When you grow up in Rhode Island, as I did, you absorb a lot of good news about the place. You learn that that the Ocean State is the birthplace of religious freedom and the Industrial Revolution; that the state is home to 400 miles of coastline, top-notch colleges, amazing restaurants, and the Newport Folk and Jazz Festivals; and that, generally speaking, we have good reasons for our optimistic motto: "Hope."
Later, when you return to live in Rhode Island as an adult, as I also did, you start to pick up on the bad news. You learn that our state—the nation's smallest—played an "outsize role" in the transatlantic slave trade; that we never fully recovered from the collapse of local industry; and that even after the death of our most famous political rogue, ex-con and former Providence Mayor Buddy Cianci, our politicians keep resigning in disgrace and/or getting indicted. A 2014 survey found that Rhode Islanders were the least likely in the country to praise their state.
But, a few years ago, there was a bit of bad news that seemed to exceed all others. In 2011, the Centers for Disease Control published a study indicating that Rhode Island had the highest rate of suicide attempts in the country. It was just one study, yes; but years later, it's still being cited by mental health advocates and medical researchers. And, more than any other fact, it seems to illustrate the horrifying extent of our local malaise. Is my home state the most hopeless place in the US?
That's a question I recently spent weeks investigating, by sifting through statistics and news reports and interviewing psychiatrists, government employees, researchers, and mental health advocates. And by the time I had arrived at a few answers, a new presidency had caused calls to suicide hotlines to surge. Now, my research seemed to have taken on broader urgency; an exploration of Lil' Rhody's depression may offer insights for a country where suicide rates recently hit a 30-year high.
But first, a few disclaimers.
One, suicide defies neat and tidy explanations. The American Association for Suicidology's list of risk factors runs three pages long, and includes everything from a history of trauma or abuse to a major psychiatric disorder (including mood disorders, eating disorders, and schizophrenia) to a recent divorce, and much more. Suicide is complicated, and any discussion of it should reflect that.
It's also astonishingly common. Nationally, there are almost three suicides for every homicide. In 2014, suicide was the second leading cause of death in the country for people between the ages of 10 and 34. In September, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) reported that 9.8 million American adults had serious thoughts of suicide in the past year. If it sounds to you like this problem doesn't get nearly enough attention, you'd be right. As a 2014 USA Today headline put it, "40,000 Suicides Annually, Yet America Simply Shrugs."
Thirdly, although Rhode Island seems to have an above-average frequency of suicide attempts, its rate of completed suicide is actually pretty low: 10.7, for every 100,000 residents, which places it in the bottom fifth of the country. (The national average is 13.4 per 100,000 people.) This gap between suicide attempts and completed suicide can be explained pretty simply: guns. Guns are by far the most common means of suicide in the US, and they are also the most effective (as opposed to, say, pills, or carbon monoxide).
"Places where gun ownership is higher tend to have higher suicide rates, because a little higher mix of people who are attempting attempt with guns," says Cathy Barber, a researcher at the Harvard School for Public Health and director of the school's "Means Matter" project. Rhode Island's low rates of gun ownership and completed suicides are paralleled in other low-gun-ownership, low-suicide-rate states like Massachusetts, New York, New Jersey, and Connecticut.
Lots of attempts but not many completed suicides. That leaves the question of what it is about the Ocean State that's been pushing more folks toward despondency and self-harm.
Some are fairly obvious. A 2015 report commissioned by the state legislature, for instance, paints an alarming portrait of the state's mental health. Among the report's findings: "Unemployment among parents in Rhode Island is higher than in other New England states, more children live in single-parent households, more children have inconsistent insurance coverage, and one in five children in Rhode Island is poor," which leads those children to "face greater economic, social, and familial risks for developing mental health and substance use disorders than children in other New England states and the nation."
Young adults in the state, subsequently, were found to be more likely to experience serious psychological stress than their peers nationally. The report also cites Rhode Island adults as having the highest rate of psychiatric general hospital admissions nationally.
Meanwhile, the state's mental health system seems ill-equipped to address this urgent and substantial demand. The same report reveals that one in five RI Medicaid beneficiaries hospitalized for mental illness had no follow-up treatment 30 days after discharge. In March of 2016, two mental health advocates described the state mental health system as "in shambles." (In a phone call for this article, the acting head of the state's top behavioral health agency disagreed with that characterization, saying the system was "being restructured" and experiencing "growing pains.") Combine those two factors—high rates of mental illness and inadequate care—and you're likely to have bad outcomes. And we do.
What else tends to cause people to sink into depression? Money, or lack thereof. "Suicidal behavior and depression occur more commonly in periods of economic slowdown," says Bob Swift, a professor of psychiatry at Brown University Alpert Medical School, who points out that RI was the New England state hit hardest by the Great Recession. One of the grave repercussions was the long stretch between 2013 and 2014, when we had the highest unemployment rate in the country. Denise Panichas, director of the Samaritans of Rhode Island, which runs a suicide-prevention hotline and collects (admittedly non-scientific) data about callers, tells me that "from 2008 onward, financial issues were almost always included in what people talked about" during calls.
And then there's the state's ongoing battle with substance abuse. As recently as 2015, Rhode Island led the country in illicit drug use and also had the nation's third-highest rate of alcohol poisoning deaths. And, like so many other states, it remains in the throes of an opiate overdose problem so bad that the governor has dubbed it a crisis. Last year, there were at least 270 fatal overdoses in Rhode Island. The year before brought 290.
Not every overdose is considered a suicide—untangling and identifying the exact causes of an overdose can be complicated—but experts say you can't fully separate substance abuse from the discussion of mental health. "If you have ongoing mental illness and you have an addiction on top of that, things are just worse, and [likewise], if you have a an underlying addiction and you have mental illness on top of that, things are just worse," says Jody Rich, an epidemiologist at Brown's medical school who specializes in addiction. Add the two together, he says, and "you're going to get more adverse outcomes."
Rhode Islanders joke about how we're rarely more than one or two degrees of separation from each other. But the state's famous smallness may also be contributing to our situation by amplifying the persistent—and tragic—stigma around mental health. If you're depressed, and concerned about anonymity when seeking mental health care, "in Rhode Island, what are the odds you're going to bump into a teacher, a friend, a neighbor…if you go to the doctor?" says Jessica Litwin, a board member at the Mental Health Association of RI. See someone you know on your way to get help, she says, and you might think, "Is it worth it?" and turn around.
In April of 2015, a 25 year-old Brown University graduate student named Hyoun Ju Sohn fell to his death from the 12th floor of the school's Science Library, in Providence. Police ruled it a suicide. It was a highly visible moment that brought up an obvious, yet important point: Every suicide is a human story.
Brandon Foster, a 21-year-old senior at the University of Rhode Island, was one of 129 suicides counted by the Rhode Island of Department of Health in 2015. Today, his Twitter and Instagram pages live on, as heartbreaking, de facto digital memorials. His Instagram posts are now forums for comments like "I miss you so much" and "You were so amazing. Hope you're enjoying peace now." Two days before he passed away, Brandon tweeted, "Now I just want to be done with life itself." His brother Cody, a 19-year-old Civil Engineering student at the Community College of Rhode Island told me, "From my personal experience, something like suicide can happen in just a matter of moments." You can't take anything for granted "and certainly can't wish for time to go by quickly," he says. "Before you know it you'll regret those two things."
In her recent testimony submitted to state lawmakers, Panichas reminded them that a suicide marks the end of pain for a victim, but the beginning for so many others. It could be the 911 operator who last spoke with the victim, or the family member or law enforcement officer who found them. "On the bridges, it could be the car in front of or behind a jumper," she wrote. "On the water, it could be a fisherman or coastal patrol. In the prison, it could a cell mate or a guard." In recent years, some news outlets have asked if it's time for suicide-barrier fencing on the state's iconic Claiborne Pell Bridge.
During my reporting I also spoke with Jim McNulty, the executive director of the Mental Health Consumer Advocates of Rhode Island, who lives with bipolar disorder and who has, himself, struggled with suicidal thoughts. One of the things people need to understand about suicide, he says, is that people who contemplate it feel that their backs are to the wall. "It can be that we can't struggle any longer [or that] we're tired," he says. He was once hospitalized for almost two months after a suicide attempt. And he says what brought him—and "all the people I know…who have either committed suicide or who have given it a serious run"—to that point wasn't existential angst. It was emotional pain. "That's what drives you to it," he says. (It can also sometimes be unremitting physical pain, he says.)
Swift left me with this simple advice: If someone expresses suicidal thoughts, take it seriously. Try to get them help. The good news is that for most people, suicidal thoughts are fleeting, he says. "Many times, it's a very impulsive thing. Somebody feels that their life is over and they're alone, things are hopeless, and they do attempt something and don't succeed, fortunately." From there, if friends and loved ones get involved, "a lot of positive things [can] happen….and they no longer feel suicidal," he says.
After my conversation with Swift—who (this being Rhode Island) lives down the street from my parents—I felt a little more hope, after all.
For more info on suicide and suicide prevention, go to the American Society for Suicide Prevention, or the Centers for Disease Control and Prevention. Free and confidential support is available nationwide via the National Suicide Prevention Lifeline : 1-800-273-8255. For Rhode Island-specific information about suicide prevention, go to can be found at samaritansri.org or health.ri.gov/violence/about/suicide/.