After a week in which two celebrities killed themselves and health authorities reported a national increase in suicide, this difficult topic is getting plenty of attention. But mental health experts said Friday it isn't enough to know the classic warning signs, which are not evident in many people who end their lives. In addition, they said, people should learn how to approach friends and loved ones they think may be at risk of hurting themselves, and speak to them frankly and compassionately.
Suicide rates have been rising in nearly every state, including a 34 percent increase between 1999 and 2016 in Pennsylvania, according to a new report from the Centers for Disease Control and Prevention. In 2016, nearly 45,000 people age 10 or older died by suicide, making it the 10th leading cause of death and one of only three top causes that are rising.
Celebrity chef Anthony Bourdain, 61, died Friday morning. Designer Kate Spade, 55, died Tuesday.
Spade and Bourdain were close in age to those with the highest suicide rates for their genders. For women, the highest rate of suicide occurs in those 45 to 54. For men, the suicide rate is highest for those 65 and older.
"Suicide can affect anybody. It is not a condition that is simple," said Matthew Wintersteen, a clinical psychologist at Thomas Jefferson University. "The conversation really has to be about help-seeking and supporting people who need help."
One reason people often do not seek help is because of the stigma associated with mental illness.
Teenagers and young adults have been more receptive to the message that they shouldn't be ashamed of mental illness and that it is treatable, but perceptions have not changed as much among older adults, Wintersteen said.
People who have what outsiders might regard as lives of good fortune, like Spade and Bourdain, may find it especially hard to admit they need help, said Thea Gallagher, clinic director of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania Perelman School of Medicine.
"People may feel they don't deserve to feel bad, that they have all these great things on paper," Gallagher said. "Most of us have a lot of great things on paper, but it doesn't mean we won't struggle.
"Feelings and mental health don't really discriminate, even if you have money."
Often it is not obvious that someone needs help.
Depression, anxiety, withdrawal from normal activity, isolation from friends and family, aggression and feelings of hopelessness are behaviors associated with suicide, Wintersteen said.
But more than half of people who died by suicide did not have a known, diagnosed mental health condition, according to the CDC.
It is always worthwhile to seek help. The majority — more than 80 percent — of people who seek help for depression are able to address the illness with therapy or medication, according to the National Institutes of Health.
"Suicide is a permanent solution to a temporary disease that could be worked out with treatment," said Ron Donatucci Jr., who leads the Philadelphia-based Michael P. Donatucci Foundation Inc., founded in memory of his brother, who died by suicide. "There's so much out there that can help you."
"It's a shame it takes celebrities to open up the dialogue and realize it does affect everyone," said Donatucci, whose group sends doctors to high schools to teach students and faculty how to recognize depression and anxiety, and help those in need.
For many, the warning signs are subtle.
Increased anxiety or substance use, reckless behavior, and mood changes are among the "more difficult warning signs" that people often don't associate with suicide, Wintersteen said.
Relationship problems, physical health problems, and stress caused by job, money, legal or housing challenges often contribute to suicide risk, according to the CDC.
"Most of [the signals] aren't people talking about suicide," he said.
Knowing the signs to look for is only part of the challenge. Approaching someone you think may need help is difficult not only because of the topic, but because most of us don't know how to have the conversation.
"Many people feel out of their depth and they're afraid of saying the wrong thing," said Stacey Cahn, a clinical psychologist and clinical associate professor of psychology at Rowan University Wellness Center. "You're much better off having the conversation and maybe not every word comes out the way you would have scripted it, maybe you're not eloquent — that's OK."
Cahn suggested picking a time when you can approach the person alone. Use "I" sentences to convey your concern about specific changes in their behavior you are worried about. ("I've noticed you haven't returned my calls for the past couple of weeks and I'm concerned because that's not like you," rather than "You don't want to talk to anybody, you don't want to hear what other people have to say.")
Your job is to make sure the person knows you aren't judging them and are there to help, she said.
People are often too cautious when it comes to talking specifically about suicide, but Cahn says that if you're worried, it's worth asking the question, "Are you thinking about suicide?"
"More often than not, people err in the direction of not asking. That's where the problem is," she said.
Asking the question, Cahn said "signals to the other person you're concerned and you can handle the conversation."
Some people may try to dismiss questions about how they're feeling because they don't want to burden others, Wintersteen said, but you can't give up too quickly.
"If you're worried about somebody, you need to take it one step further and say, 'OK, but I'm really worried about you and I'm worried things aren't fine,' " he said. "We want to deny the fact that anybody we care about is hurting, so it becomes complicated and challenging to push the envelope further when someone really is in trouble."
If the person does open up to you, it's important to listen carefully — rather than to try to fix the problem, Wintersteen said.
"We try to solve problems for our loved ones sometimes by talking. We try to talk someone out of being depressed or try to tell them what to do to get better," Wintersteen said.
"If we start by listening, that will also help us figure out what they need."