For the person who puts a bullet in his head, the pain and suffering are over. For the friends and family, it is only the beginning.
In fact, the anguish of those left behind can be so paralyzing that they are three times more likely to also kill themselves, said Karl Rosston, Montana's suicide prevention coordinator.
They are called survivors of suicide and they must somehow navigate a lifetime journey of grief, guilt and confusion. And they comprise a significant and growing segment of the population.
At least 38,364 suicide deaths were reported in the U.S. in 2010, according to the latest data available from the Centers for Disease Control and Prevention. This latest rise in deaths places suicide again as the 10th leading cause of death in the U.S. Nationally, the suicide rate increased 3.9 percent over 2009 to equal approximately 12.4 suicides per 100,000 people. This is the highest rate of suicide in 15 years.
For every suicide in the country, there are an average of six direct survivors, according to the American Association of Suicidology. Some national suicide experts say that number is conservative. But based on this figure, there are approximately 5 million survivors in the U.S. in the past 25 years, or one out of every 65 Americans.
The ripple effect of a single suicide is even greater in the Native American community, where the number of direct survivors is at least 25 or even the entire community.
Montana, which has had one of the highest rates of suicide in the nation for more than 30 years, is populated with thousands of survivors.
Consider that during 2010, at least 227 Montanans took their own lives. Another 225 people committed suicide in 2011. That’s more than 2,700 survivors in just two years.
They often experience a wide range of grief reactions, including shock, depression, abandonment and even post-traumatic stress syndrome. Some experience relief, particularly if the suicide followed a long and difficult mental illness.
Anger toward the deceased, another family member, a therapist and even themselves is common, said Joanne Harpel, senior director for pubic affairs for the American Foundation for Suicide Prevention.
Survivors also often experience guilt, thinking, “If only I had ….”
And, traditionally, suicide has carried with it the stigma of being a bad parent or bad spouse.
They are not likely to seek support or mental health treatment, Rosston said. Those who do are often hindered by a lack of support groups for survivors of suicide. There are very few. The Department of Public Health and Human Services has been working with the Tamarack Grief Resource Center in Missoula to offer training to therapists in different communities so that more groups can be started.
The shortage of mental health professionals and mental health treatment facilities in the state compounds the challenge.
As of Nov. 1, there were 146 licensed psychiatrists in Montana. Patients can wait anywhere from two weeks to three months or longer to see a psychiatrist. In some area of the state, there is one psychiatrist serving a vast, multicounty area.
In the U.S., there are about 50,000 psychiatrists — too few to serve all the patients who need help, especially in rural areas, according to the American Psychiatric Association. About half of the practicing psychiatrists are over the age of 55, and many will soon retire.
Adult survivors find that they improve their ability to cope by participating in formal support groups with others who have experienced loss through suicide, Rosston said.
Shame or embarrassment may prevent the survivor from reaching out for help, said Joan Nye, chair of the Montana Chapter of the American Foundation for Suicide Prevention.
“Survivors sometimes feel that others are blaming them for the suicide,” Nye said. “Some feel as though they need to deny what happened or hide their feelings.”
The best thing is attending a support group, said Nye, who leads such a group in Billings.
It’s the one place where your story is never old news,” Nye said. “You can talk about your feelings. You can tell your story. You can share. You can listen. For everyone else, it’s fairly old news rather soon after your loved one’s suicide.”
What is vital to know, Rosston said, is that a survivor of suicide is three times more likely to also kill themselves.
Children who survive the suicide of a parent or guardian frequently struggle with guilt and feelings of abandonment, Rosston said.
“Children need to know that the death was not their fault and that their continued care is certain,” he said. “Honest, age-appropriate communication with the child is critical.”
More money is needed for research and effective education, Nye said.
She said suicide is to the 21st century what the AIDS epidemic was in the in the '60s, '70s and '80s. Thirty or 40 years ago, if the cause of death was not listed in a death notice or obituary, it was presumed to be AIDS. Today when that happens, the cause of death is presumed to be suicide.
Because of the money available for research and enhanced treatments over the years, HIV has been downgraded from being a fatal disease to a chronic condition.
The same, Nye said, must be done for mental illness, which is often the underpinning of suicide.
It is imperative to get “Hollywood types” on board to increase awareness and money so research can be done the upward trend reversed.
“We just have to have people understand that mental illness is like any other illness,” Nye said. “People don’t try to buck up and live with their asthma or diabetes without help. Why do they do that with mental illness?”