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From the Townsend Letter
November 2016

Integrative Medicine for Suicide Prevention:
Effective Models to Prevent a Global Public Health Epidemic
Part 2
by James M. Greenblatt, MD, and Virginia Ross Taylor, PhD
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Social Media
A possible link between social media use and suicide risk deserves study, especially because of the pervasiveness of social media in the lives of most American teenagers and young adults. On a typical day, 70% of teens, or 17 million young people, spend time on social networking sites. In fact, nearly all Americans between 18 and 24 – or 98% of them – use social media (O'Keefe & Clarke Pearson).
Some research studies trace a link between intense involvement with the Internet and disturbances in daily functioning and real-life social interactions (Morahan-Martin & Schumacher). Because of a tendency to promote a virtual life rather than deepening real relationships, the American Pediatrics Association Council on Communications and Media identified "Facebook depression" as a potential problem for both 'tweens and teens (O'Keefe & Clarke-Pearson). One research team described teenagers and young adults as subject to "iDisorders," which they define as the relationship between technology use and deteriorating psychological health (Rosen et al.).
Heavy Internet use can signal mental health problems, but what about a connection with suicide? It has long been known that media reporting and film and television portrayals of suicide can increase the risk of suicide in young people. On occasion, a rash of suicides using a particular method has occurred after a media depiction of its use. As some methods are more lethal than others, these media events may influence the outcome of suicide attempts modeled after them. Possibly the Internet could promote similar contagion.
Studies from the Pew Research Center suggest that reliance on social media can perpetuate poor body image, problems with self-esteem, and depression. Today 92% of teenagers go online daily, and 24% report being online "almost constantly." Especially for young girls with eating disorders, this unprecedented connectedness causes serious concerns. Although some online communities promise support in recovery, a larger number, and those increasingly visited by girls struggling with eating disorders, promote just the opposite. Websites such as Pro Ana and Pro Mia draw in young, vulnerable girls with suggestions about how to lose weight quickly and how to deceive parents or doctors who may be monitoring their food intake. Many other sites foster a culture of thinness by featuring photos of girls proudly displaying severe weight loss as ideals and offering inspirational quotes and encouragement to lose even more weight. In the hands of an adolescent struggling with an eating disorder, the Internet is an unmonitored invitation to harmful information with the potential to accelerate the eating disorder.
Nationwide, 68% of girls report having had a negative experience on a social networking site (O'Keefe & Clarke-Pearson). Instances of cybersuicide – cases of attempted or completed suicide influenced by the Internet – have been featured in both the academic and the popular press.
Through social media and the Internet, young people can find both information and communities that encourage suicide. A recent study of suicide sites found them easily accessible through all the major search engines. Although the total numbers of prosuicide and suicide prevention sites are about the same, the most frequently occurring sites, producing the top three hits, are all prosuicide. The site Alt Suicide Holiday (ASH), for example, is so easily accessible that it can be reached using 10 different web addresses. Prosuicide websites provide explanations of different methods of suicide and compare them by speed, certainty of outcome, and likely amount of pain. While it is illegal in Australia to use the Internet to promote suicide or furnish information about how to do it, in the US these sites are not illegal. Even Wikipedia provides detailed information about suicide methods and their effectiveness rates. The Internet also provides avenues for ordering prescription drugs and poisons that circumvent both customs and government regulation.
Prosuicide websites appear to be accessed by people considering killing themselves. A cross-sectional study based on detailed review of inquest reports of suicides in areas served by 12 coroners in England found that the Internet was consulted before each death. The investigators concluded that easy access to information about suicide methods on suicide websites appears to contribute to a small but significant proportion of suicides, especially information concerning methods (Gannell & Bennewith).
In addition to prosuicide websites, extreme communities have formed online. Some who have visited these sites report having been encouraged to use suicide to end their struggles and find peace. Contributors to chat rooms sometimes exert peer pressure to commit suicide, idolize those who have completed suicide, and encourage others to join with them in suicide pacts. For young people who are ambivalent, this pressure can strengthen their resolve to kill themselves while discouraging them from backing out of a pact or getting help (Biddle et al).
Broader studies link Internet use with suicide. Oxford researchers published findings in 2013 that analyzed 14 previous studies. They found a strong correlation between young people using Internet forums and increased risk of suicide. Vulnerable teens tend to spend more time on the Internet than other teenagers. One study showed that more than half – 59% of young people interviewed – had researched suicide online. Of the teenagers who had harmed themselves, 80% reported researching methods of self-harm online beforehand. Biddle and colleagues (2008) conducted a Web search of 12 terms associated with suicide and found that half of these searches were conducted by those seeking information about method.
What We Can Do
How to untangle the many risk factors that culminate in an act of suicide may remain unclear. But with information now available from the field of integrative medicine, we can lower suicide risk in our patients and in our communities.
These are steps we can take now. 

Implement Nutritional Best Practices.
Nutritional interventions show great promise for suicide prevention. Omega-3 fatty acids and cholesterol are the most important molecules in the synapse, where most brain function occurs. Low levels of omega-3 fatty acids and low cholesterol levels both interfere with neurotransmission. High levels of omega-3 acids, on the other hand, even have anti-inflammatory effects. All of these – low omega-3s, low cholesterol levels, and inflammation – are treatable somatic conditions.
Testing for vitamin D status, omega-3 levels, lithium, and cholesterol is a simple part of an individualized nutritional assessment. It can reveal deficiencies that are critical to improving psychological wellbeing. If needed, supplementation with vitamin D, omega-3 fatty acids, cholesterol, and lithium can provide patients with protection against the risk of suicide.
Test For and Treat Inflammation.
Vulnerable patients should be tested for the presence of pro-inflammatory cytokines and treated with anti-inflammatory medications as needed.
Identify and Treat Epigenetic Changes that Increase Suicide Risk.
Although a genetic predisposition to suicide is not treatable in the same way, the epigenetic changes associated with suicide can be identified and reversed. Nutritional intervention can modulate epigenetic markers associated with suicide risk.

Diagnose and Treat Eating Disorders.
A more individualized approach to eating disorder treatment entails identifying and addressing the behavioral, genetic, environmental, and nutritional root causes behind the disorder. Patients need specialized intervention that minimizes frequently co-occurring depression and suicidal behavior.
Use Social Media to Promote Suicide Prevention.
We need to be realistic about use and accessibility of social media and to educate clients and communities about their dangers. Just as important, we should ensure that suicide prevention is promoted online and on social media platforms. This should include online suicide intervention tools that teens can access.
Enhance Factors that Protect against Suicide.
This two-part series has focused primarily on factors that increase the risk of suicide. In addition to addressing these factors, health professionals need to promote factors that protect against suicide. These include family and community support and a sense of belonging at school. Religious beliefs and even regular attendance at religious services have recently been identified as protective factors against suicide even beyond their benefits as social support (Burshtein, Dohrenwend, Leva, et al.).
Suicide is a complex problem. On an individual level, it devastates families; on a national level, it is an issue of great public health importance. As suicide involves the interplay of so many factors, it challenges efforts to prevent it. But no problem is more costly in terms of unnecessary suffering and loss of years of potential life. The CDC's report of the steady increase in suicides in America makes clear that we need more research in neurobiology and epigenetics to gain a better understanding of mechanisms that lead to suicide. As clinicians, we need to do a better job of monitoring patients, especially those with depression, bipolar disorder, eating disorders, and comorbid substance abuse. We need to address nutritional deficiencies and inflammation. Primary care physicians as well need to be vigilant in monitoring patients for whom they have prescribed medications that may heighten risk of suicide-related behaviors. We need more study of factors that protect against suicide. There is no more important task for us as a society than integrating the interventions we know are effective in order to prevent suicide. It is time to bring the results of research into clinical practice to prevent suicide. There is no more urgent need in all of psychiatry.


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