One of the most significant barriers to suicide prevention is the stigma surrounding suicidal thinking and help-seeking, according to the Department of Psychiatry at Leipzig University.
Erving Goffman, a Canadian-American sociologist, social psychologist and writer, defined stigma as a process based on the constructs of identity, where individuals with stigmatized conditions are socially condemned and discredited by the majority. The word “majority” is important here — because it references the pervasive shame associated with suicidality.
Since the implications of stigma are locally defined and socially embedded, completely eradicating ideologies that echo centuries-old prejudices can't be achieved overnight.
Why Are Mental Health Conditions Underreported?
Failure to report mental health conditions can, in part, be attributed to the way mental illness diagnosis has been associated with job discrimination and social exclusion.
In its Adolescent Depression booklet, Johns Hopkins Medicine reported that "depression remains largely underreported by teens with studies finding that it often takes several years before depressed adolescents and children receive appropriate treatment."
It’s important that those suffering from mental health issues feel safe to identify and report their symptoms without fear of societal disadvantage.
Normalization and Generational Perceptions of Mental Illness
Public dialogue on mental illness has been embraced by younger generations, who have cultivated online communities where comedy and nihilism play into an idea that everyone suffers from depression.
This attitude normalizes mental illness, but it can also serve as a detriment to those who actually experience suicidal thoughts. The experience of suicidal thinking appears less unique, making people less likely to ask for help.
Normalizing mental illness to the point that it becomes apathetically tolerated rather than addressed can be dangerous, and the impact is evident in recent findings on suicidal ideation among children.
In a study published in JAMA Pediatrics, researchers tracked the number of children sent to hospital emergency departments for suicide attempts over a nine-year period ending in 2016. They found that suicidal ideation has doubled among children in contrast to earlier decades.
Humza Khan, a Ph.D. student in Clinical Psychology at The Illinois Institute of Technology, believes that society has become desensitized to mental illness because we use suicidal language so frequently. But the conversation isn’t prompting change, Khan said.
"Time and time again, education has been the key to ensure that people are able to understand the different issues enough to seek solutions," Khan said. "People believe conversation is enough because we’re starting to shed light, but conversation is only good if it’s followed by action.”
The Importance of Diagnostic Procedures
Beyond culture shifts, action begins when people seek emergency services for suicidality. A diagnostic procedure, employed when someone calls a helpline or visits an emergency room, is how service providers direct patients based on their specific needs, according to Dr. Michael F. Hogan, former State Commissioner of Mental Health for New York, Ohio and Connecticut.
Hogan said 80% of the suicidal people who call the National Suicide Prevention Lifeline (the Lifeline) feel that their crisis is resolved during the phone call. But unfortunately, the Lifeline doesn't work for everyone.
When someone visits an emergency room, physicians have to quickly assess the "potential lethality" of suicidal patients. They then make a decision to discharge or admit a patient to the hospital, according to Innovationsin Clinical Neuroscience. But many facilities are overcrowded, leaving individuals waiting for their circumstances to be addressed.
Once the physical threat has been diminished, however, an emergency department is not equipped to provide further care. The situation is briefly addressed, and the patient is sent on their way.
Diagnostic procedures could alleviate demand for hospitals and allow providers to initially refer patients to more experienced health care professionals who are able to provide comprehensive, long-term treatment plans for patients who require them.
It should, however, be noted that even being enrolled in an outpatient mental health program prior to her emergency room visit did not supply Saenz with the preemptive care she needed. In a time of crisis, the program did nothing to warn her that any visit to an emergency care facility would mean a fruitless wait and little support. As such, a more comprehensive approach in outpatient programs to educating on the limitations of emergency care may be vital in redirecting those struggling with mental illness to seek other solutions if not yet physically harmed by suicidal thoughts.
Poor Emergency Care Conditions
Pre-hospital diagnostic services, though important, can't ameliorate the difficult experiences of those who have already been failed by emergency care.
"Every time I peeked my head out of the room, I was being yelled at by a staff member to stay inside," Saenz remembered. "We asked to speak to a supervisor, and they kept saying he was almost here, but he never came for us.”
In-hospital delays, like the one experienced by Saenz, can have significant emotional impacts, according to clinical psychologist Michelle Rago. Once admitted, patients will wait for a bed in the hospital psychiatric unit, or if the hospital doesn't have a dedicated unit, patients must be transferred via ambulance.
“It could be extremely painful for those people who are sitting there in that state of mind," Rago said. "The person would be transferred to a psychiatric unit if a bed is available, but if not, sometimes it can take days to possibly weeks for a bed to become available."
A 2012 survey conducted by the National Association of State Mental Health Directors concluded that 70% of emergency departments (EDs) surveyed boarded patients for at least hours or days, while 10% reported boarding patients for weeks on end.
"We had to wait hours for someone to come, and we had nothing to keep us occupied," Saenz said. "The room was dirty, the table was sticky and the chairs were extremely uncomfortable."
Research included in a U.S. Department of Health and Human Services literature review found that 61% of hospitals did not have psychiatric staff caring for ER patients while they waited.
"I was scared and had no idea what was about to happen to me," Saenz said.
Continuing Impacts of Delayed Care
After her physical health was addressed, Saenz didn’t speak with a psychiatric nurse until 14 hours after she arrived at the hospital. Patient relations assured her that this was an appropriate time frame for this standard of care.
The common thread across the flurry of studies addressing psychiatric treatment in emergency departments is delayed care. A lack of adequate medical attention can worsen existing mental conditions among suicide survivors.
Suicidal and self-harming patients who did not receive a psychiatric assessment during an ED visit were twice as likely to continue to self-harm in the next year, according to a 2018 study published in Cambridge University Press. Furthermore, statistics published by the American Foundation for Suicide Prevention show 39% of those who commit suicide visit an emergency room in the year prior to their death.
The bottom line: emergency care lacks the bandwidth to appropriately treat mental health beyond the physical threat, with poor or delayed care contributing to worsening mental states of those admitted for suicidality.
Can Managed Care Plans Restrict Insurance Coverage?
The journey to adequate mental health care does not end when the patient leaves the emergency department. After discharge, patients are faced with limited treatment options and unexpected financial strain.
John Schuler, a Ph.D. psychologist with a private practice, spent years on the Lake County Board of Health in Illinois. He explained that managed care, the insurance system currently used to address patient needs, restricts treatment so insurance companies can save money.
Managed care plans are largely credited with subduing medical cost inflation over the past four decades, but many managed care plans are provided by for-profit companies, which can prioritize profits over adequate health care coverage.
Attempts have been made to remedy the issues with managed care plans. Under the 2006 federal Health Insurance Portability and Accountability Act (HIPAA), employment-based health plans can’t discriminate against an individual member by denying eligibility for benefits or charging more because they have a particular medical condition such as diabetes or depression.
Denial of Benefits Based on Injury Exclusions
Insurers can, however, deny benefits for injuries that arise from a specified cause or activity. For example, insurers covering head injuries can choose not to cover concussions caused by extreme sports accidents. Such exclusions are known as source-of-injury exclusions. Sometimes, self-inflicted harm is a listed source-injury-exclusion, which means insurance providers can decide not to cover it.
Addressing concerns surrounding the persistence of insurer discrimination, Congress passed the Mental Health Parity and Addiction Equity Act in 2008. Under this act, insurance companies are required to apply the same criteria in determining coverage for physical and mental illnesses.
While this legislation ensures that behavioral health is incorporated into an individual's health needs, governmental enforcement of the behavioral health parity is still lacking. A national study conducted by the National Alliance of Mental Illness (NAMI) found that insurers deny mental health and substance use claims twice as much as they deny any other type of medical claim.
This issue may arise partially from the fact that mental illness lacks clear guidelines and treatment paths that exist with physical medical issues.
"There are no absolute predictive factors for suicide," Schuler noted. "Suicidal patients present with complicated problems that take up lots of treatment resources and cost a lot of money that managed care and insurance companies are disinclined to want to pay for."
Efforts to Combat Suicide and Bankruptcy
Hit with hospital fees that insurance won't cover, patients who visited the hospital for mental health issues may further struggle beneath the weight of the financial burden. A 2011 study published by the American Association of Suicidology found a connection between attempted suicide and bankruptcy, concluding that “individuals admitted to a trauma center following an attempted suicide were just over twice as likely to become bankrupt within two years compared to those who were admitted following an accident.”
Uncovered, unpaid hospital bills can be a slippery slope that leads to low credit scores and future financial turmoil.
Fortunately, the U.S. Department of Health and Human Services recently updated Medicaid managed care regulations aiming to introduce integrated care models. As explained by Health Systems & Reform, though there is no one model of integrated care, the most common populations that these integrated care models would address are individuals with multiple chronic conditions, older adults and those with moderate or severe mental health conditions.
It is likely that integrated care models will gain traction in the coming years, which is a positive note for those currently struggling with hefty insurance costs following mental health treatment.
For most mental health patients, recovery starts after hospitalization. Aftercare programs are key to providing accessible recovery plans. These programs can give patients coping tools and support systems for sustaining their recovery and reducing re-admission rates after the first year of discharge, according to the Journal of Research in Medical Sciences.
For Saenz, this wasn't the case.
"Fourteen hours after arriving, I spoke to a psychiatrist who decided to discharge me," Saenz said.
Saenz, like many others, wasn't directed to aftercare programs. She wasn't given a list of resources or facilities to connect with others experiencing mental health issues. She wasn't given a plan to heal.
"This is only the tip of the iceberg," Saenz said, as she continues to address the systemic failures by filing complaints with the New York State Office of Mental Health and New York State Department of Health.
"It's necessary that the public is made aware of how people in a mental health crisis are treated," Saenz said. "I may be young, but I'm willing to advocate and share my experiences knowing it may help somebody else to not feel alone."
Care to continue the conversation?
Visit the National Alliance of Mental Illness for advice on where to start.
Check out Mental Health America for a specialized list of support group resources.
If you're looking for a therapist, Psychology Today offers issue and location-specific recommendations.
If you or someone you know is struggling with suicidal thoughts, call The Lifeline: