program guidelines on how to reduce the likelihood of imitative suicide, similar to those other organizations have developed for the media. While we don’t have much solid information on whether suicide prevention efforts carry their own contagion risks, there’s enough evidence of contagion resulting from media stories to suggest that DOD should err on the side of caution in its own programs.

That doesn’t mean eliminating suicide prevention programs, of course — ignoring the issue most certainly won’t make it go away. But it does suggest increased care in the use of the term suicide, as well as training for caregivers, leaders, and gatekeepers in how to talk about suicide without inadvertently contributing to the problem of imitative suicides.

Overall, we know dismayingly little about what constitutes an effective suicide prevention program, but research suggests that problems with alcohol, drugs, depression, mental illness, finances, and relationships can all be risk factors for suicide. Studies also suggest that service members often lack the concrete skills needed to access behavioral health and other resources, making it less likely that they will seek help even when helpful resources exist.

What this implies is that you don’t necessarily need to label something a "suicide prevention program" for it to have a suicide prevention impact. Indeed, it may well be that many of the most effective suicide prevention tools never use the word "suicide."

Resources:

For more information on suicide best practices, see this 2011 RAND report and this 2012 report from the Military Suicide Research Consortium. You can find CDC media guidelines on reporting on suicide here, NIMH guidelines are here, and the WHO guidelines are here. You can get more information on DOD suicide prevention programs here. If you or someone you know is in crisis, call DOD’s suicide prevention hotline: Dial 1-800-273-8255 and press "1."