Suicide is the tenth leading cause of death among Americans and the third leading cause among those age 15 to 24.1 As many as 36% of suicide victims leave a suicide note.2 Researchers have analyzed such notes with the aim of identifying specific content and patterns that might aid in creating more effective strategies for preventing suicide.3-5
One study found that the presence of a suicide note is an indicator of serious intent; that is, when the initial attempt fails, those who had left a suicide note were found to be at increased risk of subsequent completed suicide.4 Researchers also found that 75% of suicide notes contained the theme “apology/shame,” suggesting that many suicide victims might have welcomed an alternative to suicide to solve their personal predicament. Tragically, however, most suicide notes are not discovered until suicide has been attempted or completed.4
That’s where social media comes in. As platforms for self-expression, social networking sites such as Facebook, Twitter, and Tumblr are sources of real-time information that could aid in suicide prevention.6 With that in mind, we:
• present 2 cases in which a patient announced her suicidal ideation on Facebook
• consider the opportunities that social media present for early intervention
• propose high-tech monitoring methods for high-risk patients.
CASE 1 Major depressive disorder (MDD) and nonadherence
Ms. S, age 24, has a 4-year history of MDD and treatment nonadherence. She had no history of suicide attempt or inpatient treatment, but she had briefly engaged in psychotherapy before discontinuing visits. Physically healthy and employed as a security officer, Ms. S recently broke up with her boyfriend who had abused her physically—and against whom she had an order of protection.
On the day in question, Ms. S posted several status updates on Facebook expressing hopelessness, which, over the course of the day, escalated to expression of frank suicidal ideation:
• “I am ugly, no man would ever want to live with me.”
• “I have made no effect on the world and I’m just a waste of space.”
• “It’s sad that I want to die but such is life. We all die one day.”
• “I’m going to kill myself. It was nice knowing you world. Goodbye everyone.”
CASE 2 Substance abuse and previous suicide attempt
Ms. B, age 21, had a remote (approximately age 16) history of a suicide attempt and was actively abusing 3,4-methylenedioxymethamphetamine (MDMA [“Ecstasy,” “Molly”]) and Cannabis. She was not receiving outpatient care. One afternoon, Ms. B walked into the emergency department (ED) and said she had just taken 17 ibuprofen pills with the intent of killing herself.
On initial evaluation, Ms. B was irritable and uncooperative, denying all psychiatric symptoms and refusing to divulge details of her recent behavior. Her mother, who had not accompanied her daughter to the ED, reported that Ms. B had engaged in excessive risk-taking—speeding, driving while intoxicated, having multiple sex partners—for the past 5 years, resulting in several arrests for minor offenses, and she had been depressed and was sleeping and eating poorly in the 2 weeks leading up to the suicide attempt.
Two days ago, her mother added, Ms. B had posted disturbing notes on Facebook: ”Life is useless,” she declared in one post; “I’d be better off dead,” in another.
Suicidal content online
Worldwide, Facebook has 1.35 billion active users each month.7 Thus far, a limited number of posts indicating suicidal intent have been reported in the lay press,8 but evidence suggests that the use of social media for this purpose is an emerging trend.9
A search of the literature yielded only 3 case reports.8,10,11 In one case, a delayed response to a suicide note resulted in a failure to prevent the suicide.8 In another, a clinician’s discovery of a patient’s explicitly suicidal Facebook post led to what the team leader described as a more meaningful therapeutic relationship.10 The clinician’s discovery might have been pivotal in preventing the patient from committing suicide.
The authors of these case reports explored the idea of using Facebook for suicide prevention, raising a number of practical and ethical issues. Among them are the potential for immediate intervention by other Facebook users and the extent to which suicidal posts on social media sites induce copycat suicides.8
Issues associated with clinicians’ use of social media to follow or monitor patients include the ethical concepts of beneficence and nonmaleficence, privacy and confidentiality, clinical judgment, and informed consent,8,10 including potential benefit and harm and the difference between actual and perceived privacy violations. Bennett et al11 recommend developing guidelines for the use of social media to enhance medical care and provide appropriate protections to both patients and providers.
Reporting suicidal content. Although the primary purpose of Facebook is to give users the opportunity to share life events and thoughts with friends and family, the company does address the question of suicidal content in its Help Center (Box 1).12 As our 2 cases illustrate, however, intervention can be significantly delayed.