Suicides in Philadelphia rose sharply last year, a disturbing statistic that experts say they are trying to understand.
The 32 percent increase in self-inflicted deaths reflects higher numbers at virtually every age and among nearly all racial and ethnic groups.
Whites and men - particularly young and middle-aged men - make up the vast majority of cases. Women were up the most by percentage.
"We are concerned," said Deputy Mayor and Health Commissioner Donald Schwarz, who called the increase "extraordinary."
The police and the medical examiner "are looking at both the method of suicide and the circumstances of suicide," he said.
Job losses can push people over the edge. But the economic downturn really worsened toward the end of 2008, a pattern that is not fully reflected by the statistics. And no other county around the region experienced such an increase.
It could turn out to be a one-year anomaly. Still, the 196 suicides in 2008 are more than half the number of homicides recorded that year.
Homicides have been the subject of intense media coverage and public outrage.
Suicides often go unnoticed.
"Part of our work has been to convince communities that don't think they have a gun problem that they do, and part of the problem is that people are shooting themselves," said Charles Branas, an associate professor of epidemiology at the University of Pennsylvania who has studied suicide and homicide here and nationally.
"They don't think there is a problem because there is no public scrutiny."
Firearms account for about 41 percent of the city's suicides. That's lower than the national average of more than 50 percent.
While cities may have a reputation for violence, experts say, their rates of gun ownership are lower than elsewhere; firearms are the most lethal method available.
These are among the surprises that emerge from a look at the city's 196 suicides last year, up from 148 in 2007.
Here's another: Adolescents in the city say they attempt to kill themselves nearly twice as often as their peers across the nation, said Brian Daly, director of the Philadelphia Youth Risk Behavior Survey. But they go through with it at rates well below the national average.
While psychologists and psychiatrists successfully treat suicidal patients, preventing suicides across a broad population is difficult. There is no equivalent to the laboratory test for the flu, which both tells a doctor how to treat a patient and alerts public health authorities to prepare for spreading disease.
Experts say a number of conditions or circumstances are linked to suicide, and a combination of them - often triggered by sudden change such as divorce, relocation or death of a loved one - makes people most vulnerable. Research shows that dramatic news media coverage of suicide can be a trigger as well.
"Depression, especially for the older adult population, and then drug and alcohol use are major risk factors," said Gregory K. Brown, a psychology researcher at Penn's Center for the Treatment and Prevention of Suicide.
Higher income tends to make suicide less likely. Isolation - from friends, church and community - makes it more likely.
That may help explain why New Jersey, the most urbanized and one of the wealthiest states in the nation, has among the lowest rates of suicide.
Major metro areas such as Philadelphia usually are at or below the national rate. Rural communities are highest.
Every case is different, and perhaps the most important factor - what psychiatrist Marc Rothman calls "the imminent state of mind before suicide" - often isn't known until afterward.
Rothman, the chief medical officer at Friends Hospital in Northeast Philadelphia, recalled a case he followed at another residential institution several years ago.
A middle-aged man, admitted for anxious depression, had been improving during treatment. "Shortly before he was going to be discharged his wife told him on the phone that she was going to leave him," Rothman said, "and he went into his room and hung himself with a shoelace."
For decades in the United States, elderly white men have been at highest risk for suicide. While that is still the case, an October analysis of seven years of national suicide data found new trends among men and women.
"Whites aged 40-64 years have recently emerged as a new high-risk group for suicide," the authors concluded in the American Journal of Preventive Medicine.
National statistics lag three years behind, so it is impossible to determine how Philadelphia's 2008 suicide numbers compare. But they hint at a similar trend here.
So what could be behind last year's broad increase?
While experts don't discount the possibility that accelerating layoffs played a role - some crisis hotlines report more calls, others do not - they caution that a single year's change cannot be linked to a cause, financial or otherwise. Suicides in the Army are up. In the city of Baltimore, they are down.
There have been swings in Philadelphia's numbers before, although none quite this large. Suicides declined 16 percent in 2006 and remained unchanged in 2007 before rising last year.
"I'm more interested in learning why it went down in 2006, because that has potential to give us a clue for prevention," said city Medical Examiner Sam Gulino, who said he came to Philadelphia 10 months ago with a strong interest in using information about deaths of all kinds to prevent more in the future. Gulino said his arrival did not affect how deaths were classified.
And while 2009 has just begun, Gulino said that only 10 deaths so far have been determined to be suicides. Eight were in January. If no pending cases turn out to be self-inflicted, last month's tally would be the lowest of any January in at least seven years.
A continuing decrease would be welcome news. Either way, Branas, the epidemiologist who studies homicide and suicide, said 2008 could be seen as an opportunity to raise the issue for discussion.
"We should be thinking about suicide as a real public health problem," Branas said. "And I think we're not."
Experts say many people have suicidal thoughts at some point in their lives. The lowest point is temporary. The causes can be treated - ask for help.
National Suicide Prevention Lifeline: 1-800-273-8255.
City of Philadelphia Suicide Hotline: 215-686-4420.
Links to emergency centers and suicide-prevention information: http://go.philly.com/help