The Most Tragic of Escapes Understanding the Complex Issue of Suicide

Suicide is a frustrating paradox, Dr. Ken Jaffe said. It’s certainly not an incurable disease, yet it’s among the most difficult types of death to prevent.

“The bottom line is that suicide is difficult to predict, but that doesn’t mean that important things can’t be done to heighten our awareness and get people the help they need,” said Jaffe, a psychiatrist at Holyoke Medical Center.

According to the most recent statistics from the National Institute of Mental Health, suicide is the 10th-leading cause of death in the U.S., accounting for almost 35,000 deaths in 2007.

“It’s a relatively rare event — roughly one in every 30,000 people, although that varies to some degree by age group and other factors — but when it happens to a loved one, the fact that it’s rare doesn’t really mean much,” Jaffe said.

Dr. Barry Sarvet, vice chair of the Department of Psychiatry and chief of the Division of Child Psychiatry for Baystate Health, noted that psychiatric illness is a major contributor to suicidal thoughts, and the illnesses most associated with suicidal behavior are depression, bipolar disorder, schizophrenia, and substance abuse.

“Depression is the biggest one and the most prominent one, and sometimes if people have a combination of depression and substance abuse, it kind of multiplies the risk,” said Sarvet, who is also board president of the Western Mass. chapter of the American Foundation for Suicide Prevention. “When people are addicted to drugs, they feel helpless, and they’re apt to lose their judgment when they’re intoxicated — to lose their perspective that things can get better. People self-medicate their depression through substance abuse, but even though they think that makes them feel better, it only makes things worse.”

He stressed that clinical depression is a far different beast than merely being upset about the circumstances in one’s life. Yet, those circumstances can exacerbate depression.

“Stressful things like the holidays, families not getting along, or being out of work, having financial problems — all these can trigger an episode of depression, and once that depression starts to take hold of a person, they become profoundly affected by it, and the depression becomes like a black hole, and they can’t see their way out of it,” Sarvet told HCN. “And the more hopeless they are, the less they’re able to function well, and their problems worsen. It starts a vicious cycle that sometimes leads to suicidal behavior.”

Dr. Chhewang Norsang, a psychiatrist at Providence Behavioral Health Hospital, echoed that idea.

“Certainly, some people are faced with a life situation that they feel is impossible to deal with, and that hopelessness is the hallmark of suicidality,” he said. “This may be an internal conflict or an external conflict. Internal issues may include self-esteem or guilt, while external causes can be the loss of a loved one, aging, life-threatening illnesses, and financial issues.” The latter, he noted, is especially relevant these days, because so many Americans are struggling to find work.

“Many people display symptoms and signs that, in hindsight, we could have picked up on, but the one I’ve found most useful is this: if anyone talks about suicidal feelings, that’s a huge thing. It’s a symptom of depression, but it’s also a cry for help.”

Dead Reckoning

Plenty of red flags exist to identify suicidal thoughts, but many are difficult to detect, said the doctors who spoke with HCN.

“The single most powerful risk factor is a previous serious suicide attempt,” Jaffe said. “If someone has made a serious suicide attempt in the past and they’re again feeling suicidal, that’s someone you worry about, and someone you may very well want to hospitalize.

“Probably the second-highest risk factor would be the successful suicide of a close family member,” he continued. “If someone comes into the emergency room very depressed, and, ’by the way, my mom killed herself five years ago,’ or ’my dad killed himself,’ that’s someone you’re going to be particularly worried about — just as worried as if someone told you he had made a serious suicide attempt himself.”

Norsang agreed, and added that other signs of someone contemplating suicide might include a rapid deterioration in function at school or work. However, “it’s such a complex issue that it’s very hard to pinpoint any early warning sign as being diagnostic of future action.”

And most suicide risks aren’t discovered in a medical setting, he added, because “50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of suicidal people have a psychiatric diagnosis, but 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} do not.”

Jaffe noted that “red flags for someone being seriously depressed include sleep disturbances, appetite disturbances, withdrawal from friends and family, loss of interest in previously enjoyable activities, significant changes in behavior, and, of course, making suicidal statements.”

People who suspect serious depression in a family member or other loved one should encourage them to seek medical help, he said. But because of the nature of the condition, it’s often a tougher sell than telling someone to get treated for, say, chest pain.

“When many people are seriously depressed, they feel hopeless, and it’s hard to believe that anyone can help them,” he told HCN. “But, in fact, there’s good evidence that depression is very treatable with a combination of antidepressant medication and therapy.”

Unfortunately, “there’s also a problem with stigma,” Jaffe said, noting that people often view depression as something to be embarrassed about. “But I think that’s improving as more and more public figures come forward talking about their own treatment. The public has come a long way in realizing that this is a medical illness and not a personal failing. I always stress to people that this is no more your fault than having a migraine headache would be your fault.”

Those elements — stigma, hopelessness, withdrawal from loved ones — can muddy the waters and make it difficult to recognize a problem until it’s too late, he said.

“People often get frustrated and ask, ’why can’t we do a better job of predicting depression? What makes it so hard, even among people who have many high risk factors?’ Fortunately, the majority of people do not commit suicide, and you certainly don’t want to be mandating everyone into treatment who has risk factors. But you do want to pay attention to it and encourage people to get help, because depression is a very treatable disease.”

Teenage Tribulations

Suicide spans all age groups, but it poses a specific danger to adolescents, who are dealing with a unique set of social stresses, among other issues, at a vulnerable time in their lives. In fact, while their overall rates of suicide aren’t much different than the population as a whole, suicide remains the third-leading killer of Americans between ages 15 and 24.

However, Sarvet said, parents and others often find it difficult to separate the signs of suicidal attitudes from the moodiness and defiance to which teens are prone, and even when they have concerns, they’re often frustrated by the wall of attitude that middle- and high-schoolers can construct around themselves.

“The trick with teenagers is not to be distracted by their irritable and negative behavior,” he said. “When teenagers get depressed, they end up getting very negative, very defiant with adults. They get to be disrespectful and irresponsible and end up getting people mad at them, and when you’re mad at them, it’s hard to see the depression — you just see the brat you’re mad at.”

The challenge, he said, is to look beyond that picture at how they’re really feeling and try to be compassionate, even when they’re acting out. He recognizes that can be difficult.

“How can you be compassionate with someone who’s behaving in a negative way?” he said. “When they’re depressed, they can be hard to talk to. But when they’re approached with compassion by someone who has a good relationship with them, they often open right up. The biggest barrier to identifying teenage depression is often that nobody asked them, not that they weren’t willing to tell.”

Norsang said teens generally have a lower success rate in suicide attempts, and that older people, particularly men, typically opt for more violent means, like firearms, that are more likely to end a life. “With younger people, it’s often a cry for help because, with the ways they try to commit suicide, like poisoning and suffocation, there’s a chance for rescue.

“They may be people who have very poor coping skills due to some early traumatic experiences during their formative years,” he added. “For them, everything is a crisis — they move through life from crisis to crisis, and the anger is always directed toward themselves. Cutters and overdosers often try to relieve that emotional pain by inflicting physical pain on themselves, but they often complete the act by accident and do lose their lives.”

And any such cry for help should not be minimized, he said, if only because of what statistics lay out in sharp relief: that one-third of people who unsuccessfully try to end their lives will try again within a year, and 10{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} will succeed on a subsequent attempt. “Those are high figures,” he said.

Looking Up

For those who do seek help for suicidal thoughts, Norsang said, the prognosis can be very good, but there aren’t any quick fixes.

“A lot of studies show that hospitalization keeps the patient safe initially, but in the long run is not therapeutic,” he said, adding that the best course is often treatment that directly addresses any underlying psychiatric illness but also includes cognitive therapy.

With the latter, “the most important thing initially is to validate their emotional pain,” he explained. “Out in the community, often living by themselves, there’s no one to validate those feelings.”

He referred to three ’i’ words the behavioral health community uses to describe how depressed or suicidal patients perceive those feelings: inescapable, interminable, and intolerable. “You have to acknowledge that emotional pain — ’I understand what you’re going through.’ I think that’s a key part of therapy.”

“Sometimes,” Sarvet said, “you can tell when people have given up — classic signs, like they start giving away their money or take out life-insurance policies, or they make comments to people suggesting things might be better if they weren’t around. Whenever they make a comment like that, when they send the message to people that they are contemplating suicide, you do have to take it very seriously.”

After all, just starting the conversation, as awkward as it might be, may at lease force someone to recognize they don’t have to suffer in silence, and that the pain might be tolerable and terminable after all — and escapable without resorting to the most tragic of escapes.