Suicide: The fourth-leading cause of American deaths abroad

By Gary Stoller, USA TODAYUpdated 2h 2m ago

Tom Miller jumped from the eighth floor of a hotel in the Philippines in February, and Gerhard Habel hanged himself in his apartment in Thailand last April.

These incidents aren't entirely unrelated. Suicide by an American in a foreign country is a more common occurrence than might be thought. It's the fourth-leading cause of death abroad from non-natural causes after road accidents, homicides and drowning, according to the Centers for Disease Control and Prevention.

The deaths of Miller and Habel stand out, though, because they were reported to the media by local police, and some information about the tragedies was made public.

Though more than 125 American suicides abroad are reported annually to the State Department, there is no public profile of most who commit the tragic act. For privacy reasons, the State Department will not provide victim information such as name, age, gender or addresses abroad.

"The travel medicine community could take preventative steps if there was more knowledge about risk factors and circumstances of those individuals who are committing suicide abroad," says Stephen Hargarten, director of the Injury Research Center at the Medical College of Wisconsin.

The Centers for Disease Control and Prevention does keep a profile of those who commit suicide within the USA.

Of more than 33,000 suicides annually, males represent 79% of all suicides, and suicide rates are highest among those 75 and older.

USA TODAY spent two months investigating suicide abroad, tabulating 10 years of State Department data, searching newspapers throughout the world, reviewing thousands of studies in professional journals and interviewing psychologists, sociologists, travel medicine experts, medical examiners and forensics experts worldwide.

USA TODAY's analysis of State Department statistics — which show only the date and city where a suicide occurred — found that a suicide abroad is reported an average of every 2½ to three days.

In reality, American suicides abroad are probably much more frequent. The State Department says many American deaths abroad — regardless of cause — are not reported to it.

Medical examiners and forensics experts say that suicides abroad may be classified as accidents, drowning or a cause other than suicide, because many countries do not properly investigate or perform autopsies to determine cause of death.

From October 2002 — when the State Department began reporting deaths abroad — through December 2011, 967 American suicides abroad were reported to the State Department, according to USA TODAY's analysis.

The past four years have the highest annual totals: 129 in 2011, 133 in 2010, 114 in 2009 and 111 in 2008.

It's unknown what portion of those suicides involved vacation or business travelers, Americans living abroad, dual nationals returning home, students studying abroad or inmates in foreign jails. The State Department says the deaths do not include government workers and military personnel.

Every year, Mexico is, by far, the country where more Americans commit suicide than any other. Last year, 26 American suicides there were reported to the State Department.

The second-highest number of American suicides last year — 13 — were in South Korea.

Other countries with a relatively high annual number of American suicides are Germany, Thailand and Costa Rica.

Many possible causes cited

Though data on the psychiatric health of travelers is very limited, psychologists and travel medicine experts say there are many reasons why a traveler might commit suicide abroad.

Stress while traveling "is often unexpected and can lead to unpredictable behavior," says Assunta Uffer-Marcolongo, president of the Toronto-based International Association for Medical Assistance to Travelers.

In people who are depressed or schizophrenic, or have mood disorders, "travel can trigger thoughts, emotions and behaviors that — if not managed and supported by medical professionals — can lead to hurting themselves or others," she says.

A 2010 survey of doctors affiliated with the association found that 21% of them see travelers with mental health concerns every year, Uffer-Marcolongo says.

Psychologists and travel medicine experts say people with mental health problems sometimes travel abroad to get away from their problems but then find that distance doesn't solve them.

"Suicidal people try to get away geographically from their problems, but everywhere they go, the problems are there," says Ronald Maris, a social psychologist and founder of the Center for the Study of Suicide. "People who are more mobile tend to be more suicidal."

Thomas Gutheil, a professor of psychiatry at Harvard Medical School, says "dislocation and disorientation, which can happen with travel, are risk factors" for suicide at home or abroad.

"Sometimes, the wish to leave the country masks a wish to leave one's troubles or depression behind," Gutheil says. "When the depression stays with you, some people may give up hope."

Psychologists say that foreign languages and customs can disorient people traveling abroad, make them feel lonely and unable to fit in.

Vulnerable people — particularly solo travelers — "sometimes break down in strange environments with lots of novelty and few social support," Maris says.

Some people intentionally travel to landmarks or "iconic sites" — including well-known bridges, towers, mountains and buildings — to commit suicide, says Eric Caine, chairman of the psychiatry department of the University of Rochester Medical Center in Rochester, N.Y.

Psychologists say that some people travel to other countries for assisted suicide or to more easily obtain drugs used to commit suicide. Use of drugs or alcohol drugs can also lead to "accidental suicide," Uffer-Marcolongo says.

Adventure travelers are sometimes hospitalized for "acute situational psychosis" caused by "extreme and grueling" mental and physical activity, she says.

Similarly, some travelers "become overwhelmed by their surroundings" — sometimes called Stendhal or Jerusalem Syndrome — and "exhibit symptoms of psychosis."

Rates higher for elderly, young

Many elderly Americans — including retirees and former military personnel — live abroad, and there's a growing number of young people studying abroad. Psychologists and medical experts say suicide rates are highest among elderly people, and suicide is the third-leading cause of death of 15- to 24-year-old Americans.

Some studies report that it can be very stressful to live abroad or move abroad for a job.

A 2008 study by Marius van Aswegen, a South African industrial psychologist, found that "extensive travel and international assignments have a substantial impact on an individual's psychological well-being."

A 2009 study by van Aswegan reported that relocation to a foreign country can cause culture shock and, "in extreme cases," lead to "severe levels of distress."

Australian public health and tropical medicine experts Louise Stewart and Peter Leggat say in a 1998 study that people with culture shock "tend to suffer alone, thinking that they are the only ones not coping well with their new circumstance."

Stewart and Legatt point to a 1986 study by British medical experts that says "contact with an unfamiliar culture" may be stressful, "potentially harmful" and lead to culture shock, hostility and poor interpersonal relations between people of different nationalities."

Some psychologists say that a foreign country's suicide rate may be relevant to the likelihood of an American who lives in the country committing suicide there. Other psychologists say that Americans carry abroad unique psychological problems, and the suicide rate of a foreign country does not necessarily apply to an American living there.

Guilherme Borges, a professor at the National Institute of Psychiatry in Mexico City, says that Americans living in Mexico bring their own unique problems with them when they move to Mexico and, in the short term, wouldn't be affected by the causes that contribute to Mexicans' suicide rate.

Though many more American suicides are reported in Mexico than in other countries, the suicide rate in Mexico is low.

According to the most recent World Health Organization statistics, seven males and 1.5 females per 100,000 Mexicans committed suicide in 2008.

That compares with 17.7 males and 4.5 females per 100,000 Americans who committed suicide in 2005, WHO statistics show.

Borges, who authored a study that shows Mexican migrant workers in the USA have a higher suicide rate than Mexicans in their home country, says many elderly Americans retire in Mexico, and that may be one of the reasons why so many Americans commit suicide there.

A simple explanation could be that more Americans travel to Mexico, and more live there, than any other foreign country. But there are few American suicides in Canada, the second-most visited country and the No. 2 nation for Americans relocating abroad.

Ilan Shrira, a social psychologist at the University of Florida, says suicide rates are high in Arizona, Nevada and Colorado — states where a large number of residents travel to Mexico. The rates are lower in Northeastern and Midwestern states, where many residents travel to Canada.

Societal differences involved?

Shrira says it's also possible that more American suicides in Mexico are reported to the State Department than those in Canada. More people may travel by plane to Mexico than to Canada, and the State Department may be contacted to help ship a body back by air, he says.

Michael Baden, a forensics pathologist who testified in the O.J. Simpson murder trial and other high-profile cases, says Canada has a good coroner system, while Mexico's system is "haphazard."

"I'd imagine it would be more likely in Mexico for homicides to be called suicides than in Canada," Baden says.

Several psychologists and medical examiners — including Shrira, who questions whether some drug overdoses in Mexico are "misclassified" as suicides — say there is greater availability of drugs in Mexico than in Canada.

Rita Marker, executive director of the Patients Rights Council, which provides information about euthanasia and assisted suicide, says sodium pentobarbital, which can be used for suicide, can be bought inexpensively in Mexican pharmacies and clinics.

Last year, Arturo Jose Iniguez, an assistant district attorney in Cameron County, Texas, committed suicide by ingesting that drug, according to the attorney general's office in the Mexican state of Tamaulipas.

Armando Villalobos, Cameron County's district attorney, said it's possible that Iniguez was forced to drink the drug, accidentally overdosed or committed suicide.

Though psychologists have various theories why a relatively large number of Americans commit suicide in Mexico, few offer theories why South Korea ranks second.

USA TODAY's analysis shows that 25 American suicides in South Korea were reported to the State Department during the past two years, while only six were reported in Canada.

According to the most recent U.S. Commerce Department data, only 599,000 U.S. residents traveled to South Korea in 2010, compared with 11.7 million who went to Canada and 2.4 million who traveled to the United Kingdom, Americans' most popular overseas destination.

The most recent State Department statistics — published in 1999 — show that just 30,000 Americans live in South Korea. More Americans live in 19 other countries, including Canada, where 688,000 Americans live.

Some psychologists suggest that the relatively large number of American suicides overseas in South Korea may involve many dual-nationals returning to their home country, and Shrira and Caine point out that South Korea has a high suicide rate.

According to the World Health Organization, 40 males and 22 females per 100,000 South Koreans committed suicide in 2009.

Whether it's South Korea, Mexico or another country, more data is needed to establish profiles of the Americans committing suicide abroad, psychologists, travel-medicine experts and medical examiners say. Then preventive action can be taken and, maybe, lives saved, they say.

"There isn't a large body of research on travel and mental health issues, but it's starting to become a prominent concern in the travel medicine field," Uffer-Marcolongo says.

The State Department says its officers at consulates and embassies abroad are not mental health professionals but can put Americans in contact with suicide-prevention resources, English-language hot lines, mental health experts and social-service agencies.

Hargarten of the Medical College of Wisconsin says government agencies and the medical community need a joint effort.

"Federal agencies, such as the State Department and the Centers for Disease Control should work together with academic health centers towards improving our knowledge and understanding of these tragic events of U.S. citizens," Hargarten says. "As we have seen with other challenging areas of health, greater knowledge leads to evidenced-based prevention strategies and programs."

Suicide: The fourth-leading cause of American deaths abroad