In Florida’s murder capitol, gun suicides are overshadowed by gun homicides

It had been scarcely a year since his son was discharged from the Navy following a suicide attempt, Ramon Day said, and only a few months since he’d voluntarily undergone in-patient care at Mental Health Resource Center in Jacksonville, Fla.

So, when then 25-year-old Tyler Day returned from a Department of Veterans Affairs counseling appointment and offhandedly mentioned that he’d bought a gun, his father was stunned.

“You having a gun upsets me a great deal,” Ramon Day said, recalling his fright over his son’s revelation back in the summer of 2011. “If you would do me a personal favor, return the gun.”

Tyler Day did return the gun. But whatever relief his father felt was short-lived. 

“If you are receiving this email,” his son had written in November 2011, according to Day, “know that I love you and I just can’t continue living in the world with what I’m dealing with. So, good-bye.”

Tyler Day had gone to a shooting range, rented a gun and fatally shot himself. “It hits you like a ton of bricks,” Day said.

Jacksonville, where the Day family lives, is Florida’s reputed murder capital, with most of those deaths by a rising tide of gun violence. Much less attention is paid to the region’s suicides, or that firearms were used to commit 97 of the 158 suicides, or 61%, that the Florida Department of Health counted in 2020 in Duval County, population 957,000. Of those residents, 890,000 are in Jacksonville. In 2019, firearms were the cause of 94 of 177, or 53%, of suicides documented in Duval County. In 2010, 58 of 114, or 51%, of suicides were by firearms. 

In 2019, Duval County’s suicide rate of 17.4 per 100,000 people was higher than both the national rate of 13.9 per 100,000 and Florida’s statewide rate of 14.5 per 100,000, according to the federal Centers for Disease Control and Prevention’s most recent data.

Nationally, the suicide rate rose 33% from 1999 to 2019, according to the CDC. Suicide rates rose 15% in Duval County and 37% statewide during the same period, the the state's health departement reported.

Suicide ranked last on the list of 11 top causes of death annually between 2015 and 2020, according to a study published in March 2021 in JAMA (Journal of the American Medical Association) that also concluded there was a 6% nationwide decline in suicides between 2019 and 2020. That, researchers wrote, was the biggest decline in four decades.

Those trends notwithstanding, the 211 suicide hotline that Lutheran Services Florida Health Systems funds through United Way still has been inundated, said Christine Cauffield, chief executive officer of that organization. It provides, among other services, mental health counseling for the uninsured and under-insured, support to foster youth and foster families and Head Start for preschoolers to Floridians in 23 counties. “We have not seen a downturn in the number of calls, unfortunately, because people are still struggling with the depression, the anxiety, the feelings of hopelessness, even as we’re starting to open up,” Cauffield said.

Several factors fuel silences surrounding suicide

Part of the reason why suicide often is off the public radar is the social stigma attached to it. Relatives of those who kill themselves often are ashamed to disclose that information; and the news media have a long-standing practice of not putting suicides in the headlines.

But during a pandemic that has driven record numbers of people to seek mental health counseling, some have talked more openly about mental health issues, including suicide. In the last year, Florida has increased spending on mental health care, a system that experts have long described as chronically underfunded, overburdened and confusing because, among other reasons, separate groups provide overlapping services.

Critics have, at least in part, linked Florida’s comparatively poor health outcomes on Gov. Ron DeSantis’ and his predecessor’s refusal to expand Medicaid coverage, including for mental health treatment, for the working poor through former President Obama’s Affordable Care Act. The federal government currently funds 90% of those added Medicaid costs.

But DeSantis has been applauded for adding $25 million last December to mental health services funding in schools and accepting $23 million in federal COVID-19 relief aid to expand mental health and substance abuse services. The state budget for the upcoming fiscal year expands the 211 hotline, telemental health services for rural children and mental health training in schools. Cauffield described the administration’s approach to mental health as a “breath of fresh air.”

Some local entities, including Lutheran Services Florida Health Systems and Here Tomorrow, a nonprofit that opened in January, have used the ramped up focus on mental health as an opportunity to offer new and additional services aimed, among other things, at increasing mental health care access. 

Mental Health for America ranked Florida 48th, overall, for its access to care and menu of mental health services.

Grand Jury: Florida's mental health care is "a mess"

Convened in February 2019 in the wake of the 2018 Parkland school shooting, a  special grand jury examining Florida’s mental health care system decried the state’s lack of funding, interagency conflicts over privacy and information-sharing, inadequate or ineffective services and other deficiencies.

“To put it bluntly, our mental health care ‘system,’ – if one can even call it that – is a mess,” the grand jury's report read.

Not fixing such deficiencies would come at a human cost, the grand jury warned. “It is clear to us that inadequately addressed mental health issues have the peculiar potential to spiral out over time into criminal acts and violent behavior resulting in serious injury and loss of life,” according to the report.

Cauffield agreed that Florida’s mental health care system is underfunded, but lamented the broad brush with which the report painted Florida’s behavioral health system. She said that several aspects do function well, such as the 211 crisis line for people experiencing suicide ideation and other mental health crises.

Still, Cauffield acknowledged that there’s room to improve Florida’s mental health system. She argued that the seven Department of Children and Families-designated entities that provide care remain siloed, in spite of legislation that was intended to improve communication and information-sharing. That creates confusion and wastes resources, she said.

“If the legislative intent had been carried through, we would not be seeing these various systems operating independently … I do believe that there is a lot of duplication and services and it could be managed much more efficiently through the managing entity model,” she said.

Lax gun laws make suicide-by-gun easy to do

In 2004, biologist Mark Zeller’s depression and suicidal thoughts became so severe that he was committed to a mental health care facility under the Baker Act, which allows for people having a serious mental health crisis to be committed, against their will, to an in-patient psychiatric facility. When he left after a three-day stay, he checked into a hotel where he shot and killed himself.

His wife still doesn’t know where he got the gun.

“If my husband hadn’t had access to that gun, he could still be here,”  said Lisa Zeller,  the volunteer regional director of the Northeast Florida Suicide Prevention Coalition whose paid job is as the Florida Department of Law Enforcement’s chief of forensic services.

Florida has some of the most permissive gun laws in the country, allowing, for example, people to purchase firearms without a permit and for those with conceal-carry permits to carry guns inside the state capitol building.

In 2018, implementing their first significant restriction on gun ownership in years, lawmakers did pass a law that lets law enforcement officials petition the court to confiscate firearms and prevent gun purchases by people in danger of harming themselves or others. That red-flag law was a reaction to the Parkland school shooting.

But, in May, DeSantis signed legislation restricting local governments from enacting their own gun laws. 

Curtailing access to guns is one way to prevent suicides. Improving access to mental health care may be just as important, experts said. Zeller’s teen son struggles with serious mental health issues, she said. While he now has a therapist that his mom believes provides excellent care, she pays out of pocket for his sessions. Her health insurance doesn’t cover his counseling services.

Zeller said it has been extremely difficult to get her son the care he needs. If it’s this hard for her, how difficult is it for people without her mental health care savvy and resources?

“It shouldn’t be this hard … ” she said.

Costs of mental health counseling can be prohibitive

Good Therapy has reported that counseling can cost anywhere from $60 to $250 or more per session, with insurance covering some or none of those expenses. There are resources for the poor, and the rich can afford it; but those in the middle can struggle to access care, experts say.

Even if money isn’t an obstacle, time sometimes is a barrier. Zeller said that when the couple sought counseling for her husband, several of the therapists they contacted said it would be months before they could slot him for a session.

Alaina Rachelle Stanley, a crisis response counselor at Baptist Behavioral Health, said that some therapists cannot accommodate new clients for as much as six months out. “A lot of the calls I’m getting, especially with the teenagers, is [about] depression and suicidal ideation,” she said.

Angling to improve access to care are such organizations as Here Tomorrow,  which pays for therapy for clients needing such assistance and pairs clients with state-certified peer specialists, who are diagnosed with mental illnesses, or have cared for a loved one with mental illness, but are thriving. When a person calls Here Tomorrow, a peer specialist contacts that person within 24 hours and helps steer that person into counseling.

Here Tomorrow Executive Director Hannah Hackworth, a licensed clinical social worker who started her career in an in-patient clinic two decades ago, recalled what ran through her mind, in 2016, when she launched Here Tomorrow.

“I remember having this thought going through my mind, you know, ‘Wow, nothing’s changed in 20 years. Here I am back on the in-patient unit,’” she said.

The experience ultimately inspired her to launch the nonprofit, which opened its doors in January.

Jeff Yalden, Here Tomorrow’s community outreach director, said the agency wants to normalize the conversation about mental health and meet people where they are, be it over the phone, on the computer or in person.

“If someone is showing suicidal ideation, you don’t want to leave them alone,” Yalden said.

Lutheran Services Florida Health Systems, which also employs peer specialists, is  seeking to expand services that improve continuity of care. Last year, Lutheran received an $800,000 federal grant intended to prevent suicides during the pandemic. Through that grant, Lutheran and its partners, which include the Mental Health Resource Center, Hubbard House, Changing Homelessness and local hospital emergency departments, hired care coordinators to assist people deemed at increased risk of suicide attempts, including those experiencing homelessness and domestic violence, as they navigate the mental health system.

“The goal of these calls is to have the individual who is in crisis to deescalate that crisis and … to get them the help they need,” Lutheran’s Cauffield said.

Since that program launched in the fall of 2020, there has been a 35% drop in hospitalizations among the roughly 200 persons-in-crisis who comprise 15% of the population that Lutheran Services Florida Health Systems serves, Cauffield said. Visits to the emergency room, detoxification from substance abuse and crisis care also have dropped in this population. “We have an average recidivism rate of around 3%, which is absolutely unheard of in the industry.”

That federal Substance Abuse and Mental Health Services Administration grant financed a 16-month program at Lutheran Services. And Cauffield said the nonprofit is applying for more underwriting of its endeavors. “We’d love to have more funding to be able to wrap our arms around a greater percentage of our high utilizers.”

Some had more suicidal thoughts during pandemic

While, overall, suicide trended downward, young adults and children were among those who especially suffered suicidal thoughts during the pandemic.

A CDC analysis found that mental health related emergency room visits by youths aged 12 to17 increased 31% from 2019 to 2020. Emergency room visits for girls aged 12 to 17 who were suspected to have attempted suicide increased 50% from February 2020 to March 2021, as compared to the same time period a year prior. In Jacksonville, Baptist Health reported that its Wolfson Children’s Hospital saw a 300% increase in mental and behavioral health admissions during the pandemic. “Many of these include intentional overdoses, overwhelming anxiety and depression and eating disorders,” Baptist Health reported.

Additionally, the CDC found that during one week in June 2020, 40% of adults reported struggling with mental health or substance abuse and dubbed that “a considerable increase”  above from the year prior. A quarter of people aged 18 to 25 said they’d contemplated suicide during that analyzed period. Unpaid caregivers, racial/ethnic minorities and essential workers also were disproportionately likely to struggle with mental health during the pandemic.

Regret and guilt over a son's suicide

These days, Ramon Day said he mostly remembers good times shared with his son. He remembers Tyler Day’s intellect, curiosity and good nature. 

He also still feels regret and guilt regarding their last conversation. He admonished Tyler for not finishing a college paper that was due the next day. His criticism was so fiery, so harsh that his son, in that moment, Day said, just stopped talking. 

The next day, Tyler killed himself.

“That’s why I will go to my grave blaming myself,” Day said. “ … I didn’t call back, and I should’ve called back.”

Rationally, Day said he knows he’s not to blame for his son’s suicide. Tyler had some demons. He’d first spoken of suicide when he was a little boy. He was briefly treated in a psychiatric facility during middle school. 

Losing a beloved son, Day said, is part of what drives him to better understand Florida’s mental health system and its deficiencies but also social stigma surrounding mental illness.

Day agrees that fewer firearms might result in fewer suicides. He also said much more needs to be done to increase access to and continuity of mental health care, and raise everyone’s capacity and willingness to lend an ear or a kind word to someone struggling with mental health.

“Suicides,” Day said, “are a symptom of a greater difficulty than the presence of guns in our society.”