Opinion | Upending the Notion of What It Looks Like to Be Suicidal

The death of Stephen “tWitch” Boss in December hit the entertainment world and many in the medical and Black communities like a thunderbolt. It is seemingly unfathomable how someone with so much love, light, and promise who exuded happiness could end his life at just 40 years old, in a hotel room just a 14-minute walk from his home where he lived with his wife and three children. It just does not make sense.

His death and the deaths of so many others should send shock waves throughout the medical community as an impetus to effect positive change in preventing suicide. What is the why? What is the how? How can someone appear to the world as the epitome of joy but in reality be silently hurting and struggling to this degree, yet even their closest loved ones do not know? There is a hidden epidemic afoot, and we, as physicians and healers, must do everything in our power to rid our communities of it.

When I was a medical student, I learned that those who were considered to be at greatest risk of being “successful” (which is an adjective I’ve always cringed at using in referring to this topic) at suicide were older, white males. U.S. suicide rates today are highest among non-Hispanic American Indian and Alaska Native people, followed by non-Hispanic white people. Yet, we’re also are seeing an increasing number of Black men deciding to end their lives. From 2018-2021, suicide rates increased by 19.2% among non-Hispanic Black people, with especially high rates among Black men. Many factors likely contributed to this trend, but the data clearly show an increase in mood disorder symptoms during the pandemic. As we search for answers to what I would now consider to be one of society’s most pressing issues, we must revisit how we define, screen for, and understand depression with suicidality. We are clearly missing so many who are not meeting the classic definition — whether in regard to “typical” demographics or emotional presentation — of what it means to be suicidal.

Depression post-pandemic and access to care is becoming a newly defined health disparity. As suicide rates rise among Black men, I’m concerned that they do not have the same level of access to mental health services as some other racial and gender-defined groups, and this is accentuated in rural communities that often possess limited resources. The affordability of online services for cognitive behavioral therapy and counseling creates barriers to care. Stigma plays a role too: Black men are often uncomfortable with discussing their mental health, especially with non-Black and non-male medical practitioners for fear of being considered too weak to deal with the pressures of life. This stigma, which many of us unashamedly accept, is responsible for the untimely deaths of so many Black men and women. Too often we’re told to “just pray,” “depression is not real,” or “man up” or “woman up,” when all that’s needed is kindness, affection, understanding, and resources for treatment. Sadly, too many were never afforded these interventions.

In the early 1990s, I had an uncle commit suicide. The truth is, we knew about his mental illnesses for years and my family did everything in their power — especially my mom and my late grandmother — to afford him the treatments and services he needed. But so many people don’t even get a shot at this support. Oftentimes people around them may not know they need help — they are not speaking out, not sharing their true thoughts, and not being open about their emotional woes. They are often the people who appear the strongest. They smile ebulliently. They take care of everyone else. They foster joy for so many. They are empathic. They are sympathetic. They are bending over backwards to tend to the needs of others but they, themselves, have no recompense for their own emotional toll. Those are the emotions we want to know about, need to know about, and must know about.

These are the people for whom I write this piece. They appear strong, but feel weak, and hide it consciously from us, not affording us the opportunities to help. They are the unspoken and unmentioned in our long-standing efforts to study depression. They are the collective silent.

Psychiatrists often emphasize the unpredictability of suicide, but perhaps we don’t have to accept this as the status quo.

It is time for the medical profession to redefine depression and how we screen for it. As suicide rates increase among the Black community, we must innovate and study the efficacy of new screening tools for Black men and women, and incorporate the psychosocial factors that disparately impact these groups.

It is time for us to better understand and act on the health disparities and inequities that exist pertaining to access to mental health resources and services for Black men and Black women.

It is time for broader implementation of and funding for mental health counseling services within daily primary care in the private sector, health systems, and community health centers.

To the collective silent, please speak. For when you speak, your words will bring abundant life.

Earl Stewart, Jr., MD, is an internal medicine physician in Atlanta, Georgia, a 2023 Doximity Digital Health Fellow, and a 2023 Climate and Health Equity Fellow with the Medical Society Consortium on Climate and Health.

If you or someone you know is considering suicide, call the 988 Suicide and Crisis Lifeline.