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The pandemic has placed Americans under unprecedented stress. It stands to reason that suicide rates would rise across the board.

But according to Paul Nestadt, MD, early data out of Maryland suggests that suicides during the initial COVID-19 wave actually dropped, compared to previous years. At the same time, Nestadt’s research also found that suicide rates among Black Marylanders rose sharply. In this Mental Health Video, he explains his findings, and what they might mean for clinical practice.

is assistant professor in the Department of Psychiatry and Behavioral Science at the Johns Hopkins School of Medicine, with a secondary appointment in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health. He also serves as the co-director and supervising psychiatrist for the Johns Hopkins Anxiety Disorders Clinic.

New data out of Maryland includes some surprising numbers. 

Who Is at Risk for Suicide During COVID-19?

More attention should be paid to reducing suicide following criminal arrest. A recent report from 

Dying Inside: The Hidden Crisis in America’s Jails

” sheds light on deaths among individuals with criminal justice involvement.

 investigated deaths in 523 of the largest jails in the country. Of 7571 deaths between 2008 and 2019, 4998 individuals were in pre-trial detention, meaning they had been arrested but have not yet gone to trial. They have not been found guilty. They are in jail because they have not been able to post bail or are otherwise denied release by a judge while awaiting their case, sometimes pending placement in a state psychiatric hospital for treatment to render them mentally fit to continue with their legal case.

According to the report, over 2000 deaths in jail were because of suicide. Of these, 1500 deaths were among individuals who were pre-trial or awaiting indictment. For example, 

 surveyed 11 jails in Washington State between 

 During this period 10-year period, the average inmate population across the state’s jails was 8442 and there were 160 deaths overall. There were 61 deaths by suicide in the 10-year period, , which was the leading cause of death during the study interval. An additional 24 deaths were because of drugs or alcohol.

Although these numbers of deaths by suicide are shocking, they are not surprising. Past studies have found that suicide is the leading cause of death in jails and makes up more than 

 Studies have also found that the initial pre-trial lockup period, which is the interval immediately following arrest and booking, is associated with 

Additionally, a recent study from researchers at the University of Washington looked at suicide among individuals with criminal justice involvement, but who were out of custody and living in the community (eg, on probation or parole).

 Community justice involvement included parole, probation, or arrest within the past 12 months. The study reveals that recent arrest status is associated with higher prevalence of suicide attempts than parole, probation, or no involvement with the criminal justice system. In this population, the highest prevalence of suicide (ie, the group with recent arrest) also had the highest prevalence of substance use disorders. Earlier studies have identified an increased risk of drug-related death following release from correctional facilities.

These studies reveal that the period after recent arrest may be a particularly vulnerable time for suicide. Although more research is needed, a hypothesis for this is that a recent arrest is a unique stressor that contributes to suicide risk.

Correctional facilities like jails have a constitutional responsibility to provide necessary mental health services to individuals in their custody.

 Despite increased attention to suicide and efforts to bolster suicide awareness in correctional facilities, the numbers remain too high. Similarly, despite growing attention to crisis response teams and substance use treatment resources, individuals with recent arrest who are in the community may not have reliable access to these resources.

These studies have important public health implications. They suggest the need for heightened attention to suicide risk among individuals with a recent arrest. They also suggest the need to consider arrest status when developing and implementing programming aimed to reduce suicide risk. With recent attention to alternatives to traditional policing, now is an ideal time to think about the ways that arrest can impact an individual psychologically.

Clinicians and policy makers should consider ways to bolster suicide risk reduction measures at multiple points of contact within the criminal justice system, ensuring that those at elevated risk for suicide are appropriately identified and directed to suitable services. All participants in the criminal justice system (from law enforcement to legal counsel to correctional staff to psychiatrists) should be aware of suicide risk in this vulnerable population and understand ways that they can help individuals get screening, support, and the services they need.

is a clinical and forensic psychiatrist, and the Director of the UW Center for Mental Health, Policy, and the Law.

1. Eisler P, So L, Szep J, et al. Why 4,998 died in U.S. jails without getting their day in court. Dying inside: the hidden crisis in America’s jails. 

 October 16, 2020. Accessed December 9, 2020. 

https://www.reuters.com/investigates/special-report/usa-jails-deaths/

2. Smith G. Jail deaths in America: data and key findings of 

https://www.reuters.com/investigates/special-report/usa-jails-graphic/

3. Noonan M, Hohloff H, Ginder S. Mortality in local jails and state prisons, 2000–2013 - statistical tables. Bureau of Justice Statistics. August 4, 2015. Accessed December 9, 2020. 

https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5341

4. Mumula CJ. Suicide and homicide in state prisons and local jails. U.S. Department of Justice. Bureau of Justice Statistics. August 4, 2015. Accessed December 9, 2020. 

https://www.bjs.gov/content/pub/pdf/shsplj.pdf

5. Bryson WC, Piel J, Thielke S. Associations between parole, probation, arrest, and self-reported suicide attempts. 

6. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison--a high risk of death for former inmates. 

7. Merrall EL, Kariminia A, Binswanger IA, et al. Meta-analysis of drug-related deaths soon after release from prison. 

The period following arrest can be particularly dangerous, both in custody and in the community. 

Suicide Risk Following Criminal Arrest 

In most cities around the nation, police departments, fire departments, and emergency medical services respond to calls related to substance abuse, emotional distress, and other mental health issues—whether they are trained to handle these issues or not.

But what if there were an equivalent of an EMT or paramedic for psychiatric problems? That is the idea behind CAHOOTS (Crisis Assistance Helping out on the Streets). In this Mental Health Minute, Ben Adam Climer explains the history, philosophy, and efficacy of the CAHOOTS program.

worked for CAHOOTS as a crisis worker for 5 years and an EMT for 2.5 of those years. He now lives in Pasadena, CA where he helps Southern California cities develop CAHOOTS-style programs.

An innovative program sends mental health first responders out onto the streets. 

Paramedics for Mental Health?

Patients, especially patients with suicidal thoughts, need an interview that feels like an alliance being built. Professionals who are matter-of-fact, earnest, connected, and seem like they are truly interested are going to be the most helpful. 

You can read more on suicide from Dr Khan and Mrs Fuad 

is Medical Director, Psychiatric Services, Wentworth-Douglass Hospital, Dover, NH;

is Master of Science candidate, Johns Hopkins University, Baltimore, MD.

What makes your patient feel good and what breaks them apart?

Establishing Human Connection

The reflection of her face in the mirror has faded from memory, although I often recall the red yarn that held her hair away from her face. The red hue was impossible to ignore.

I cannot remember her name and would never recognize her facial features if I saw her again—which I would not and could not. All I see in my mind’s eye is a static image, like a cut-out paper doll that never changes, forever fossilized in time.

She tied the yarn loosely behind her head, in tune with the fashion dictates of the day. It was not the yarn that grandmothers used to knit sweaters or socks—this yarn was made from many twines. That yarn became a bow, with loose ends trailing down, but not too far down. The yarn turned a low-slung 1950s-era ponytail into a professional woman’s fashion statement. It was worlds away from the high-perched ponytails of bubble gum-chewing bobbysoxers of yesteryear. This ponytail was perfect, without a hair out of place. According to the male chief resident, who reminded me to mirror this same woman whom I saw in the mirror, that was the way female physicians should dress—or so he said.

Loose locks left over from the free-wheeling 1960s, when women wore flowers in their hair, San Francisco-style, were discouraged, if not disdained. The only thing worse, that same senior resident mused, was a Jewfro, which was too ethnic for poker-faced psychoanalytically trained psychiatrists. Yet tight hair buns were too severe; psychiatrists-in-training were expected to project some empathy—but not enough to break tight boundaries.

The woman in the mirror was a senior resident, about to complete her program at a time when American women were still relatively rare in medicine. A few outstanding female physicians had made inroads in psychiatry. This young woman was also said to be outstanding, or so I was told—but not by her, for she never said a word.

More than once, I calculated how much time she devoted to perfecting her appearance, since she always seemed to be standing in the same place, like a mannequin, whenever I entered the anteroom to the restroom. She never spoke and never even turned her head; she merely nodded as she looked me in the eye, via that ever-present intermediary: the mirror. And I nodded back, too intimidated to start a conversation with a senior resident and one, at that, who was identified as “perfect.”

A short grosgrain ribbon encircled her collar and crisscrossed above the top button, somewhat like a man’s necktie, but feminized, as per the dictates of the day. In another era, that part of her “uniform” would have screamed Catholic school girl, especially if accompanied by a plaid skirt. But in this era it said “professional woman’s apparel,” which evolved into a uniform of its own. In hindsight, that picture-perfect ribbon that wrapped around her neck, like a noose, foreshadowed events to come.

There was something film noir-ish about this silent reflection, but film noir was not on my radar yet. Yet film noir was intimately linked to psychoanalysis, with Freudian-informed dream scenes and psychoanalytic-style voiceovers that simulated internal monologues or unconscious ideas. Voiceovers—rather than direct dialogue—narrated acts from the past or expressed unspoken thoughts in the present. Yet, there were no sounds in our superficial exchanges, no conversation at all. To this day, I wonder what that voiceover might have said or what she herself was thinking, had she chosen to speak. And I wonder if I should have spoken first.

For now, what I do know is that she died by her own hand, hanging herself some months later, shortly before finishing residency. As typically happens in the aftermath of 

—years or even decades later—we wonder what we could have said or should have seen. Perhaps tears had been streaming down her face, carefully concealed by makeup before modeling in the mirror.

Apparently, no one saw this coming, for surely someone in charge might have said something or done something. I can say nothing with certainty, save for the fact that a Jungian term, persona, and not a Freudian concept, best explains the indelible impression she made on me back then and decades later.

The reasons behind her suicide remain as mysterious as her reflection in the mirror. I first heard of the tragedy through a billing clerk, who dashed about frantically, checking on the residents’ well-being, and looking relieved whenever she saw someone alive. It was she who said that a young female resident had died, whose name was still unknown. The concept of copycat suicides had not been coined, but this middle-aged, motherly woman intuited this possibility. Other information arrived via rumor only. Post-suicide debriefings were not part of the protocol back then, although they are now standard when residents or medical students take their lives. The chief resident—the one who anointed her as the chosen one, the one to be emulated, for she was perfect in appearance—never said another word.

Perfection is one trait that is most closely linked with depression. Perfectionists are always operating at a deficit, because it is impossible to be perfect. The unquenchable need to be perfect at all costs and under all circumstances has been loosely linked to 

 in general and to physician suicides as well.

Physician suicides have been on the radar for decades, if not for centuries, but these tragic events are attracting even more attention today. More and more doctors complain about burnout and many chose early retirement, even in the face of physician shortages. Statistics show that half of all physician 

Today’s buzzword is burnout—perhaps to soften the fear of impending suicide and perhaps to prevent the worst consequences. There are many reasons for physician burnout, including among other factors, dissatisfaction with unwieldy electronic health records, loss of professional autonomy in the face of managed care, overwhelming medical school loans, declining prestige or power in society, and stigma associated with seeking psychiatric help. Age-old scourges of drugs and alcohol may also be involved; although doctors are no more likely to develop alcohol problems than non-doctors, they can access lethal drugs more easily.

There are many contributors to professional dissatisfaction, just as there are many contributors to depression itself (besides plummeting dopamine levels). And there are many contributors to that final act of suicide. However, this is not news, even though contemporary stressors have changed. According to a recent Medscape article, the high rate of physician suicide, compared with the general population, was known 150 years ago.

The numbers are striking, yet most suspect that the rates of doctor suicides are underestimated and that many unexplained deaths are not recorded as suicides. Between 300 and 400 physician suicides occur each year. To put it differently, about one doctor dies by their own hand every day. The size of an entire medical school class completes suicide every year. Male physicians have twice the risk for suicide as men in the general population, even though they care for their medical health better than average, with lower rates of smoking, cardiovascular disease, or cancer. 

 by female physicians approximate the number of male physician suicides but, because women overall are half as likely to complete suicide as men, the comparisons between rates of suicides of female physicians and rates among female members of the general population is glaring. Female physicians are 4 times as likely to die from suicide as women who are not physicians. (Computing the statistics gets confusing, but it is worth doing.)

What does this say about this unnamed resident whose reflection I saw in the mirror? That her untimely death was consistent with statistics? Yes, but no. She was in a program that mandated personal analysis, which may or may not have been helpful, so we cannot blame stigma for avoiding psychiatric treatment. What can we blame, if anything at all? Perhaps nothing, or perhaps our own refusal to see past the mask and to admit that outward perfection is not necessarily perfect.

What I can say with near certainty is that I never saw her personal reflection in the mirror. I saw only the reflection of her persona, the theatrical mask presented to the public used to conceal the inner anima or soul or authentic being. Jung borrowed this term from Greek theater, where masks established an actor’s fictional identity on stage. Thousands of years later, this word remains relevant.

Perhaps this persona also hid an unexpressed and unacceptable shadow side, to use Jung’s vocabulary. As per Jung (and I have no proof that he was even remotely correct), each of us has a shadow side, which we must confront and eventually reconcile. Yet it is probably extra difficult for people who must be perfect to come to terms with such imperfections.

What can we learn from this sad story, other than the fact that perfect poses may be nothing more than poses and that the poseur may be enduring greater distress than is apparent to the untutored eye? Perhaps this vignette can remind us of the need to pay even closer attention to those who appear perfect—and to avoid imposing demands for perfection at every step along the way.

 is assistant clinical professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

1. LoboPrabhu S, Summers RF, Moffic HS, Eds. 

Combating Physician Burnout: A Guide for Psychiatrists, 

1st ed. Washington, DC: American Psychiatric Association Publishing; 2020.

3. Gold KJ, Schwend TL. Physician suicide—a personal and community tragedy. 

4. Duarte D, El-Hagrassy MM, Castro e Couto T, et al. Male and female physician suicidality: a systematic review and meta-analysis. 

As typically happens in the aftermath of suicide—years or even decades later—we wonder what we could have said or should have seen.

Of Personas and Perfection—and Physician Suicide

 finds that suicide attempts during pregnancy and after childbirth are increasing, nearly tripling over the past decade Nearly 24,000 individuals are at risk for suicide. Suicide is already among the leading causes of deaths among new mothers, and pregnancy/post-delivery are considered risky times for depressive symptoms. 

“Suicide deaths are a leading cause of maternal mortality in the US. It is a public health crisis that has silently grown worse,” lead author Lindsay Admon, MD, MSc, an obstetrician-gynecologist at Michigan Medicine Von Voigtlander Women’s Hospital and researcher with the University of Michigan Institute for Healthcare Policy and Innovation, said to the press.

Evaluating data from the Maternal Behavioral Health Policy Evaluation (MAPLE) study, researchers found 2683 out of 595,237 insured mothers aged 15 to 44 across the US had suicidal ideation or thoughts of self-harm. According to the findings, the prevalence of suicidal thoughts or self-harm in childbearing individuals in the years pre- and post-pregnancy almost tripled between 2006 and 2017.

Maternal suicidality overall increased from 0.2 to 0.6%, with the greatest increases seen among Black; low-income; younger individuals; and people with comorbid anxiety, depression, or serious mental illness.

“The increases and disparities in suicidality over time, and the likelihood that suicidality is both under detected and under treated remains concerning,” stated Kara Zivin, PhD, senior author and professor of psychiatry and obstetrics and gynecology at the University of Michigan, who personally struggled with suicidality during her own pregnancy. “This research indicates we have more policy and clinical work to do to support struggling women and their families.”

Zivin also noted numbers can be hard to pinpoint, as maternal mortality statistics reported by the Centers for Disease Control and Prevention (CDC) excludes suicide deaths by listing them as incidental or accidental. However, during pregnancy, women are in much more frequent contact with their health providers. This increases opportunities for doctors to identify depressive symptoms during pregnancy and postpartum.

“We need to improve screening for mental health wellness during and after pregnancy,” Admon said. “We know that untreated mental health conditions put both moms and their children at higher risk for adverse health outcomes, including preterm birth and maternal suicide.”

Admon and her fellow study authors had this to say about what steps need to be taken in the future: “We need to seek health system and policy avenues to better identify suicidal symptoms in childbearing women. It’s critical that we intervene as early as possible and provide necessary therapies to reduce the risk of the most tragic outcome.”

1. Admon LK, Dalton VK, Kolenic GE, Ettner SL, et al. Trends in Suicidality 1 Year Before and After Birth Among Commercially Insured Childbearing Individuals in the United States, 2006-2017. 

2. University of Michigan. Suicide Risk During Pregnancy, After Childbirth on the Rise. News release. November 16, 2020. 

https://www.newswise.com/articles/suicide-near-misses-during-pregnancy-after-childbirth-on-the-rise

Suicide attempts among pregnant or postpartum mothers have nearly tripled over the past decade. 

Pregnancy and Postpartum Suicide Risk: The New Numbers 

Modern medicine has achieved considerable success in containing and, in some cases, eradicating epidemics of debilitating and lethal infectious illness. In recent decades there has also been significant progress in the prevention, diagnosis, and treatment of major psychiatric disorders. Yet, major psychiatric illness 

highly associated with significant morbidity and mortality.

 Suicide is among the most frequent lethal outcomes of major psychiatric illness.

Since the start of this century, suicide rates have increased dramatically across the age range. Among the many disturbing trends, the suicide rate among pre-adolescents and younger adolescents has increased 178% from 2007 to 2017. During this period the incidence of suicide has increased 76% among older adolescents.

 Suicide is now a formidable public health epidemic.

Evidence-based harm reduction suicidology has arisen in response to this alarming development. This conceptual framework emphasizes the importance of prevention, by restricting access to lethal means and through psychoeducation, including reducing stigma and heightening public awareness of prodromal and/or warning signs. It also involves risk assessment screening and/or evaluation and case formulation, as well as safety and treatment planning. Finally, this approach includes strategic outreach to patients and their families, offering timely access to care that is specifically tailored to the needs of the suicidal patient. The goals of programs based on this model include improved safety, reduced risk, and amelioration of comorbid medical and psychiatric conditions that contribute to elevated risk.

 is a complex multi-determined biopsychosocial phenomenon, and the suicidal patient remains an elusive 

 for effective prevention, identification, and intervention.

Substantial barriers to suicidal harm reduction remain. At-risk patients have a high incidence of concurrent mental illness, personality disorder, and substance abuse. They are often beset by difficult and seemingly intractable life circumstances. The considerable demoralization and hopelessness that characterizes a substantial percentage of patients at risk for suicide contributes to a high level of skepticism and mistrust of the mental health care system and reluctance to engage and remain in treatment. This constellation of difficulties has a negative impact on efforts to reduce death by suicide.

Formal risk assessment, a cornerstone of contemporary evidence-based clinical practice, is notoriously unreliable with respect to predictive validity, regardless of approach and thoroughness. It generates low hit rates: unacceptably high rates of false positives and false negatives.

 Moreover, there are mixed findings with respect to the efficacy of safety planning in reducing the incidence of suicidal behavior.

Despite the recent developments in evidence-based suicidology, which include several promising risk assessment models and diagnostic tools, suicide remains unpredictable in each case. Consequently, many patients with concerning risk factors for serious self-harm are discharged from inpatient, outpatient, and emergency department settings. Psychiatrists and other mental health specialists. keep their fingers crossed that this turns out to have been a reasonable decision and that the patient remains safe—at least in the short term.

, which is the most well-known and influential harm reduction initiative to date. This training and consultation program is a multipronged effort to incorporate best practices from evidence-based suicidology as outlined above. It has successfully integrated these practices in ways which are relatively easy for psychiatrists and other health care professionals to learn and execute. It has made a substantial contribution to improving the standard of care for suicide prevention, evaluation, and treatment.

Fostering hope while not raising unrealistic expectations regarding outcome should be a key objective of any public health care initiative. Regrettably, the term Zero Suicide implies the perfect outcome of irrevocably eliminating suicide. At the same time the literature promulgated on Zero Suicide states only in passing that this is an aspirational goal but is otherwise silent as to its attainability. Despite this quiet qualification, the very name Zero Suicide implies that suicide is a condition that can be eradicated, much like some infectious disease epidemics, and that this is the ultimate objective of this program.

Suicide, however, is a very different societal ill then the 

 of this century. Advances in medical technology and treatment have significantly curtailed these diseases. Unfortunately, there is no evidence that methods can be devised that would entirely eliminate suicide, despite the powerful human need to attain maximal control over existential threats.

The moniker of Zero Suicide runs the distinct risk of raising false hope for patients, their loved ones, and their health care providers. Suicide assessment and treatment, for the foreseeable future, is likely to continue to be more art than science. Advances in suicidology may well succeed at lowering the incidence of suicide, perhaps even on a sustained basis, but are quite unlikely to eliminate it.

There is a substantial evidence regarding the negative effects of patient suicide on loved ones and their health care providers. These include potentially destabilizing and protracted feelings of anxiety, depression, anger, loss, shame, guilt, and failure.

 One can only hope that the concept of Zero Suicide does not have the unintended consequence of exacerbating these reactions in people who have lost someone to suicide by virtue of its utopian vision of a society free from death by suicide.

The developers and promoters of Zero Suicide need to rethink their brand and consider that such a title, although uplifting in some respects, is also misleading. A name change would be highly desirable, one that reflects a greater appreciation for the unrelenting human penchant for self-destruction but also instills hope that evidence-based research and practice can eventually result in better outcomes. Short of a name change, the literature on Zero Suicide ought to include a clear and unequivocal statement that the goal of this initiative is limited to finding increasingly effective ways to save lives by sharply reducing the occurrence of suicide, but not trying to extirpate it.

The views expressed in this article are those of the author and do not necessarily reflect the opinions of

 is a clinical and neuropsychologist, Emergency Services, Seacoast Mental Health Center, Portsmouth, NH; and an allied health professional, Department of Medical Services, Section of Psychiatry, Exeter Hospital, Exeter, NH. He reports no conflicts of interest regarding the subject matter of this article.

This article was originally posted on September 18, 2020, and has since been updated. Scroll down for the 

Premature mortality across most psychiatric disorders

2. Frankl R. Suicide deaths rising in children 10-19 years. 

3. O’Connor RC, Nock MK. The psychology of suicidal behavior. 

4. Murray D, Devitt P. Suicide risk assessment doesn’t work. 

. March 28, 2017. Accessed September 17, 2020. 

https://www.scientificamerican.com/article/suicide-risk-assessment-doesnt-work

5. Zalsman G, Hawton K, Wasserman D, et al. Suicide prevention strategies revised: 10-year systematic review. 

6. Milner A, Witt K, Pirkis J, et al. The effectiveness of suicide prevention delivered by GPs: a systematic review and meta-analysis. 

7. Miller IW, Camargo CA Jr, Arias SA, et al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. 

8.Stanley B, Brown GK, Brenner LA, et al. Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department. 

9. Gutkin NJ. Losing a patient to suicide: what we know. 

A well-meaning mental health initiative may be setting unrealistic expectations.

What’s in a Name: The Problem with Zero Suicide

Statistics of Suicide

International Survivors of Suicide Loss Day is Saturday, November 21, 2020. Here are some statistics around suicide to help put things in perspective. 

Veteran suicide is a large concern, especially during this isolating pandemic period. Veteran suicide prevention is the top clinical priority of the United States Department of Veterans Affairs, but what is being done about this issue?

Judith A. Feld, MD, MPH, MMM, stresses the need to advocate for accessible, high-quality, and proactive behavioral health care and outreach. 

According to the National Veteran's Suicide Prevention Annual report of 2019, veterans are 1.5 times more likely to attempt suicide than non-veteran adults. Mental health professionals are uniquely positioned to help advocate for these individuals. 

Veteran Suicide: Proactive Prevention

Many factors have come into play during the coronavirus 2019 (COVID-19) pandemic, not the least of which has been meeting the flood of challenges in the realm of mental health. Rather than paint a bleak picture, Christine Moutier, MD, presents the unique opportunities for clinicians in identifying risk and preventing suicide.

In this podcast, Moutier discusses her recent paper published in 

Suicide Prevention in the COVID-19 Era: Transforming Threat Into Opportunity

." Moutier is chief medical officer of the 

American Foundation for Suicide Prevention

The unique opportunities for clinicians in identifying risk and preventing suicide are discussed in this podcast.

Suicide