The Vicious Spiral of Suicidality

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A study published in the November 2016 issue of JAMA Psychiatry suggested that patients were at an increased risk of suicide during the three months immediately following their discharge. They were fifteen times more likely to commit suicide than similarly matched patients who were treated for non-mental health issues. Individuals without any outpatient care in the months before their hospitalization were at an even higher risk. Individuals diagnosed with depressive disorders were at the highest risk, followed by those with bipolar disorder and then schizophrenia.

The lead author of the study, Mark Olfson, was interviewed on the JAMA network about the study. He said one of the limitations of the study was it didn’t have the level of detail to get at why depression and depressive disorders were the highest short-term risk of suicide. However, he speculated that since one of the symptoms (diagnostic criteria) for depression was related to suicide, and many individuals are hospitalized because of suicide attempts or suicide risk, this is “probably what conveys their short-term risk of suicide following hospitalization discharge.” He added that effective approaches to suicide risk reduction should involve strengthening a patient’s connectedness, reducing social isolation, and engaging them in outpatient care. In his review of the study for Mad in America, Justin Karter quoted the study authors as saying:

These patterns suggest that complex psychopathologic diagnoses with prominent depressive features, especially among adults who are not strongly tied into a system of care, may pose a particularly high risk. As with many studies of completed suicide, however, the low absolute risk for suicide limits the predictive power of models based on clinical variables. These constraints highlight the critical challenge of predicting suicide among recently discharged inpatients based on readily discernible clinical characteristics.

The association of suicide risk and hospitalization has been evident in previous studies. For example, a 2005 study reported in the Archives of General Psychiatry, found there were two sharp peaks of suicide risk around psychiatric hospitalization. There were during the first week after admission and in the first week after discharge. The length of hospitalization was also a factor, with individuals receiving less than the median length of stay having a significantly higher risk. The study also confirmed previous reports that prior admission to a psychiatric hospital is also associated with a higher risk of suicide.

This study, to our knowledge, is the first to explore how suicide risk differs by diagnosis across the phase of psychiatric hospitalization. We find that affective disorders increased the risk for suicide the strongest across all phases of time since hospitalization compared with other diagnostic groups. We also find that affective and schizophrenia spectrum disorders tend to have a more intensive effect on the risk of suicide, whereas substance abuse disorders have a more prolonged effect on the risk of suicide.

In an article for the website, Speaking of Suicide, Stacey Freedenthal cited the recommendation by David Rudd, a nationally known suicide expert, who recommended initially seeing an individual at least twice in the week after discharge. The elevated risk of suicide after hospitalization was not necessarily related to a premature discharge. Referencing David Rudd, she said:

Instead, suicidal intent is fluid, impossible to predict from one moment to the next, let alone day-to-day. Of course, whatever led to hospitalization in the first place, whether a suicide attempt, mental illness, or some other crisis, places a person at higher risk than normal for suicide.

However, there was a 2014 study reported in Social Psychiatry and Psychiatric Epidemiology that found psychiatric admission in the previous year was highly associated with completed suicide. “Furthermore, even individuals who have been in contact with psychiatric treatment but who have not been admitted are at highly increased risk of suicide.” The authors said the relationship was one of association, rather than causation. “People with increasing levels of psychiatric contact are also more severely at risk of dying from suicide.”

An editorial in the same issue by Large and Ryan said that compared to those who had no psychiatric treatment in the previous year, those who received medication were 5.8 times the risk of suicide; those with at most outpatient psychiatric treatment had 8.2 times the risk; patients with emergency department contact without an admission had 27.9 times the risk; and admitted patients had 44.3 times the risk of suicide. These ratios were after controlling for other risk factors.

The strongest risk factors for suicide after discharge were: prior suicide attempts and depressive symptoms. Additional risk factors include: hopelessness, worthlessness, guilt and a family history of suicide. Large and Ryan said they believed it was likely that a proportion of individuals who suicide during or after an admission to hospital do so because of factors inherent in the hospitalization. They argued that such suicides should be considered as “nonsocomial”—acquired in a hospital.

There was a significant positive correlation between a PTSD diagnosis and suicidality in a study by Panagioti, Gooding, and Tarrier. Comorbid major depression was a compounding risk factor. The association of suicidality and PTSD persisted across “studies using different measures of suicidality, current and lifetime PTSD, psychiatric and nonpsychiatric samples, and PTSD populations exposed to different traumas.”  Another study of national suicide rates in 25 European countries concluded that stigma towards persons with mental health problems could influence suicide rates within a country. The authors hypothesized that possible mechanisms could include stigma as a stressor, or social isolation as a result of stigma. Large and Ryan said:

There is now little doubt that suicide is associated with both stigma and trauma in the general community. It is therefore entirely plausible that the stigma and trauma inherent in (particularly involuntary) psychiatric treatment might, in already vulnerable individuals, contribute to some suicides.

So it seems there is a vicious spiral with suicidality. Together, depression and suicidality may lead to hospitalization, which itself is a risk factor for suicide. Hospitalization, particularly when it is involuntary, can lead to stigma and trauma, which exacerbates feelings of worthlessness and hopelessness—-themselves further risk factors in suicide.

How then do we help the chronically depressed and suicidal person? Perhaps the place to start is by not harming them any further. We need to recognize and minimize the potential for stigma and trauma from hospitalization. We need to address feelings of helplessness and worthlessness from very beginning of any contact with a depressed and suicidal person. In Cruel Compassion, as he reflected on how to avoid further harm with chronic mental patients, Thomas Szasz gave the following quote of C.S. Lewis that I think is helpful here.

Of all the tyrannies a tyranny sincerely exercised for the good of its victim may be the most oppressive. . . . To be “cured” against one’s will and cured of states which we may not regard as disease is to be put on a level with those who have not yet reached the age of reason or those who never will; to be classed with infants, imbeciles, and domestic animals. . . . For if crime and disease are to be regarded as the same thing, it follows that any state of mind which our masters choose to call “disease” can be treated as a crime and compulsorily cured. . . .Even if the treatment is painful, even if it is life-long, even if it is fatal, that will be only a regrettable accident; the intention was purely therapeutic.

Szasz went on to add:

To help the unwanted Other, we must therefore first relinquish the quest to classify, cure and control him. Having done so, we can try to help him the same way we would try to help any person we respect—asking what he wants and, if his request is acceptable, helping him to attain his goal or accept some compromise.


Suicide is NOT Painless


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Recently we all heard of the successful suicide of Robin Williams. The media aftermath has stirred up a shit-storm of debate and controversy. I asked someone who lost a loved one to a completed suicide how they reacted to the news. The person’s hope was that since Robin Williams was a celebrity, that a constructive dialogue would occur and help someone else decide not to try suicide. So I want to introduce you to some suicide statistics that relate directly to the tragic loss of Robin Williams. And perhaps start us thinking about how we can help prevent other people from trying to end their life.

The Center for Disease Control and Prevention (CDC) maintains a wealth of statistics on suicide at “National Suicide Statistics at a Glance.”  Among the trends in suicide rates for males between the age of 45 and 64, suicide by firearms were most common, 15.52 per 100,000 in 2009. Suicide by suffocation was second. “Suffocation suicide rates among males aged 45 to 64 years have increased 103.5% since 2001 from 2.91 to 5.92 suicides per 100,000 in 2009.”

“From 1991 to 2009 the suicide rates were consistently higher among males 65 years and older compared to the younger age groups.” But they were decreasing, from 40.12 per 100,00 in 1991 to 29.09 in 2009. HOWEVER, the rates of males between 25 and 64 increased from 21.27 per 100,000 in 2000, to 25.37 per 100,000 in 2009.

I then looked at the latest census figures available on the US census website for males between the ages of 25 and 64 to estimate the number of males these suicide statistics would reflect. Roughly 2,000 men like Robin Williams between the ages of 25 and 64 successfully completed suicide—480 who did so by suffocation—in 2009, the last year statistics were available. So there were 479 other families who suffered the pain of a completed suicide, as does the family of Robin Williams.

What can you do to help prevent more suicides? Look at the website for the National Strategy for Suicide Prevention  (NSSP) for information. The NSSP has a number of goals and objectives to facilitate suicide prevention:

  • Foster positive public dialogue; counter shame, prejudice, and silence; and build public support for suicide prevention;
  • Address the needs of vulnerable groups, be tailored to the cultural and situational contexts in which they are offered, and seek to eliminate disparities;
  • Be coordinated and integrated with existing efforts addressing health and behavioral health and ensure continuity of care;
  • Promote changes in systems, policies, and environments that will support and facilitate the prevention of suicide and related problems;
  • Bring together public health and behavioral health;
  • Promote efforts to reduce access to lethal means among individuals with identified suicide risks;
  • Apply the most up-to-date knowledge base for suicide prevention.

From the revised NSSP, the Action Alliance selected four priorities in suicide prevention that, if accomplished, they hope will help the group reach its goal of saving 20,000 lives in the next five years. These priorities are:

  1. Integrate suicide prevention into health care reform and encourage the adoption of similar measures in the private sector.
  2. Transform health care systems to significantly reduce suicide.
  3. Change the public conversation around suicide and suicide prevention.
  4. Increase the quality, timeliness, and usefulness of surveillance data regarding suicidal behaviors.

One agency I worked for required counselors to complete the background paperwork and have the necessary forms signed during the initial session with a new client NO MATTER WHAT. In a way that was understandable, because if the person never returned and you didn’t have the right forms signed, the agency wouldn’t get paid for the time you spent with the individual. But it made it difficult for the counselor if someone was in crisis, or needed some encouragement. One time I broke that rule and inadvertently helped prevent a suicide.

The more information and forms I completed, the greater was my impression that the woman was discouraged and hopeless. So I stopped the paper pushing and really talked with her about her problems. She had struggled off and on with drug use for over twenty years and didn’t have much hope at that moment that she could stop and get her life together. Her last relapse had led to the breakup of a long-term relationship. We talked and I was able to help her see she could re-establish abstinence; maybe even reconcile the relationship. There was some hope.

When she returned for the second appointment we completed the required paperwork that I didn’t do during the first session. And then she told me she had decided before our first counseling session that if she felt as hopeless after the session as she did before it, she had intended to kill herself. People will sometimes say that they intended to kill themselves, but not really have more than the idea of suicide. But she has a prior history of attempts; and she had a plan that would have been successful if she attempted it.

We have a responsibility to be with one another, to make space for one another, to be kind to one another… and hopefully through doing so, we make life that much more bearable. We do our best suicide prevention by letting go of the goal of suicide prevention, and, instead, creating alternatives.

I think this quote’s essay is headed in the right direction for suicide prevention. Maybe the best technique is to simply be committed to letting people know that you care enough about them to enter their darkness and help them move out into some light.

What more can you do to help prevent the pain of suicide?