Many clinicians regard suicide as murder – self-murder. Killing affects far more than those left dead. Many a suicide ends a life of intolerable anguish and pain. Some also send a furious message of failure and betrayal to friends, family, community and society. Today, suicide increasingly inflicts mass murder. We mourn the dead of the Germanwings flight that killed 150 in the Alps, its pilot researching suicide and cockpit doors in the days before the crash. We mourn the dead of mysterious Malaysian Airlines Flight 370 that ended somewhere in the Indian Ocean, its pilot perhaps acting similarly to the Germanwings’ pilot, Andreas Lubitz. Yet the question is many people’s minds is – what can we do to prevent this happening again? Answering that question requires recognizing the complexity and public health causes and effects of suicide:

1. Depression is a large risk factor for suicide – but many who kill themselves are not depressed. This may be particularly true for adolescent suicides, who wake up “okay” in the morning and are dead in the afternoon. Impulsivity is a major and generally unaddressed factor in suicide; many who die act within minutes of making a decision previously rejected or never even considered.

For depression produces a huge and increasing economic, social and psychological burden well beyond suicide. The overall economic costs may approach or exceed those for either cancer and heart disease. According to the CDC, 12% of American women aged 45-59 are currently depressed; perhaps 7% of adults at any given moment. They deserve not incarceration for potential self harm but prevention programs and better community and individual treatments than drugs and the smattering of psychotherapy commonly used today.

2. Power and personality strongly affect suicide’s potential for murder. Combining narcissism with totalitarian ideas is a particularly toxic mixture. Religious leader Jim Jones took more than 900 of his followers into death. Joseph Stalin arguably killed more humans than anyone in the twentieth century. Stalin was seminary student, a gang leader, extortionist, train robber and all-around thug before he became a major political leader. He might have been depressed when the Nazis invaded the Soviet Union in 1941, but that brief episode does not explain why he murdered tens of millions – including many of his most fervent supporters.
3. Ideology can quickly destroy any concern for common humanity. Perhaps the suicide bombers of ISIS are met in heaven by 72 virgins, or as one German linguist argues from the literary evidence, 72 white raisins. But separating people into those who “know” the truth – from everyone else – has made suicide-murder an increasingly common military, political and ideological weapon. Many a suicide-mass murderer has recognized, as is claimed for pilot Andreas Lubitz, that extreme actions sear their lives into the collective memory, even if that memory remains infamously infamous.
4. Means matter greatly. A loaded airliner is a frighteningly potent weapon. Successful suicide is much more common when people easily access lethal weapons.  The blurring line between suicide and murder includes the fact that more American now kill themselves with guns than murder others. The NRA correctly sees guns as a matter of individual rights. It must also recognize that it is a public health issue. Surely we can uphold our constitutional right to bear arms without adding tens of thousands filling up the cemeteries.
5. Put their livelihood at risk and people will lie. Pilots who declare themselves depressed must undergo increased surveillance, treatment, and bureaucratic messes. The result is that many never admit the truth – not just to the authorities but to themselves. Many truck drivers do not acknowledge they might have sleep apnea because they don’t want to lose their jobs. As someone who has treated narcoleptic aviators who flew without mishap for decades but fell asleep during mandatory eye exams, it’s clear there are many more obstacles to transport safety than depression.

Suicide is complex, its causes manifold, its results indescribably painful. Yet many “medicalized” attempts to prevent transport related suicides will fail. Decreasing the means for lethality – like requiring two people in the cockpit or finding a way for co-pilots to get back inside locked cockpits where their fellows may be suicidal – or just snoozing – possess a greater chance of success.

What may also help save lives is recognizing suicide is a societal, not just an individual problem. Every time we lose others we lose a part of ourselves. Minimizing those losses means both reforming our acknowledgement and treatment of depression – and a willingness to engage public health measures to prevent violent death.