Night Falls Fast Read online

  Medications and other medical treatments are effective—often remarkably so—in preventing or diminishing the pain and suffering of the major psychiatric illnesses most closely linked to suicide. Less clearly, except in the case of lithium and probably the antidepressants and the newer antipsychotics, they lessen the chances that a suicidal individual will kill him- or herself. Medications, hospitalization, and ECT save many but by no means all lives. Psychotherapy or a strong therapeutic relationship with a doctor can make all the difference in whether some patients ultimately live or die. The very success of psychopharmacology in treating serious mental illness has had the unfortunate effect of minimizing the importance of psychotherapy in healing patients and keeping them alive. Most managed health care companies, for example, cover the costs for medication visits, although often only very brief ones, but do not provide any meaningful coverage for psychotherapy. Despite the extensive and elegant series of studies conducted by Myrna Weissman and Gerald Klerman at Yale University, which showed that the combination of psychotherapy and antidepressants was more effective in treating depression than either treatment alone, and despite convincing recent work from many groups in the United States and Britain demonstrating better outcomes in bipolar and schizophrenic patients who receive a combination of medications and psychotherapy rather than drugs only, there remains a pervasive belief in many psychiatric and research quarters that medication by itself is sufficient to deal with serious mental illness.

  Some of the reluctance to aggressively encourage psychotherapy in patients who suffer from depression, manic-depression, severe personality disorders, or schizophrenia is understandable. Psychotherapy is expensive, difficult, and time-consuming to do and to study, and there are deep conflicts within the psychotherapeutic community about which kinds of therapy work best for which kinds of patients and illnesses; what the nature of clinical training should be; and for how long psychotherapy should last. Territorial and economic disputes between psychiatrists and clinical psychologists are legendary and often riven with mistrust and resentment. It has been too easy to draw an arbitrary distinction between psychological and biological factors in mental illness, and nowhere has this divisiveness been more destructive than in the conceptualization of the causes and treatments for suicidal behavior.

  The complexity of the suicidal mind and brain demands for its care a complexity of clinical thought and treatment. Psychotherapy alone, if used without addressing or treating the underlying psychopathology or biological vulnerabilities, is generally unlikely to prevent profoundly suicidal individuals from killing themselves. The ability to diagnose psychopathology accurately and to refer patients to colleagues for medication when necessary is a nonnegotiable fundamental of good clinical practice. Not to do this is malpractice.

  The polarization of opinions about the correct treatment of suicidal patients was highlighted by a 1994 court ruling against Thomas Szasz, an influential psychiatrist and vehement critic of the concept of mental illness, as well as an adamant opponent of the use of “coercive” efforts to keep an individual from committing suicide. Szasz’s philosophical opposition to “coercive” prevention of suicide is based, in part, on his strongly held belief that there is no connection between suicide and mental illness, a belief supported neither by the clinical and scientific literature nor, indeed, by any data presented by Szasz himself. His views, which had a strong professional and popular following in the 1960s and 1970s and are still widely cited, can best be conveyed by his own words:

  Why do we now give psychiatrists special privileges to intervene vis-à-vis suicidal persons? Because, as I have noted, in the psychiatric view, the person who threatens or commits suicide is irrational or mentally ill, allowing the psychiatrist to play doctor and thereby, like other doctors, to save lives. However, there is neither philosophical or empirical support for viewing suicide as different, in principle, from other acts such as getting married or divorced, working on the Sabbath, eating shrimp, or smoking tobacco. These and countless other things people do are the result of personal decisions.… Psychiatrist and patient are both lost in the existential-legal labyrinth generated by treating suicide as if it constituted a psychiatric problem, indeed a psychiatric emergency. If we refuse, however, to play a part in the drama of coercive suicide prevention, then we shall be sorely tempted to conclude that the psychiatrist and his suicidal patient richly deserve one another and the torment each is so ready and eager to inflict on the other.

  For those who disagree with Szasz, and I obviously am one (and am grateful that my psychiatrist was another), and believe that committing suicide is not altogether the same thing as eating shrimp or working on the Sabbath, it was of no little interest to read that in 1994 Szasz agreed to pay $650,000 to the widow of one of his patients, a physician who had suffered from manic-depressive illness and killed himself. The legal complaint filed against Szasz charged that he instructed and advised his patient to stop taking lithium in June 1990; in December of the same year, the doctor, after beating himself in the head with a hammer and inflicting lacerations to his neck, hanged himself with battery cables. The complaint further charged that Szasz had failed to render “psychiatric medical care and treatment in conformity with the customary and accepted sound standards of medical care,” “failed to properly diagnose and treat,” “failed to provide proper therapy to treat manic depression,” and “failed to keep adequate and proper medical records.” Although Szasz’s attorney maintained that the patient had stopped taking lithium of his own accord and Szasz himself did not concede he had committed malpractice, the court ruled that the widow was to receive $650,000 in settlement. Szasz, despite his distaste for the psychiatric establishment, was a member of the American Psychiatric Association, and it was the organization’s malpractice insurance carrier that ended up paying the settlement.

  Philosophical views and assumptions about the causation of suicide, while strongly held and necessarily and importantly debated, are not sufficient to disregard the massive and credible medical, psychological, and scientific research literature about suicide. Ignoring the biological and psychopathological causes and treatments of suicidal behavior is clinically and ethically indefensible. But so too is disregarding the psychological and social roots of suicide and ignoring potentially useful psychological and social treatments. The mental pain of the suicidal condition is engulfing and unbearable. The therapist, as Ned Cassem at Harvard points out, must have the “capacity to hear out carefully and to tolerate the feelings of despair, depression, anguish, rage, loneliness, emptiness, and meaninglessness articulated by the suicidal person. The patient needs to know that the therapist takes him seriously and understands.” Directness on the part of the clinician is important, as is clear communication about treatment, about expectations about the time course and problems of recovery, and about ways to contact the therapist in case of emergency.

  Morag Coate, a British writer who suffered from severe, recurrent psychosis, described the doctor’s role in saving her life:

  Because the doctors cared, and because one of them still believed in me when I believed in nothing, I have survived to tell the tale. It is not only the doctors who perform hazardous operations or give life-saving drugs in obvious emergencies who hold the scales at times between life and death. To sit quietly in a consulting room and talk to someone would not appear to the general public as a heroic or dramatic thing to do. In medicine there are many different ways of saving lives. This is one of them.

  Most of the studies of psychotherapy, or of psychotherapy combined with medication, have focused on the treatment of psychiatric illness; few have dealt specifically with measuring changes in suicidal thinking or behavior. Marsha Linehan, a psychologist at the University of Washington, recently reviewed twenty controlled clinical trials utilizing different forms of psychotherapy with patients at high risk of suicide. In most studies, the patients were selected on the basis of having made at least one suicide attempt. The psychotherapeutic intervention
s that seemed to be most effective, particularly in patients with borderline personality disorder, sharply focus on changing specific suicidal behaviors and thoughts. These therapies, especially those that are based on identifying and modifying maladaptive behaviors and thinking, appear to work reasonably well in decreasing deliberate self-harm. Keith Hawton at the University of Oxford, in a comprehensive review that included studies of both psychotherapy and medication effects, also found promising results in altering suicidal behaviors. Specific emphasis in several investigations was placed on teaching patients to more effectively handle situations of interpersonal conflict, which, for many of them, had preceded their suicide attempts. It remains unclear whether these therapies prevent actual suicide or suicide attempts only.

  Psychotherapy can be extremely helpful not only in sustaining patients through times of terrible psychological suffering and encouraging them to learn better ways of handling suicidal impulses but also in helping them to deal with the critical and gnarly problem of treatment noncompliance. An unwillingness to take medications as prescribed or to keep psychotherapy or medical appointments is a pervasive and potentially life-threatening problem.

  Many patients never fill even their initial prescriptions, either because they do not want to take medication or because they cannot afford it; many more stop taking their medication after a few days, weeks, or months of treatment because they experience unpleasant or disabling side effects, feel well and see no point in continuing in treatment, find their dosage schedules too confusing, or simply do not believe they have a psychiatric illness. Perhaps 20 percent of all medical patients on long-term maintenance medications take “holidays” (that is, they stop their medications for a period of time); this can be catastrophic, especially with drugs such as lithium that clear from the body very rapidly.

  Compliance is less than ideal in most patients who have any kind of chronic illness. (By way of comparison, in medical conditions such as epilepsy, chronic lung diseases, hypertension, and glaucoma, overall compliance rates range between 50 and 75 percent.) For patients taking antidepressants, the compliance rate is between 65 and 80 percent; for antipsychotic medications, about 55 percent; and for lithium, about 60 percent. (The one study that directly compared one-year compliance rates with lithium and valproate, the anticonvulsant, found compliance rates of 59 percent and 48 percent, respectively.) Compliance rates are even lower in patients who have attempted suicide and who have been given follow-up appointments by emergency room staff or by nurses, doctors, or social workers on the inpatient wards of psychiatric hospitals.

  Psychotherapy increases medication compliance in many patients with psychiatric illnesses, and some, but not all, of the programs designed to facilitate follow-up treatment—programs that actively involve and educate patients and their families, as well as emergency room doctors and nurses, about the gravity of suicide attempts and the need for ongoing treatment; programs that facilitate follow-up care through home visits or keeping in touch through letters or telephone calls—have increased the likelihood that adolescents and adults at risk of future suicidal behavior will enter—and stay—in treatment.

  Individuals who are at risk of killing themselves because they have in the past attempted suicide or been severely suicidal, who have psychiatric illnesses that are closely linked to suicide, or who have a strong family history of suicide can do several things to make suicide less likely. Being well informed about mental illness, actively involved in their own clinical care, and very assertive about the quality of medical and psychological treatment they receive is a good start. Patients and their family members can benefit by actively seeking out books, lectures, and support groups that provide information about suicide prevention, depressive and psychotic illnesses, and alcoholism and drug abuse. They should question their clinicians about their diagnosis, treatment, and prognosis and, if concerned about a lack of collaborative effort or progress in their clinical condition, seek a second opinion.

  Those who are on medications should request, when possible, written information about the drugs, their potential side effects, and which of the side effects need to be reported to the doctor immediately. Certain medication side effects, or flare-ups of symptoms in the underlying psychiatric illness, are of particular concern if someone is suicidal, and these symptoms and side effects—agitation, severe anxiety, marked sleeplessness, restlessness, delusions, feelings of violence, or impulsivity—should be openly and quickly communicated to the clinician. Several recent clinical studies have shown that teaching patients to recognize early symptoms of their illnesses and drawing up written plans that specify emergency steps to follow in case of relapse are helpful in avoiding the kinds of escalation of illness that can lead to hospitalization, loss of jobs and close relationships, or suicide.

  If someone is acutely or potentially suicidal, guns, razor blades, alcohol, knives, old bottles of medications, and poisons should be removed from the home. Medications that can be used to commit suicide should be prescribed in limited quantities or closely monitored, and alcohol use, which can worsen sleep, impair judgment, provoke mixed or agitated states, and undermine the effectiveness of psychiatric medications, should be discouraged.

  The recovery from severe depression or psychosis is a deceptively difficult and dangerous time. This has become especially true in recent years because the length of psychiatric hospitalizations has gone from years or months to only days. Patients leave the relative safety of a hospital, often still very ill, and return to their disruptive lives and chaotic moods.

  More than forty years ago, Sylvia Plath wrote in her journal, “And, when our lives crack, and the loveliest mirror cracks, is it not right to rest, to step aside and heal?,” but few now have the time or financial resources to heal as they should. Medications take a painfully long time to take hold, and the recovery period is jagged, discouraging, and never easy. A setback after finally feeling better again can be devastating, if not lethal. The frustration and rockiness of this period can be predicted, and the clinician’s doing so can take away some of the sting.

  Almost inevitably, family members and friends are drawn into the painful world of possible suicide. They, too, can be most helped, and helpful, by being educated about the clinical situation; learning about the illness and its treatments; inquiring about reasonable expectations for recovery and the likely time course involved; and seeking out information and help from patient support and advocacy groups. If a family member or friend is acutely suicidal, it may be necessary to take away their credit cards, car keys, and checkbooks and to be supportive but firm in getting them to an emergency room or walk-in clinic. If the person is violent, it may be necessary to call the police. These are difficult things to do but often essential.

  The National Depressive and Manic-Depressive Association, a national patient-run advocacy and support group based in Chicago, makes the following specific recommendations to family members and friends who believe someone they know is in danger of committing suicide:

  Take your friend or family member seriously.

  Stay calm, but don’t underreact.

  Involve other people. Don’t try to handle the crisis alone or jeopardize your own health or safety. Call 911 if necessary.

  Contact the person’s psychiatrist, therapist, crisis intervention team, or others who are trained to help.

  Express concern. Give concrete examples of what leads you to believe your friend [or family member] is close to suicide.

  Listen attentively. Maintain eye contact. Use body language such as moving close to the person or holding his or her hand, if it is appropriate.

  Ask direct questions. Find out if your friend [or family member] has a specific plan for suicide. Determine, if you can, what method of suicide he or she is thinking about.

  Acknowledge the person’s feelings. Be empathetic, not judgmental. Do not relieve the person of responsibility for his or her actions.

  Reassure. Stress that suicide is a permanent solution to te
mporary problems. Provide hope. Remind your friend or family member that there is help and things will get better.

  Don’t promise confidentiality. You may need to speak to your loved one’s doctor in order to protect the person. Don’t make promises that would endanger your loved one’s life.

  If possible, don’t leave the person alone until you are sure they are in the hands of competent professionals.

  There are several excellent advocacy and research organizations, many of which have patient and family support groups and all of which are actively involved in issues having to do with suicide prevention and mental illness. (Further information about these groups is given in the Appendix.)

  Often it is helpful, when a potentially suicidal person is improved or well, to have a contingency planning meeting that involves the doctor or therapist, family members, and friends. Not only is the individual who is at risk less likely to be guarded or confused, he or she is better able to express clear and highly specific wishes for treatment: who is to be contacted and how, what others can do that is helpful, what others may do that is not helpful. Patients who decide, when rational, that if they again become suicidal they wish to be hospitalized or receive antipsychotic medications or undergo electroconvulsive therapy, but who also know that they are unlikely, when ill, to consent to this, may in some areas of the country draw up “Odysseus” arrangements. Based on the mythic character’s request to be strapped to the mast of his ship so that he might avoid the inevitable call of the Sirens, Odysseus agreements (or advanced instruction directives) allow patients to agree to certain treatments in advance.