We have recently heard news of high profile celebrities completing suicide. As tragic and eye opening as such news is, this psychiatrist’s opinion is that the discussion has been superficial and speculative. It also, rather unsatisfyingly, concludes by only offering up the national suicide hotline. What appears to missing from the discussions is not the term mental illness, which has acquired its own negative connotation because of its repeated association with mass shootings over the years, it’s actually the more appropriate terms: depression and mood disorder. This is important because more than 90% of completed suicides are associated with mood disorders. These are also among the most readily treatable of mental illnesses, with early warning signs of worsening mood that would usually be recognizable by loved ones, allowing them and professionals to intervene earlier. Herein lies the silver lining to such dark clouds surrounding suicides.
What makes people want to plan their own death? The reasons are varied, but among the common symptoms that many find unbearable are: persistent anxiety, insomnia, hopelessness, helplessness, and chronic pain. Not surprisingly, many individuals turn to alcohol or drugs to ease the burden of such symptoms. We know that such substances can end up exacerbating the very symptoms they are trying to cope with. Most concerningly, they can also powerfully influence judgment during such states, making the person think there are no alternatives and making them act upon their anxiety and hopelessness in self-destructive ways. We also know that the negative thinking patterns intrinsic to depression can make a person simply not want to seek help or to write off the effectiveness. It is such thinking and decision-making that needs to be recognized and addressed to halt the descent of the person into ever worsening and destructive patterns of thinking and behavior that end up only feeding each other. Thus, what the person chooses to do about their symptoms can either help, perpetuate or even worsen depression. Individuals naturally vary in what is often referred to as their coping style. Certainly, withdrawal and avoidance of treatment can be important factors in the downward descent toward suicide. On the other hand, physical activity, reaching out and regular structured activity (such as work) can help prevent such a decline. There’s more to the story than just symptoms and how individuals cope with them: feelings. Oftentimes there are deep-seated and painful ones that are truly difficult for most human beings to share. These include shame, guilt, regret, and inner turmoil, mostly at feeling unable to cope or having let themselves or others down. Such emotional reasoning also tends to worsen depression and can itself generate another terrible cascade of negative, self-berating thoughts. Or to put it more basically: beating oneself up. So, what can we do to prevent suicides? The answer is not a simple or easy one. It involves recognizing and exploring the person’s feelings as well as associated symptoms of depression. Depression can be manifest either in what the person says and does. There may be a significant change from their usual level of functioning. It is important to pay attention to the person’s demeanor: hunched posture, limited eye contact, poor self-care and a monotone voice can be obvious clues. Finally, persistent rumination about the past or present, pessimism about the future, and negative thinking can also be signs of a major depressive disorder.
When physicians are assessing the severity of depression, they are not just confirming a depressed mood, they are looking for other associated symptoms to confirm the diagnosis and its severity. This includes changes in what is referred to as biological functioning. These are disturbances in basic bodily functions such as appetite, sleep, activity, and interest in hobbies, socializing or sex. In some depressions, people may end up sleeping more, in others, less. In melancholic depression, weight goes down by more than 10%, along with a worse mood in the mornings. In more atypical depressions, people may end up eating more and gaining weight, together with an unusually sensitive and fragile sense of self and a very heavy feeling in the arms or legs. Once a mood disorder has been diagnosed, it needs to be treated as soon as possible. Most depressions are treated in the outpatient setting, with more severe symptoms requiring hospitalization to ensure the person’s safety. Some depressions, if mild in severity may not require antidepressant treatment. Instead they may benefit from a specific kind of therapy called CBT that helps a person recognize and challenge the tendency toward negative thinking. However, the decision to start medication should be made in consultation with a physician familiar with such treatment. The most severe depression might also benefit from a specialized medical treatment called ECT (Electroconvulsive Therapy). Suicide should be assessed at every appointment. Proper assessment is more than just asking if suicide is present or not. Some patients fear disclosing such thoughts for fear of being hospitalized against their will or because of shame. In truth, physicians are encouraged to ask patients about suicide to help demystify the shame or guilt associated with such thoughts and to help normalize the experience of such thoughts when depression symptoms are worsening. As a psychiatrist, when I ask about suicide, it is to get the proper context of such thoughts. Are they only in relation to the severity of symptoms at a time? Do they result in the patient stewing over ways to do it? Most importantly, what plans have or have not been made or attempted? Suicide needs to be assessed on a spectrum of thinking, ranging from fleeting thoughts that may last only seconds, to the other end involving actual planning and acting. Unfortunately, many patients just get a barrage of questions on a checklist that neither encourages honesty nor builds any meaningful rapport with the person asking about what kind of suffering has given rise to such thoughts. Of course, the science of suicide risk assessment involves more than just asking the patient about it. Subjective reports are but one factor in such an assessment. As a psychiatrist, I must consider my patient’s whole history (including childhood traumas, family history, their own history of mood disorder, prior suicide attempts and their usual coping style) that would make them vulnerable to future suicide. In addition, I must make a judgment about how vulnerable they are right now, based upon how they look to me, the range and type of mood symptoms, and how much they rely on drugs or alcohol. Then there is the person’s support network. Who do they live with? Who do they tend to confide in? Is there adequate structure and meaning in their life (work, children, family)? All these risk and protective factors must be considered in making a judgment about how high the risk of suicide is. Even with all this information, no physician can predict a suicide. However, if vulnerabilities and symptoms are addressed with proper, focused interventions and the right kind of support, this can go a long way to reducing the risk of suicide substantially. As a practicing psychiatrist, my goal is first to build a trusting, solid and emotionally honest treatment relationship with my patient. That way, I can get the most accurate picture of what is going on and how I and others can help. Thus, I make a point of asking the patient to call me directly if they are having worsening or changing symptoms, issues or concerns about their medication or new stresses that make it hard for him or her to cope as before. In addition, if I am concerned, I will see them more frequently, be in phone contact more often, change medication dosage or type, refer them to a therapist, or reach out (with the patient’s permission) to close family or friends. Only if I am convinced that the person is at foreseeably high risk will I facilitate hospitalization. The decision as to what to do is a highly individualized one, based upon the full range of information available to me and upon my patient’s current state of mind. In my approach to reducing the risk of suicide, I emphasize patient education as a key aspect. This helps empower him or her. The patient will then know why the doctor is proposing a certain course of treatment, dosage etc., what therapy is supposed to address, and what crucial part the patient themselves can play in their own recovery. In addition, I try to instill hope by informing patients just how treatable most depression and mood disorders are with the right kind of medication, psychiatric follow up, and therapy. If there is any silver lining to the cloud of suicide in our society it is that the causes can be identified and addressed with a treatment alliance with your health care provider(s).
