The Elephant In the Room
There are only a few emergency situations in the practice of psychiatry. However, these emergencies can be devastating not just to the patient, their family, and society, but everyone involved, including the care providers. And suicide is the most feared of them all.
Suicide is a hard topic to raise and discuss. Not only in the clinical situation but also in the non-clinical settings. Families, friends, in school/work and society – we are afraid to talk about suicide. But ignoring it does not make it go away. And one day, we are jarred awake with the ugly presence of this menace in our society.
Two noteworthy suicides in our recent collective conscious is of Kate Spade and Anthony Bourdain. Not to mention the countless number of deaths attributed to suicide by everyday Americans. According to recent CDC (Center for Disease Control) reports, suicide rates have increased by 24% between 1999 and 2014, from 10.5 to 13 suicides per 100,000 people, the highest rate recorded in 28 years. In absolute numbers, nearly 45,000 suicides occurred in the United States in 2016 — more than twice the number of homicides — making it the 10th-leading cause of death. Among people aged 15 to 34, suicide is the second-leading cause of death.
Why did they do it? is what all of us are asking, whether it is in regard to Kate and Antony or anyone else. In working with people struggling with mental illness and suicidal feelings, the common factors I have come to recognize are just a handful.
Hopelessness (or despair) and isolation are, in my experience, the 2 most common factors that have been associated with suicidal feelings and attempts. Studies have also identified hopelessness as a close indicator of suicidal feelings. Despair and utter hopelessness is a sense that they cannot solve whatever issue or problem they are facing. Coupled with the sense that no one, absolutely no one else in this world “gets” them. No one can help them. No one else has faced such problems and no one else can have a solution. When one is walking around with thoughts like these, an environment where one is unable to discuss suicidal or other negative feelings only adds to the problem. This terrible isolation can be devastating to us humans.
There is also the issue of co-occurring alcohol and drug use, which can exacerbate faulty thinking and decision making, while also increasing disinhibition – making a suicide attempt all the more likely. The recent increase in opioid addiction also muddies factors, as not all opioid deaths are suicidal…many are accidental in nature.
Parallel to the rising rates of suicide is an increase in the rates of depression, anxiety and other mental illnesses in our population. This is probably not surprising. Our modern society places enormous stress on its citizens in terms of social/economic pressures and also in terms of the onslaught of chemical toxins our bodies have to cope with and detoxify. For millennia, our bodies have relied on robust nutrition to cope with stress and toxicity. But in this area too, our modern diets are failing us. Highly processed food, with refined flours and sugars, lacking essential nutrients, and filled with more chemicals (artificial dyes, flavors, preservatives); is what the Standard American Diet is made of.
Another factor to consider is the social isolation that many of our youngsters are reporting. As we are advancing to a more tech dependent socializing experience, it deprives us of all of the benefits of socializing even at the neuronal level. All these factors can contribute to poor stress moderation, poor coping skills, poor distress tolerance, poor problem solving skills and over time creates the state of apathy and despair that can eventually lead to suicide.
As you can see, this problem of suicide is a complex one, almost like peeling an onion. And it requires a comprehensive, multi modality intervention that addresses not just at the individual level but also at the societal level.
Some economists are calling this recent increase in suicide “deaths of despair” and linking it to the Great Recession of 2007. Interestingly, more than half of the people who died by suicide, did not have a diagnosable mental health condition. Economic despair was seen as the more common factor here. Maybe it is time to view suicide as a public health crisis. However, suicide is commonly viewed as a “mental health crisis” and the common refrain in the media is that more access to mental health treatments should be available.
Unfortunately, we are seeing that the answer to the suicide or mental health problem is not as easy as simply making mental health treatment available. In fact, rates of antidepressant prescriptions have skyrocketed since the 1990’s. A recent study has co-related the increase in suicide attempts and completed suicides in women, to a parallel increase in antidepressant usage. It is well known that antidepressants increase suicide risk in young people. It is also now known that long term use of antidepressants can result in a chronic state of dysphoria (due to tachyphylaxis – a phenomenon in which prolonged use of a substance makes it less effective over time). Of course, one cannot abandon provision of care delivery systems altogether, but it should make us all reevaluate what we are doing in response to a problem of this magnitude.
It is high time that we moved away from a simplistic “medication or therapy” solution and worked at evaluating the underlying root cause not just at the individual level but at the level of the society. For instance, a study published recently found that oral contraceptive pills increase the risk of depression and suicide in young women (aged 15 to 19) by almost 80%. In such a situation, is it justified to prescribe an antidepressant to such a young woman? Or, should we dig deeper and evaluate the hormonal imbalance caused by the contraceptive pill and work to fix that? I would argue for the latter.
Within a holistic, root cause framework, we can evaluate the role of not only hormones, but also nutrition, relationship skills, problem solving skills, etc. and put in place solutions to optimize these areas. At the level of the society, we can work towards reducing stigma surrounding mental illness and suicide, work on enhancing inter connectedness with each other, teaching meditation and other self-help skills, work for equitable distribution of nutritional and other resources, make our environments less toxic, reconnect with nature, increase awareness and provide resources for vulnerable populations (eg: teens, veterans, etc).
But all this can happen only if we talk about the elephant in the room!
- J Larsson. Antidepressants and suicide among young women in Sweden 1999-2013. Int Journal of risk & safety in medicine 29 (2017) 101 – 106.
- Suicide statistics: https://www.nimh.nih.gov/health/statistics/suicide.shtml
- Oral contraception and suicide: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2017.17060616