Night Falls Fast Read online

  Jefferson’s conjecture that Lewis’s melancholic tendencies were put on ice as long as he was actively and physically engaged but emerged later during slower, more sedentary times is perceptive, telling, and completely consistent with what is known about restless, energetic, and impetuous temperaments that have an obverse inclination to despair. Stephen Ambrose, in his excellent biography of Meriwether Lewis, Undaunted Courage, discusses at some length Meriwether Lewis’s occasional quickness of temper: “He had, however, four times lost his temper and twice threatened to kill. His behavior was erratic and threatening to the future of the expedition.… He had a short temper and too often acted on it.… [He] could not keep his ‘boisterous’ passion in check.”

  Lewis, then, had a family and personal history of depression, a quick temper and a restless disposition, and a tendency to drink heavily and, toward the end of his life, to be financially reckless and rather unaccountable in his professional obligations. He twice attempted suicide and was placed on a close suicide watch by a fellow officer. His closest friends, William Clark and Thomas Jefferson, believed the eyewitness accounts of his last days and hours, all of which had concluded that he had killed himself.

  Why, then, the convoluted theories of conspiracy, of malaria, or of syphilis, all of which have been offered as “explanations” for his death? There is little credible evidence for the “Jefferson conspiracy”; improbable speculation only for the theory of murder (much of it based on the magnification of inevitable inconsistencies in the accounts of witnesses); and next to no evidence at all for syphilis, although it is possible he had it. He may well have suffered from malaria, which was endemic along the frontier; this has been suggested by some as the explanation for his “derangement.” Cerebral malaria, which occasionally results in impulsive and self-destructive acts, is very uncommon. (Of the malaria cases reported in the nineteenth century, as well as the tens of thousands detailed in World Wars I and II and the Vietnam War, fewer than 2 percent were cerebral malaria; of those that were, suicide was a rare outcome.) A medical cause for irrational behavior may be more palatable to some historians, but it is not more plausible.

  Douglass Adair and Dawson Phelps of the Oregon Historical Society raise, I think, the critical question: “Apparently,” they write, “most of Lewis’s contemporaries who knew him well … were either not surprised to learn that he had killed himself, or had extremely persuasive evidence that his death was suicide. Does the murder theory reflect the unwillingness of American scholars (the frontier specialists in particular) to admit that a man as great as Lewis had shown himself to be … could become so spiritually desolated or mentally ill that he could kill himself?”

  I think the answer is yes, that scholars and laypeople alike find it hard to hold in their minds the thought that a great man could have been deranged or that a courageous man could have killed himself. But such men do. And the same bold, restless temperament that Jefferson saw in the young Meriwether Lewis can lie uneasily just this side of a restless, deadly despair. It is to the great credit of Jefferson that he was able to understand this complexity of human nature and to Lewis’s credit that he chose as his co-leader and explorer William Clark, a man of a complementary, more even disposition.

  In recent years, there has been a rumbling to disinter the remains of Meriwether Lewis. It is argued that doing so would settle the truth of his death once and for all, and perhaps it would. One reader of the Washington Post, for example wrote, that if it could be proved that Meriwether Lewis had been murdered, “then a blot is removed from the name of the explorer.” I wrote a letter to the Post in response. I thought it was extraordinary that suicide should be seen as a “blot”; that there was a compelling case that Lewis had suffered from manic-depression and had killed himself; and that however Lewis had died, he had lived a life of remarkable courage, accomplishment, and vision. Suicide is not a blot on anyone’s name; it is a tragedy. I believe, as do many others, that he should be allowed to keep such undisinterred peace as he might have. He has earned his rest. And, in the end, for all of us, it is his life that remains. Lewis was, as Ambrose writes, an explorer first, last, and always:

  He was a man of high energy and was at times impetuous, but this was tempered by his great self-discipline. He could drive himself to the point of exhaustion, then take an hour to write about the events of the day, and another to make his celestial observations.

  His talents and skills ran wider than they did deep. He knew how to do many things, from designing and building a boat to all the necessary wilderness skills. He knew a little about many of the various parts of the natural sciences. He could describe an animal, classify a plant, name the stars, manage the sextant and other instruments, dream of empire. But at none of these things was he an expert, or uniquely gifted.

  Where he was unique, truly gifted, and truly great was as an explorer, where all his talents were necessary. The most important was his ability as a leader of men. He was born to leadership, and reared for it, studied it in his army career, then exercised it on the expedition.

  • • •

  MERIWETHER LEWIS was a great man and the circumstances of his death unbearably sad. Shakespeare, in writing of the suicide of Mark Antony, said it best: “The breaking of so great a thing should make / A greater crack: the round world / Should have shook lions into civil streets, / And citizens to their dens.”

  IV

  Building Against Death

  —PREVENTION OF SUICIDE—

  But suicides have a special language

  Like carpenters they want to know which tools.

  They never ask why build.

  —ANNE SEXTON

  Anne Sexton (1928–1974) received the 1967 Pulitzer Prize for Live or Die, a collection of poems that included the one excerpted here. She attempted suicide on several occasions, and eventually died in 1974 from carbon monoxide poisoning. Her sister and aunt also committed suicide.

  CHAPTER 8

  Modest Magical Qualities

  —TREATMENT AND PREVENTION—

  For melancholy, take a ram’s head that never meddled with a ewe … boil it well, skin and wool together … take out the brains, and put these spices to it, cinnamon, ginger, nutmeg, cloves.…

  It may be eaten with bread in an egg or broth.

  —ROBERT BURTON

  Lithium … is the lightest of the solid elements and it is perhaps not surprising that it should in consequence possess certain modest magical qualities.

  —G. P. HARTIGAN

  MARIGOLD IS “much approved against melancholy,” wrote Robert Burton in 1621; so too are dandelion, ash, willow, tamarisk, roses, violets, sweet apples, wine, tobacco, syrup of poppy, featherfew, and sassafras. A ring made of the hoof of an ass’s right forefoot is “not altogether to be rejected,” and “St. John’s wort, gathered on a Friday in the hour of Jupiter … mightily helps.”

  The treatment of melancholy and the prevention of suicide have moved on since tamarisk and featherfew, but still it is from the natural world—a light metal, the third element in the periodic table—that we have extracted lithium, our most demonstrably effective treatment against suicide. We have, as well, found other medications that stabilize mood, fight psychosis, or tamp down anxiety, agitation, and impulsivity. We have antidepressant medications that aggressively treat the depressions often responsible for suicide. We have built hospitals to provide a sanctuary against madness and self-inflicted death, and developed psychotherapies to ameliorate pain and to help the suicidal navigate through the darkest times of their lives. We know a great deal about how to prevent suicide, but not enough. And what we do know, we do not use as well or widely as we could.

  The causes of suicide lie, for the most part, in an individual’s predisposing temperament and genetic vulnerabilities; in severe psychiatric illness; and in acute psychological stress. Addressing only one of these causes at the expense of others is unlikely to be enough to keep suicide at bay. Misdiagnosing or ineptly treating a potentiall
y lethal psychiatric illness, or underplaying the gravity of a suicide risk, can and often does have tragic consequences. Together, doctors, patients, and their family members can minimize the chances of suicide, but it is a difficult, subtle, and frustrating venture. Its value is obvious, but the ways of achieving it are not. Anyone who suggests that coming back from suicidal despair is a straightforward journey has never taken it.

  Most who commit suicide explicitly, and often repeatedly, communicate their intentions to kill themselves to others—to their doctors, family, or friends—before doing so. Many never do: they act on impulse or cloak their plans; they give no chance to themselves or others. But for those who do make clear their desire to die, it is fortunate; it allows at least the possibility of treatment and prevention. Eli Robins and his colleagues at the Washington University School of Medicine in St. Louis concluded in their landmark study of 134 suicides:

  If we had found that suicide was an impulsive, unpremeditated act without rather well defined clinical limits, then the problems of its prevention would present insurmountable difficulties using presently available clinical criteria. The high rate of communication of suicidal ideas indicates that in the majority of instances it is a premeditated act of which the person gives ample warning.

  In a clinical setting, assessment of suicide risk must precede any attempt to treat psychiatric illness or prevent suicide. Asking a patient directly about suicidal thoughts or plans is an obvious and essential part of history taking. In addition to an individual’s stated plans about suicide, there are other major risk factors that need to be evaluated: the presence or absence of severe anxiety, agitation, or perturbance; the pervasiveness, type, and severity of psychopathology; the extent of hopelessness; the presence or absence of a severe sleep disturbance or of mixed states; current alcohol or drug abuse; ease of access to a lethal means, especially firearms; lack of access to good medical and psychological treatment; recent severe causes of stress, such as a divorce, job loss, or death in the family; a family history of suicidal or violent behavior; social isolation, or a lack of friends and family; close proximity to a first episode of depression, mania, or schizophrenia; and recent release from a psychiatric hospital.

  It is difficult but essential to obtain from a potentially suicidal patient an accurate and comprehensive history of violence and impulsivity, because, in conjunction with psychiatric illness, they can create a flash point for suicide. Many patients, especially women, are reluctant to acknowledge such behaviors; others, for whom violent feelings and relationships are an integral part of their lives, may not realize that their violent behaviors are sufficiently unusual to report them to a doctor or therapist. Patients need to be asked whether or not they have a quick or violent temper; how frequently they find themselves in the middle of tempestuous relationships or participants in repeated scenes of vitriolic verbal abuse; and whether or not they experience frequent and pronounced irritability or engage in impulsive behaviors, such as bolting from social situations or attempting to jump out of moving cars.

  Treatment decisions follow from the clinical evaluation of suicide risk and psychiatric diagnosis. A clinician’s first responsibility is to evaluate the risk of imminent suicide and, if necessary, to arrange for hospitalization. Such an assessment is occasionally straightforward, but often it is not. Acutely suicidal patients who are at high risk often need to be hospitalized, both as a protective measure and in order to diagnose and treat severe mental illness, and to evaluate the patient’s psychological assets and social resources.

  Psychiatric hospitalization is generally both frightening and reassuring to suicidal patients. It continues to carry a heavy stigma and to create personal, economic, and professional difficulties for many individuals. And as we have seen, it does not prevent all suicides. Hospitals do, however, save many lives, and they relieve not only patients, but also their family members and friends, of the terrible burden of feeling responsible for their own or another’s life. Hospitalization is too often seen by both patients and their doctors as a symbolic defeat or as the treatment of last resort, rather than as an occasional necessity for a serious problem. These beliefs, which tend not to accompany decisions to hospitalize people who have other medical conditions, are pervasive and dangerous, and they stand in the way of good clinical care.

  William Styron, who described his hospitalization for suicidal depression as a “way station, a purgatory,” strongly regretted his doctor’s reluctance to admit him to a psychiatric ward:

  Many psychiatrists, who simply do not seem to be able to comprehend the nature and depth of the anguish their patients are undergoing, maintain their stubborn allegiance to pharmaceuticals in the belief that eventually the pills will kick in, the patient will respond, and the somber surroundings of the hospital will be avoided.… I’m convinced I should have been in the hospital weeks before. For, in fact, the hospital was my salvation, and it is something of a paradox that in this austere place with its locked and wired doors and desolate green hallways—ambulances screeching night and day ten floors below—I found the repose, the assuagement of the tempest in my brain, that I was unable to find in my quiet farmhouse.

  Whether or not acutely suicidal individuals are hospitalized, they need intensive care: a greater time and emotional commitment from their clinicians; specialized and aggressive use of medications; intensified psychotherapeutic or other clinical contacts; and an increased involvement between their doctors and their family members and friends. Later, we will deal in some detail with psychotherapy and with family education and involvement. Here we delve into what is known about the effectiveness of different kinds of medication in preventing suicide.

  Suicide usually requires multiple “hits”—a biological predisposition, a major psychiatric illness, and an acute life stress—but only some of these “hits” are amenable to change. There is, for example, relatively little a doctor can do to control many of the major stresses in a patient’s life: they occur too randomly, and thus are difficult to predict and even more difficult to govern. But there are things that can be done to influence or treat the underlying biological vulnerabilities to suicide, as well as the mental illnesses closely linked to suicidal behavior.

  Lithium is the most effective, most extensively studied, and best-documented antisuicide medication now available. It has been used since 1949 to stabilize the dangerous mood swings and erratic behavior associated with manic-depressive illness and, by Europeans particularly, to prevent recurrent depressions. Its effectiveness in preventing suicide is probably due to its impact on two of the most potent risk factors for suicide: its putative capacity to enhance serotonin turnover in the brain (as well as its effects on other neurotransmitters)—and thereby to decrease aggression, agitation, and impulsivity—and its power to decrease or eliminate mania and depression in most people who have manic-depressive illness.

  Recently, two researchers from Harvard Medical School, Leonardo Tondo and Ross Baldessarini, and I reviewed twenty-eight published treatment studies that together included more than seventeen thousand patients with major depression or manic-depressive illness. Patients who had not been treated with lithium were nearly nine times more likely to commit or attempt suicide than those who had been treated with it. (In a separate investigation, Tondo and his colleagues found that suicidal acts rose sixteenfold in the first year after discontinuing lithium treatment.) A 1999 study from Sweden concluded that lithium treatment resulted in a 77 percent reduction in the risk of suicide. The authors, while cautioning that patients who remain on lithium for several years make up a self-selected population, noted that patients were nearly five times more likely to kill themselves when they were not taking lithium than when they were.

  If lithium works so well to prevent recurrences of mania and depression, and if it has such a potent effect in decreasing suicidal behaviors, why isn’t everyone who suffers from a major mood disorder taking lithium? Indeed, why isn’t everyone who is suicidal taking lithium? The answers
reflect the problems, as well as the promise, of psychiatric medications. First, not everyone responds well to lithium. Some who take it respond only partially or, more unusually, not at all. Others cannot take it for medical reasons, or they find the side effects intolerable. Many others, as we shall see later, are simply noncompliant; that is, they do not take the medication as prescribed. For whatever reasons, lithium is seen by many patients as a stigmatizing treatment, or else it is seen as toxic, an attitude not helped by the attitudes and practices of many in the medical community. The difficulty was captured in a letter written to the editors of The Lancet: “Psychiatrists and other practitioners regard the use of lithium as arcane, difficult, and potentially dangerous for all but the specialist to administer,” wrote the concerned practitioners, who also noted that there was “poor quality and reliability of lithium information from official sources” and that the plasma lithium concentrations recommended by many doctors were often far too high, reflecting clinical practice that was fifteen to twenty years out of date. These attitudes are subtly pervasive in clinical practice, especially in the United States, and are the result of many factors: lithium requires monitoring of blood levels to prevent toxicity, and side effects—such as blunting of emotions, slowed thinking, and problems in coordination—affect a number of patients.