Suicide in doctors and others: remembering and preventing it if we can

Recently, SASS-MoKan, our local suicide survivors� support group, held its annual Remembrance Walk. I have written about these in the past, and have included the fact that my personal interest in the issue of suicide is the fact that my older son, Matt, committed suicide in 2002, just after he turned 24. At the time, everything seemed to be going fine in his life, and it came as a real surprise to his family, his close friends, everyone.

The Remembrance Walk is a lovely ceremony. Following a lap around a good-sized park, there is a ceremony. All the survivors stand on the grass in a circle, and the names of all those they have lost are read; at the end, a flight of doves is released. It is caring, and it is supportive. Of course, the ceremony also brings out the pain and sadness of our losses.

Matt died nearly 12 years ago, but I know others who have lost children very recently. I can tell them that the acute agonizing pain that feels as if it will never ease does, but they cannot and should not believe. It becomes less acute, less sharp, less all-consuming every minute, but it never goes away.

Recently, an Op-Ed in the New York Times by Pranay Sinha discussed �Why do doctors commit suicide?�. Because I am a doctor, and one who many of my colleagues know had a suicide in my family, several people shared this with me, although I�d already seen it. The article provides the perhaps shocking information that the suicide rate among physicians is twice the national average. Beyond this, however, it focuses on residents, doctors in training, and the enormous stresses that they are under, not further discussing the reasons why doctors in general have such high suicide rates. This is not surprising, as Dr. Sinha himself is a first-year resident (at Yale) and is obviously acutely aware of the stresses and strains of residents.

I know that this is true; I was a resident (a long time ago, in the last millennium) and I work every day with residents. It is a hard job; although these people will become, in a few years, full-fledged physicians who will range from very well-paid to extremely well-paid, they are, as residents, working for about the US average wage, but up to 80 hours a week, often with life and death in their hands. That this is fewer hours than residents used to work is good, but is of limited comfort to them. The point is that the residency is a big stress, and it occurs at an age when many people, especially males, are already at risk. The important issues that are addressed in this piece, and in several of the letters written in response to it, are the idea that doctors are supposed to be all-knowing, infallible, unwilling to admit mistakes or weakness. The op-ed and the letters make clear how obviously unreasonable and burdensome that this is, for all doctors and possibly even more for these young doctors who are even more aware, inside, of what they don�t know and are terrified of showing it.

This is National Suicide Prevention Month, which is why the remembrance walk is in September, and why there are such articles appearing. NPR recently ran a program on the increase in the number of suicides in middle-aged men has increased by 50% since 1999; older men have always had the highest suicide rate, followed by adolescents and young men, but this increase in men aged 45-65 is new. Some suggestion is that it is the economic downturn, which hit poor people well before the �official� recession; it is lower-income men who had the highest rates in this age group. Robin Williams� recent suicide was widely covered; I doubt that National Suicide Prevention Month entered into his decision. Interestingly to me, many of the commentators focused on the �how surprising, he was so funny, he made us laugh, who would have guessed� angle, while others have discussed how he, like many comedians, needed the public attention but was lost when alone. I suspect Williams was bipolar; certainly many of his activities have suggested an ongoing depression while his outer persona was so often manic.

What many of the articles, including the Op-Ed, do not discuss, however, is the fact that most suicides in the US are caused by depression, a disease. It may be unipolar (�just� depression) or bipolar (�manic depression�), but it is potentially fatal.  The stresses of being a doctor, or being a resident, are tremendous and cause people who are depressed to go �over the edge� and commit suicide, but it is important to remember that most people undergoing the same stresses do not. The underlying condition usually needs to be present for the precipitating cause to be fatal. I have previously cited what I consider to be one of the best discussions of this issue, �The trap of meaning: a public health tragedy� by CG Lyketsos and MS Chisolm in JAMA.[1]

National Suicide Prevention Month, and the activities associated with it, are critically important for raising awareness about a condition that kills 40,000 Americans a year, but is often kept secret, through shame. When I became a member of the club no one wants to be in, what are called suicide survivors (although the meaning is family and friends of someone who has completed suicide, rather than those who have personally survived a suicide attempt), I found out lots of people I knew were also members. They had parents, children, siblings, close friends who had committed suicide, but I didn�t know. We often don�t talk about our pain, but the sadness of losing a child seems to many to be more ok to talk about if it was a medical disease, or car accident, or homicide, than if it was suicide. But the loss is the loss; the pain is the pain.

I don�t have the optimism that some do about being able to prevent suicide in specific cases. I do believe that early diagnosis and treatment helps; I believe that being aware of the warning signs is important, and I will never know how many times having those who loved him around might have prevented my son from killing himself before he finally did. I can only hope that more awareness and discussion about this condition will make a difference for some, and perhaps many.

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[1]Lyketsos CG, Chisolm MS .The trap of meaning: a public health tragedy. JAMA. 2009 Jul 22;302(4):432-3. doi: 10.1001/jama.2009.1059.

Suicide: What can we say?

On Sunday, September 8, 2013, we participated in the annual Suicide Remembrance Walk in Kansas City�s Loose Park, organized by Suicide Awareness Survivor Support of Missouri and Kansas (SASS/Mo-Kan). An article previewing the walk and interviewing Bonnie and Mickey Swade, our friends who established SASS/Mo-Kan, ran in the Kansas City Star on September 7: �What to say, and not, to those left behind by suicide�. Bonnie and Mickey became our friends because we are members of a club none of us would wish to be in: suicide survivors. Their son Brett completed suicide about a year after our son Matt did, and we were in a support group together before the Swades started their own. Matt�s suicide was on December 13, 2002, which I never thought of as being �Friday the 13^th� until I realized that because of the vagaries of leap years, this year, 11 years later, is the first Friday December 13^thsince then. Thus, this post several months later.

The Remembrance Walk around Loose Park in Kansas City was well-attended on a hot morning, and culminated in all of us standing in a very large circle holding long-stemmed flowers as a distressingly long list of names was read. We counted 7 times when two (and in one case 3) last names were repeated; the list was not in alphabetical order, so this was not coincidence. As much pain it is to have one person you love having committed suicide, two or more is unfathomable. Finally, white doves were released, and the ceremony ended to the strains of �Somewhere over the rainbow�.

I have written about suicide before (July 29, 2009, �Prevention and the �Trap of Meaning�), in which I discussed an article that had recently appeared in JAMA by by Constantine Lyketsos and Margaret Chisholm titled �The trap of meaning: a public health tragedy�[1] ). The thrust of that piece was that people -- families, lay persons, psychiatrists, psychologists, philosophers, and others -- search for �meaning�, �reasons� for suicide, and that this is, essentially, pointless at best and, devastating at worst. Suicide is the fatal result of the disease of depression, a disease which is very common and not usually fatal, but can be. It may often be precipitated by a specific event or set of events (as the final episode of chronic heart or lung disease is often preceded by a viral infection) but those are not the cause. The strongest prima facie evidence is that most people in the same circumstances (whether victims or perpetrators of bad things) do not kill themselves. But enough do to have made a long list to have read at the ceremony in Loose Park.

Like everyone else, each person who kills themselves is unique, and their histories differ. Some have made previous attempts, often many times; others gave no clue. Some have been hospitalized, often many times; others never. Some have family who were sitting on the edge, awaiting the suicidal act, trying their best to help to prevent it but helpless to really do so. The families and friends of others had no idea it might happen. While those who attempt or complete suicide are depressed, some very overtly manifest that depression and some not so much. While many people who have depression never attempt suicide, some complete suicide when things are looking, to others, good. Overall, access to effective weapons increases the probability of �success�; the �lethality� (the probability that you will die from an attempt) is about 95% from guns, and only 3% from pills. Therefore, easy access to guns is associated with a higher successful suicide rate; in young men 16-24 the success rate is nearly 10 times higher in low gun control states than in high. I doubt these young men are more depressed, but they have quick and effective methods of turning what may have been relatively transient suicidal thoughts into permanent death. Of course, not all suicides are classified as such; while it is often obvious, sometime it is not: how many one-car accidents, for example, are really suicides? And, because �unsuccessful� suicide attempts are grossly under-reported, the lack of an accurate denominator makes �success� rates very hard pin down.

On one hand, the fact that most suicide attempts are not hospitalized and given intensive treatment seems to me to be a bad idea. Since the greatest predictor of a suicide attempt is a previous suicide attempt, if there is any likelihood that a suicide can be prevented it would be best to intervene at that time and try to treat the depression. On the other hand, I am not sure that there is any good evidence that treatment is terribly effective in preventing suicide. Yes, there are many people who have attempted suicide once and never again, but this may be a result of treatment or the natural history of their disease. There are people who are under intensive treatment when they complete suicide, often when least expected. Indeed, there is evidence that treatment of depression may sometimes paradoxically increase the risk of suicide by getting a person whose depression was so severe that they were unable to act better enough that they can. And, conversely, there is no way of knowing how many times, before a suicide is completed, a planned attempt was put off by an intervention that may not have even been intended, by demonstrating love and letting the person know they were needed.

It doesn�t always work. If the person is unwilling to share their symptoms and is determined to complete suicide, there is no prevention that is effective. My son was 24, deeply loved, lived in a state with strict gun control laws and probably never held a gun before. But he was able to drive to a low gun-control state, buy a carbine and bullets, and complete his suicide. He took his time and planned it, and it is unlikely to have been preventable. But many suicide attempts are not as well planned, are more impulsive, and efforts to prevent these might be successful in many cases. In a classic 1975 article in the Western Journal of Medicine[2] David Rosen interviewed 6 survivors of jumps from the Golden Gate bridge. The emphasis in these interviews is on transcendence and �spiritual rebirth�, but all agreed that putting a �suicide fence� in place might have deterred them and might deter others.

For all of us who wish mightily to prevent disease and death, suicide may be seen as the greatest affront because the death is seen as �unnecessary� and often involves people who were �healthy� (except for their depression), young, and had a future before them � sometimes (as I like to think of Matt�s) a truly promising future. But too often we, in our desire to prevent death and disease, choose to focus on the least effective interventions to do so. We will take unproven drugs (especially if they are �natural� or non-prescription), and clamor for our �right� to have marginally useful or even ineffective screening tests, but there is a vocal movement against immunizations, one of the few preventive interventions that are known to be effective. We decry mass murders in school after school, and bemoan the loss of our young people to both suicide and homicide, but resist regulation of the most effective instruments of death, guns. We all take our shoes off each time we fly because of one failed �shoe-bomber�, but ignore the thousands of deaths on our city streets.

I wish my son had not killed himself. I wish I knew how to have prevented it. I wish I could tell those of you who worry about a loved one how you can prevent it. I wish even more that I could tell those of you who don�t suspect it that you can be secure because in the absence of definite warning signs you can feel safe. I can�t do that. When there are warning signs, take whatever action you can, but the reality is that it may not be effective. When there are no signs, hope that it is because there is no risk.

As individuals, we hope and do what we can. As a society, we should decide on our priorities, and we should be guided by the evidence, not by our fantasies, hopes, or magical thinking.

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[1]Lyketsos CG, Chishom MS, �The Trap of Meaning: A Public Health Tragedy�, JAMA. 2009;302(4):432-433. doi:10.1001/jama.2009.1059.

[2] Rosen DH, �Suicide Survivors: A Follow-up Study of Persons Who Survived Jumping from the Golden Gate and San Francisco-Oakland Bay Bridges, West J Med. 1975 April; 122(4): 289�294. PMCID: PMC1129714

"Call Me Crazy": Lifetime's New Movie That Champions Hope and Resilience Around Mental Illness

*Warning: it was difficult to write this post without including a few small spoilers, but I hope you'll watch the whole film anyway.

On Saturday April 20th, Lifetime debuted "Call Me Crazy: A Five Film".  The film (which boasts a star-studded cast and director list) includes five short stories that examine the impact of mental illness from various perspectives.  Each story is named after the main character: "Lucy", "Grace", "Allison", "Eddie", and "Maggie".

In the first story, we are introduced to Lucy (played by Brittany Snow).  Lucy, a law student, has recently been admitted to a psychiatric institution after experiencing a schizophrenic episode.  She is struggling to see how she can live a "normal" life that includes relationships and a career.  Her clinician encourages her to finish law school because she has insight into something very few people understand (mental illness)- so who knows how many people she could help?

In "Grace", we meet a daughter who has been living with a bipolar mother for her entire life.  Grace is played beautifully by Sarah Hyland from "Modern Family"- I loved seeing her in a dramatic role.  We see the "highs" and "lows" of her mother's condition.  We also see the devastating impact that it has on Grace's life when it is not treated.  Grace often plays the role of caretaker- making sure her mother is safe.  We see her struggle to have her own life aside from her mother's illness.

"Allison" offers the viewers a twist.  She plays Lucy's younger sister.  So we step back from Lucy's view and we see how mental illness has affected her entire family.  Allison's childhood, her sense of safety, her relationship with her parents- were all changed as a result of her sister's illness.  She has bottled up a lot of anger and finds it difficult to support her sister through her recovery.

"Eddie" introduces the only male main character.  He is suffering from severe depression.  He has withdrawn from his wife and his friends.  He has stopped receiving help from his therapist.  We watch his wife intervene after discovering that he may be thinking about suicide.

Finally, "Maggie" introduces topics that (unfortunately) are all too common these days- post traumatic stress disorder (PTSD) and military sexual trauma among our returning veterans.  Maggie (played by Jennifer Hudson) was victimized during her time in the Army and its lasting impacts are threatening her ability to have a healthy relationship with her family.  Here we get another update on Lucy- she is now a lawyer and is representing Maggie in court.

While each story stands on its own, Lucy's story is woven throughout "Allison" and "Maggie" as well.  I really liked this strategy.  Not only because I became invested in her character during the first story...but also because seeing her evolve over time helped to demonstrate some key themes from this film- hope and resilience.

As Lucy says to Maggie: "I am living proof". [Of what?] "That there is hope".  In court, Lucy reminds Maggie's judge that having mental illness does not mean that you are a bad person or a bad mother.  She also reminds him about the importance of social support, "it is nearly impossible to get well alone".  Even though we see all of these characters at their lowest point- there is still hope that they can feel better, have strong relationships, and contribute positively to the world.

It seems fitting that Brittany Snow's character delivers these messages about hope and resilience, as she is a strong advocate for them in real life.  Together with the Jed Foundation and MTV, she founded Love is Louder.  Love is Louder is an inclusive movement that amplifies messages of love and support to combat negative messages resulting from bullying, loneliness, and stigma.  She has also publicly shared her own battles with anorexia, depression, and self harm.

As a health educator, I highly recommend this film as a resource for discussing mental illness, suicide, stigma, social support, and help-seeking.  Since each story is approximately 20 minutes, they can be broken down into segments or watched all together.  This film is a great example of Entertainment Education, which is an area of public health that acknowledges the strong impact that television and movies play in educating the public about health issues.

If you or someone you know is struggling with a mental illness, please reach out:
National Suicide Prevention Lifeline (1-800-273-8255)

"Girls" Tackles OCD: What I Hope IS NOT Happening In Our Emergency Departments

This afternoon I had the pleasure of having some downtime- so I used it to catch up on the three recent "Girls" episodes sitting on my DVR.  Having avoided spoilers, I was surprised and saddened to see Hannah (Lena Dunham) being consumed by Obsessive Compulsive Disorder (OCD).  We learn that she had a serious bout with the condition once before- in high school.  It was so serious that she sought professional help and medication at that time.  Flash forward to her post-college life and we see her plagued again...perhaps triggered by the stress of a recent break-up and a looming book deadline.

While there are several disturbing issues in the most recent episode "On All Fours" (you can see the comments in Alan Sepinwall's review for those details), I want to focus specifically on Hannah's trip to the local emergency department (ED).

I was very upset watching this scene and I'll tell you why:

We know that emergency room providers are key gatekeepers for those who are suicidal and/or suffering from mental illness.  Research tells us that 1 in 10 suicides are by people seen in an emergency department within 2 months of dying.  Acknowledging the importance of this gatekeeper role, leadership organizations in suicide prevention have created a variety of toolkits and resources to educate and train emergency department personnel to identify patient warning signs and assess their risk.

In "On All Fours", Hannah visits the ED after obsessively sticking a Q-tip in her ear, getting it stuck, and experiencing pain.  After lying to her parents by saying she has "12-15 good friends" to accompany her to the ED, she goes alone.  The scene opens with the doctor telling her, "Well, you must be feeling pretty silly."

As the doctor examines her injured ear, Hannah says:

"I've just been having a little trouble with my mental state."
"I have a lot of anxiety and I didn't think stress was affecting me but it actually is."
"I'm not saying this was an accident, but I was just trying to clean myself out."

At no point does the doctor respond to any of these statements.  He is all business, telling her to follow-up with a specialist if she is still experiencing pain in a few days.  As Hannah lays down so he can put antibiotic drops in her ear, she pleads with him to look at her other ear.  He snaps at her "there is nothing wrong with the other one."  Hannah cries on the bed because it (the drops? her situation?) hurts so bad.

He discharges her and she walks home alone.  In just a t-shirt and no pants.

Now I'm not saying that Hannah was acutely suicidal or verbalized such a threat in the ED.  However, I am saying that she made several clear statements about her mental health that should have been treated with concern and respect by a competent medical provider.  Her demeanor and her appearance deserved a kind ear, a social worker's visit, someone to ask if she was all right.

These recent episodes have been applauded for their accurate portrayal of OCD.  I hope that a future episode will show a portrayal of a caring and skilled provider using the public health prevention and education tools that are available to assist someone in desperate need of help.

For any readers that may need help:

• The National Suicide Prevention Lifeline:  1800-273-TALK
• Substance Abuse & Mental Health Services Administration: (SAMHSA) Mental Health Treatment Finder