What sends teens to brink of suicide?

Editor's note: After the death of a 17-year-old Glen Rock honors student in February, The Record embarked on an examination of teen suicide and its prevention.

For every teenager who commits suicide in New Jersey, scores of others come close -- and live.

They are people like Stacy Hollingsworth, who scoped out ravines and trees where she could crash a car once she got her driver's license. As a college freshman, she hoarded 110 pills and wound up in a student health center threatening to swallow them.

"I didn't want to die, but it was excruciating to live," Hollingsworth says.
After trying 15 prescriptions for depression, she found a combination that worked and is now in her last year at Rutgers. She's had an internship at NASA. Still, she says, the depression is always looming. She has a suicide plan should the darkest days return.

"To this day, I feel like I'm not going to live that long, so I try to make the best of it," says Hollingsworth, 23. "You have this sense you're on borrowed time."

In the the 10 years ending in 2005, 634 New Jersey residents aged 15 to 24 killed themselves. Far more tried -- a chilling fact considering that teens who attempt suicide are three to 17 times more likely to try again. Many of those who survive are torn, sometimes daily, between hope that they'll make it and terror that they won't.

One 13-year-old in Paterson has a list of things to remember if he ever again wants to end his life:

"I'll think about my family's feelings. I'll think how I wouldn't see my mother again. I'll think how I wouldn't go to my church again and how I wouldn't see the Holy Ghost. I'll think how I would never play ball with my little brother again, and I like playing with my little brother."

A 38-year-old accountant who, at 15, swigged a mix of paint thinner and vodka laced with Raid feels like Jimmy Stewart in "It's a Wonderful Life."

"Each year that goes by, I think about what I would have missed and what a gaping hole I would have left in people's lives," the Hackensack resident says. "I'd have missed college and growing up and making friends and finding happiness. I'd have missed learning to ask for help and learning it's not a weakness and walking my grandparents down the aisle at my sisters' weddings. I'd have missed going to the beach and watching sunsets and growing into myself."

Need to intervene
New Jersey has a lower teen suicide rate than nearly every other state, but public health experts say no matter how small the numbers, intervention is crucial. That's especially true for young people, who are more likely than any other age group to attempt suicide. They're also the least likely to die that way.

In that gap lies a crucial opportunity to save young lives.
"Many of the kids who attempt suicide don't intend it to be lethal," says Mark Hatton, a private psychologist in Ridgewood. "Kids who attempt are sending up a flare, and if you can pay attention to that flare, you will probably stop them from moving toward suicide."

In response to a plea by the surgeon general in 1999, suicide prevention programs have been beefed up across the nation. In New Jersey, teachers are being trained to look for troubled adolescents, while teens staff suicide hot lines in some counties. At Rutgers, Hollingsworth established a student chapter of the National Alliance for the Mentally Ill to reach others like her.

"We want to catch kids before they even begin thinking of killing themselves," says Donna Amundson, a social worker who coordinates teams of health professionals around the state to respond at schools after traumatic events.

But nationally and in New Jersey, child psychiatrists are in short supply. Many programs are at capacity. Insurance doesn't always pay for the care young people need.

More than three-quarters of those who try to kill themselves are believed to be mentally ill -- but teens are widely under-diagnosed and under-treated. So much so that The New England Journal of Medicine recently concluded there is a "silent epidemic of mental illness among teenagers."

"Still too many kids are identified as having behavior problems, not mental illnesses," says Phil Lubitz, director of advocacy programs for the New Jersey chapter of the National Alliance for the Mentally Ill. "And the kids who don't misbehave -- the kids who are just in the shadows -- don't get identified."

So it was with Zach Toskovich, who threw himself off the roof of Glen Rock High School in February. The 17-year-old had seemed so well-adjusted and high-performing. It wasn't until his parents read his suicide note that they learned of his torment and that he had tried to end his life once before.

"We'd never even known," says his mother, Jane. "He wrote about all this terrible pain and how he couldn't live with it anymore, but if you don't let anybody know, how can they help you? My husband and I keep saying, 'Zach, why didn't you tell us? Why couldn't you tell us?' We never even had a chance to help."

Laura's story

Laura C. didn't hide her troubles.

She was hospitalized at 13 after a breakdown and diagnosed with bipolar disorder. She was hospitalized again at 15 after she told her mother about her plan to poison herself because her father had died. Six more hospitalizations would follow.

The Fort Lee teen later thrived in a small high school in Manhattan for mentally ill teens, which stressed creativity and individual attention.

But she later dropped out of Bergen Community College after a semester, finding it too big and impersonal, and she quit taking her medications. She began partying so much with younger teens that the police warned her she could be charged with contributing to the delinquency of minors. She started living out of her car, preferring that to arguments with her mother. Her depression deepened when her younger sister was sent to boarding school.

At 19, Laura drove to a deserted spot in Pennsylvania, wrote a goodbye note and swallowed a bottle of medications she'd been hoarding along with two bottles of painkillers.

Then she panicked. She started driving, frantically looking for help. She crashed into a stop sign and ended up in a psychiatric ward. When her insurance company pushed for her discharge after two weeks, she gouged her leg with a paper clip so they would have to let her stay.

Four years after attempting suicide, Laura is enrolled in a partial hospitalization program in Englewood, where she spends 18 hours a week in group therapy specifically for young adults.

She's lucky to have found it: There are few such programs aimed at young adults who are not in college. She's training at the center to become a peer counselor.

"You might be saving someone's life just by talking to them," says Laura, whose mother asked that the family's last name not be used. "People have done that for me."

Laura has good and bad days. She yearns for a job like everyone else and to move out of her mom's house, something that's impossible on the $321 she receives each month in Social Security disability benefits.

"When I'm depressed -- and I do still feel like that sometimes -- I always ask 'Why? Why do I have to feel this way? Why me?' "

But, she adds: "When I'm on my meds and they are regulated and I'm feeling good, I actually look at my illness as sort of a weird gift. I have this sympathy and empathy that others don't have."

Most of all, she's grateful to be alive. "I want to live a fulfilled life," she says. "I don't want to leave this planet without experiencing all the things I want to do."

Suicide factors

Experts believe there are genetic, neurological, psychological, social and cultural factors that influence who will attempt suicide.

Imaging studies and autopsies show that the region of the brain involved in regulating emotions and behavior is different in people who attempt or commit suicide than in those who don't. That may contribute to difficulties in solving problems.

To many suicidal people, dying is the only solution. That short-sightedness is particularly common among teens.

"Because of the lack of frontal lobe development, adolescents are old enough to comprehend problems on a deeper level but they don't yet have the coping skills to deal with them, and they haven't been on the planet long enough to practice those skills," said Andy Yeager, a school psychologist for Park Ridge. "Adolescence is a double whammy because they can't foresee consequences, like that 'dead' means forever. Add impulsivity and substance abuse and you have a recipe for disaster."

That was the recipe that nearly destroyed one man, who realized in horror at age 13 that he was gay. Though he denied it to his junior high classmates, he was taunted and ridiculed.

One evening, at age 15, he slipped behind the junior high where his troubles had begun. He mixed his cocktail of Raid and paint thinner and drank.
"I decided it would be better for my parents to think I'd died of my own hand rather than from gay sex," says the man, now a Hackensack accountant, who winces at the myopia of his youth. He waited to die.

"Suddenly, a feeling washed over me of intense fear, because as bad as things were here, I didn't know what was waiting for me on the other side," he says.

He stumbled into a Burger King. "Help," he sobbed. "Help me! I need help!"

What followed were years of fumbled efforts to deal with both his mental illness and his sexuality. The teen spent time in a psych ward and was diagnosed with manic depression, but even on antidepressants, his pain persisted because he refused to tell anyone why he was so miserable.

His life improved when he took his cousin's advice to open up to his therapist. He was placed in an alternative high school, where he finally made friends. But when his psychiatrist decided he was doing so well that he no longer needed medication, his condition deteriorated. In college, he relied on drugs and alcohol to quiet his manic depression.

At age 25, he came out to his family. "I was tired of hiding," he says. It took a while, but his folks came around. He feels closer to them now that they know who he really is and still love him.

Now 38, he continues with therapy and medication. He still thinks about suicide sometimes, but he always decides against it.

"I have too much good in my life, with my family and friends," he says. "I couldn't imagine hurting them that way. And if the feeling ever gets intense, I know to talk about it with my friends and my therapist."

Why do some people survive the struggle? What does it take to keep going?

"So much depends on the person's intent when they attempted suicide, their motivation, the underlying psychiatric disorder, whether they get effective treatment, and what support systems are in place," says Lanny Berman, executive director of the American Association of Suicidology.

Todd Haegler tried to end his life three times before he got the treatment he needed.

The first time, at age 15, he drank three bottles of Jack Daniels in the woods near his Midland Park home. After he was released from then-Bergen Pines County Hospital, his only follow-up care was a stern lecture from the family doctor. At 17, he tried again -- same poison, same place -- but changed his mind after two bottles and staggered to the road. His mother sent him to a psychiatrist for outpatient care, but he received no diagnosis and no medication.

For years, he drank, took uppers, downers and hallucinogens, and tried again to end it all, this time by overdosing. Only in middle age did he resolve to get help. "I was sick and tired of being sick and tired," he says.

He signed up for a 21-day stay at Bergen Regional Medical Center in a program for people with both mental illness and chemical addictions. It worked. Now 46 and living in Hackensack, he is back with his wife and has a new baby. He sees a psychiatrist regularly. For the last two years, he has been on medication for depression and bipolar disorder.

Finally, his suicidal thoughts are quiet.

After 31 years of thinking about suicide, he now talks openly about the joy of living. As a driver for On Our Own, a self-help center for the mentally ill in Bergen County, Haegler urges patients to believe in themselves.

"I tell them there's hope and not to give up," he says. "I tell them my story and that it's a miracle that I'm alive. I tell them that things are good for me and that they've got to hang on because things will get better for them."

Keys to survival

Though the nationwide suicide rate dropped 26 percent among 15- to 19-year-olds from 1990 to 2004 -- likely due to increased use of antidepressants and stricter firearm laws -- the portion of high school students reporting attempts has remained relatively stable.

In 2005, 8 percent of high school students reported in a national Centers for Disease Control and Prevention survey that they attempted suicide in the previous year. Most experts believe those are wild exaggerations. Interpretations vary greatly about what behavior reflects a true intent to die. Does swallowing four aspirins? Does scratching one's wrists till they bleed?

In teens and young adults, a suicide attempt is frequently preceded by conflicts with parents, problems with a romance, bullying, academic difficulties or the death of a parent.

The key to survival is getting young people to talk about their problems and their thoughts of suicide. "If you can talk about it, that already significantly reduces the chance of it happening," says Hatton, the Ridgewood psychologist.

In the last few years, New Jersey has organized Traumatic Loss Coalitions in each county to spring into action at schools after deaths, accidents or suicides to help students and staff cope. The groups also train counselors, pediatricians and police officers to spot early signs of mental illness in children and teens.

Last year, the state began requiring suicide prevention units -- on social problem-solving skills and how to seek help and manage emotions -- in elementary, middle and high schools. Legislators also mandated that teachers get two hours of suicide-awareness training, which some say is already paying off.

"Teachers are sending me more middle school students than before for evaluation," said Randie Fielder, a student assistant counselor for the River Dell regional school district, which serves River Edge and Oradell. "There's a lot of drama in sixth, seventh and eighth grade, but I think teachers are starting to listen to that drama more carefully. They know what to look for now. They realize that adolescence is a training ground for adulthood, and that mental health problems, if untreated, can become very serious later in life."

One Paterson boy was just 12 when he told his school counselor he wanted to die.

The seventh-grader ended up in a hospital for 10 days, then was sent to an after-school program for young people struggling with suicidal thoughts, depression and other mental illnesses.

After nearly a year of intensive group and individual therapy four days a week, he has learned not to get overwhelmed by his feelings. He recently graduated from the program.

"I know I might be depressed sometimes and maybe have suicide feelings," he says. "But I know I'll know how to handle it if I do."

"He's so much more assertive and he's learned to ignore things he wouldn't have been able to before," such as teasing by fellow students, says Jennifer Hayes, the program's director.

The same weekend that counselors took him out for Chinese food to celebrate his progress, 2,000 people gathered in Manhattan for a 20-mile overnight walk organized by the American Foundation for Suicide Prevention.

Some wore white beads, signifying the loss of a child to suicide. As dawn approached, the exhausted participants gathered by the East River and scrawled notes of remembrance:

"In loving memory of my little brother, Mike. R.I.P. Sweet Angel."

"Jesse, gone too soon and too young, but we'll watch your little girl."

"Brian -- I do this for you. Miss you day after day, hour after hour. Love, Mom."

Jane Toskovich sobbed for her son, Zach. She was embraced by another North Jersey mother, whose shoulders shook with grief, and dread.

The woman's 16-year-old son has been depressed since he was 8. Twice in the last 18 months, he has tried to kill himself by overdosing. She will always remember the thud she heard when her son collapsed.

"Every time I hear a loud noise, my heart stops," she says.

"I worry every day when I wake him up, when he goes off to school, when he's due back at home, when he's upstairs," she says. "I know what it's like to live in fear."

Above her, the night sky was fading slowly. Clouds blocked the sun. Clearly, it wasn't going to be a bright day, but at least the darkness had begun to lift.

Staff Writer Patricia Alex contributed to this article. E-mail: padawer@northjersey.com and diskin@northjersey.com

Valuable data

New Jersey is one of 17 states in the Centers for Disease Control and Prevention's National Violent Death Reporting System, which links police reports, death certificates and coroners' records.

It culls demographic data, toxicology reports, mental health history and treatment, previous attempts, problems with family, friends, school, job and the legal system, violence in the home and method of suicide.

The goal is to use that information to develop targeted and effective prevention strategies.

The quality of the data is uneven due to kinks in the infrastructure, but it is revealing nonetheless: For example, one third of teen suicides nationwide occurred within 24 hours of a family argument or school suspension. More than half of those deaths were committed with a firearm -- and, 82 percent of the time, the gun belonged to a family member. That prompted a public education campaign about the link between suicide and firearm storage in the home.

In New Jersey, preliminary data indicate that male adolescent suicide is often an impulsive act in response to a problem at home or in school, frequently less than 24 hours before the suicide. As a result, prevention efforts now emphasize ways to reduce family conflict.

New Jersey's research also shows that adolescent girls who kill themselves typically have more established mental illnesses than male teens. About one in seven suicide victims up to age 24 had a criminal or legal problem. One in five had substance abuse problems.

-- Ruth Padawer

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Q&A

Suicide prevention organizations offer the following answers to common questions:

What are signs someone might be considering suicide?

Sadness, anxiety, guilt, helplessness or hopelessness. Trouble eating or sleeping, or sleeping all the time. Withdrawing or losing interest in hobbies, work or school. Trouble concentrating. Irritability or impulsiveness. Substance abuse.

What's the difference between suicidal behavior and adolescent moodiness?

Watch for extreme changes in behavior: a shy, bookish child suddenly hanging with a partying crowd; or a gregarious child staying in his room all the time.

Do young people hide signs?

Don't assume that everything is fine just because a kid is quiet, doing well in school, and has a lot of friends and a bright future. Depressed and suicidal people can work hard to hide feelings while functioning socially and academically. Making the decision to die sometimes helps the person appear calm and behave normally.

Is cutting oneself a suicide attempt?

Sometimes cutting and other self-mutilation are ways of handling difficult or stressful feelings. Many do not go on to more lethal behavior. But, for some, it is a prelude to suicide. Either way, the person needs counseling.

If you are worried someone is thinking about suicide, should you ask them?

Yes. People don't start thinking about suicide because someone has brought up the subject.

What should you say?

Be direct and be willing to listen. Don't be judgmental or act shocked. Urge counseling. Offer support. Don't be sworn to secrecy; let him know you plan to seek help.

What signs suggest suicidal thoughts have turned into a serious plan?
Talking openly or writing about death, dying or suicide, or indirectly about "wanting out" or "ending it all." Taking unnecessary or life-threatening risks. Giving away personal possessions. Seventy-five percent of all people who die by suicide give some warning to a friend or family member, though the message is sometimes missed.

What should you do?

Take action. Remove means, such as guns or pills. Do not leave him or her alone. Get help from a crisis agency, emergency room or a psychiatric hospital.

If somebody really wants to die, can anything truly stop them?

Most people who think or talk about suicide are ambivalent about dying. Suicidal ideas frequently result from treatable mental disorders so getting professional help is essential. Medications or therapy may be needed.


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Facts and figures

There are huge variations in suicide rates by age, gender, race and geography:

AGE

Though adolescents are far more likely to attempt suicide than older people, their attempts are very unlikely to be fatal. Those under 20 have the lowest rate of suicide of any age group; the rate climbs as people age. Suicide is 50 percent more likely among those over 65 than those aged 15 to 24. People over 85 have the highest suicide rate.

GENDER

Adolescent girls have both the highest rate of attempts and the lowest rate of suicides compared to the rest of the population. High school girls are twice as likely to report attempting suicide than boys. Yet among youth 15-24, boys are four to five times more likely to kill themselves.

RACE

Suicide attempts vary widely by race, too. In 2005, 15 percent of Hispanic female high school students nationwide reported that they attempted suicide the previous year, compared to 5 percent of white males. Yet whites are more likely to kill themselves. Among 15- to 24-year-olds, whites are 53 percent more likely to commit suicide than blacks. The rate among black females is the lowest of all groups.

GEOGRAPHY

New Jersey consistently has a lower suicide rate than nearly every other state. Around the nation, suicide rates are generally highest in rural states. Alaska's suicide rate is 23.6 per 100,000 people. Montana's and Nevada's are 18.9. New Jersey's is 6.9.
New Jersey, with 2.3 million youths aged 5-24, had 16 firearm suicides in 2004, while Arizona, with a higher gun ownership rate but only 1.7 million youths, had 79 firearm suicides.

OVER TIME

Suicide rates for those aged 15-24 tripled between 1955 and 1975, particularly among males, then remained stable through the early 1990s. Since its peak, the rate has plummeted 26 percent among 15- to 19-year-olds and 22 percent among 20- to 24-year-olds -- drops likely due to stricter firearm laws and new psychiatric medications.

The rate of teen suicide rose somewhat from 2003 to 2004, but experts say it's too soon to know if that's a statistical blip or a reversal of a decade-long trend.

Ruth Padawer

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