When Suicides Come in Clusters

In 1980, two young girls living in northern Sri Lanka committed suicide by eating the seeds of the Yellow Oleander, a common ornamental shrub that grows in most parts of the tropics and is cultivated across Sri Lanka in gardens and hedges. In the following year there were 23 cases of oleander poisoning, apparently spurred by the publicity of the first suicides. There were 46 in the year after that and hundreds of cases in the following years. Since oleander became associated with suicide in Sri Lanka, the number of deaths has risen steadily and health services across the island have been besieged by new cases. Suicide by oleander poisoning remains a major cause of death in Sri Lanka for young and old alike despite an aggressive government campaign to eliminate oleander plants and there seems to be no end in the foreseeable future.

While copycat suicides are not as common as feared, the existence of suicide clusters has been confirmed by studies launched by the Centers for Disease Control (CDC). The actual reason that suicide clusters happen is hard to fathom. Although suicides can come in waves, with one suicide other to commit or attempt to kill themselves, the full extent of the cluster is hard to chart (since not all attempted suicides are reported). Since suicide clusters are most commonly seen in people under the age of 25 or younger, most research studies and literature reviews focus on that age range. There are other high-risk groups however, including psychiatric inpatients, members of minority groups experiencing economic or cultural discrimination, prison inmates. Most recently, we’ve seen a sharp rise among U.S. soldiers deployed on extended missions in remote settings such as Iraq and Afghanistan.

In recent years, suicide has become one of the top five causes of death worldwide for children between the ages of 15 and 19 according to the World Health Organization. A 1987 study of youth suicide by the Centers for Disease Control found that 1 to 5 percent of all youth suicides occur in clusters. Since the suicide of a friend or age peer is often a traumatic experience for adolescents (many of whom are left bewildered by the lack of warning signs), the death of one teen might influence other teens feeling suicidal. Media influences, including the suicide of a well-known celebrity or personal idol can have a similar influence on depressed young people (also known as the Werther effect),

So how can suicide clusters be prevented? Despite calls for responsible reporting of suicide, especially youth suicides in the news media, the tradeoff between journalistic freedom and the possible impact that it can have on impressionable young people can’t be effectively determined. Although young people appear especially susceptible, predicting when the next suicide cluster will occur is virtually impossible. Since suicide clusters cannot be prevented, mental health professionals need to identify suicide clusters and attempt to intervene afterward to keep the cluster from expanding further. In one recent study on suicide clusters in young people published in Crisis: The Journal of Crisis Intervention and Suicide Prevention, a team of researchers based at the University of Melbourne in Australia examined 155 research studies on suicide clusters and how experts managed to prevent additional deaths. Based on their study, they came up with the following list of six recommendations for an effective community-based strategy:

1. Developing a community plan using “response teams” of mental health professionals, teachers, parents of teenagers, law enforcement officers, crisis center workers, and members of the local news agencies. After members of the team receive specialized training in posttraumatic stress management, the team members develop a coordinated plan to deal with suicide clusters.
2. Young people affected by suicide can be referred for educational/psychological debriefing to help them deal with grief and suicide thoughts. The debriefings can be conducted individually or for large groups (including entire schools as needed). Debriefing sessions involve providing information on suicide prevention, stress and grief coping strategies, and who to contact if further help is needed.
3. When debriefings are not enough, young people asking for extra help can receive psychological counseling. Group and individual counseling for young people affected by suicide can include addressing guilt and responsibility, recognizing grief reactions, learning that suicide cannot always be prevented, and how to deal with personal suicidal thoughts.
4. Teachers, parents, and counselors can often recognize high-risk cases who seem particularly in need of help. Having a strategy in place for referring high-risk cases for further screening by mental health professionals is especially important.
5. Ensuring responsible media reporting of suicide clusters. Although organizations dealing with multiple suicides have reported good success in establishing guidelines for responsible suicide reporting, the impact of sensational news stories on communities dealing with suicide clusters cannot be underestimated.
6. Recognizing that the problem can continue despite the suicide cluster apparently being contained. When a community has been traumatized by multiple suicides, the trauma can drag on for months or years afterward. Anniversaries, irresponsible media stories, and failure to the issues that triggered the suicide cluster to begin with need to be identified.

Although community strategies for dealing with suicide clusters show some promise, their actual validity is still undetermined. Although many of the recommended approaches have become common in recent years following multiple suicides, there is still no broad agreement on how they can be used properly. Ultimately, the responsibility is on all of us to recognize how far-reaching suicidal behavior can be, especially when the contagion is spread by word of mouth or sensational media stories.

Whether that damage can be contained before too many more lives are lost is a question that remains to be answered.