Night Falls Fast Read online

  Parents, if there is a history of mental illness or suicide in the family, can help their children who may be at risk. By knowing their family’s psychiatric histories, being educated about the symptoms and available treatments for mental illness, and discussing these issues openly and in a matter-of-fact way with their children, parents make it more likely that the children will seek help if they become depressed or start using alcohol or drugs. College-age children are at particular risk for mental illness and suicide because first episodes of depressive illnesses or schizophrenia are most likely to occur at this time; they are away from home for the first time and subject to new stresses; they may use alcohol or drugs more heavily; or they may radically alter their sleep pattern, which can, in turn, precipitate a psychotic episode.

  I am often amazed at how many parents who will check into the social and athletic facilities of a college, visit the libraries and residence halls, and request the success rates of the college in getting its graduates into law school, medical school, or doctoral programs do not inquire into the quality and accessibility of its student health facilities. Counseling and psychiatric services vary enormously in quality from campus to campus, and it can be helpful to make inquiries about how well the student health center deals with students who have mental illness. It is also a good idea to obtain from the psychiatry department of the nearest teaching hospital or medical school a list of clinicians who are specialized and competent in the treatment of psychiatric disorders. Mental health advocacy groups such as the National Alliance for the Mentally Ill and the National Depressive and Manic-Depressive Association also can be helpful in providing information about local clinicians and support groups. The list will hopefully never be used, but getting it in advance makes sense. The same parents who have ensured that their children are educated about AIDS, sexually transmitted diseases, and drug abuse often do not discuss the symptoms of depression, an illness that is common, potentially lethal, and highly treatable. Yet only accidents are more likely than suicide to cause death in this vulnerable age group.

  Fortunately, students are beginning to take it upon themselves to educate their fellow students about mental illness. (University and college administrations are now somewhat more aware of the prevalence of mental illness in their undergraduates and graduate students and increasingly shaken into action by the too-frequent suicides of young people. But they are not nearly aware or active enough.) I have had the pleasure and privilege of meeting with hundreds of students across the country, many of whom have struggled for years against severe depression, manic-depressive illness, or alcoholism. A disturbing number have nearly died from their suicide attempts. Rarely do their parents or professors have any idea of the extent of their suffering or what it takes for them simply to show up for class, take their examinations, or write their papers.

  I recently met with a group of students at Harvard University who had established a mental illness awareness program for students on campus. They sponsor lectures, work with a professor from the psychiatry department who acts as their adviser, maintain a Web site, and run a support group for students who suffer from mental illness. The founder of the group, Allison Kent, is a gutsy, lively, and warm young woman who has turned her own pain from manic-depression into a great source of hope and support for others. She has described her own experience as a student:

  I have a mental disorder. When I got sick my freshman year, I remember flipping through The Unofficial Guide to Life at Harvard and other publications, frantically looking for a peer group addressing mental illnesses. I had thought Harvard had a group for just about everything. I mean there couldn’t be a Free Thought Society, a Texas Club, and an Anime Society and not one addressing an issue as basic as mental health. But I was wrong. The only thing I found was that the stigma that mental illnesses have in society was just as prevalent and pervasive here at Harvard.…

  Take a look around at your fellow students some day. Realize that I am not unusual. We are often hidden, the mentally ill, but we are hidden both in homeless shelters and at Harvard. Help reduce our burden by educating yourself and your friends about the pervasiveness of mental illness and learn about how it can be successfully treated. As we acknowledge our own vulnerability and accept vulnerabilities in others, we make the world easier to live in for all of us, not just the mentally ill. No one should need to cry herself to sleep alone.

  CHAPTER 9

  As a Society

  —THE PUBLIC HEALTH—

  As a society, we do not like to talk about suicide.

  —DAVID SATCHER, M.D., PH.D.,

  Surgeon General of the United States

  MORE THAN three thousand people turned out for the funeral of John Wilson in May 1993, and thousands more lined the streets of Washington to watch as his coffin passed. Wilson’s death stunned the nation’s capital, where he had served with impatient intelligence as chairman of the D.C. Council. Those of us who live in Washington and who were hopeful that he would some day be elected mayor were horrified to hear that the blunt, charismatic Wilson, only forty-nine years old, had hanged himself. Rumors of mercurial outbursts and erratic behavior had circulated for months, but his suicide was a shock. It forced an uncharacteristically reflective pause in the city’s rushing ways and, within hours, provoked a rash of questions: How could so admired and well loved a man—elegant, vivacious, and scathingly witty—do such an irremediable thing? Did he know, or was he just past caring, that his suicide would be devastating to those whose hopes and lives he represented? Would his suicide have an imitative, cascading effect, especially on other African-American men in the city? Had he been in treatment? Was he taking medication? If so, what kind? Most of all, could society—or the medical system—have prevented Wilson’s suicide?

  John Wilson was no stranger to depression. The illness ran in his family, and he had, on at least four earlier occasions, tried to kill himself—he had slashed his wrists, played Russian roulette, taken an overdose of his antidepressant medications, and attempted to hang himself. During the course of his last illness, his psychiatrist, family, and close friends had pleaded with him to check into a hospital, but he had refused. Perhaps he thought there was nothing that could help him; but he also hoped to be mayor some day and believed, at a visceral level, that hospitalization would be political suicide. Probably he was right, but possibly not. In any event, he killed himself before the city could show its subtler colors.

  Accounts of Wilson’s last few weeks reveal a man captured by private despair and slowly unraveling in public. Peter Perl, in the Washington Post, describes his final days:

  What was constant, his friends say, was an unrelieved grayness seeping into him, taking over. “What finally closed in on John … was bigger than just the question of running for mayor” or pursuing other career options. “He was more depressed, and depressed more consecutively.… He became darker and less shakable from the grip of depression.”

  Only once did Wilson talk in public about the pain of his depression. On May 7 [less than two weeks before he killed himself] he scrapped a prepared text on children and violence, and instead began revealing his own illness to a group of psychiatrists and other professionals at a meeting of the D.C. Mental Health Association. “We can talk about me being a politician, but we can also talk about me as a person who deals with depression, a very painful, very difficult disease … [that] leads to a great feeling of being lost, of a hole in your body,” he said. He told them the disease was particularly deadly in the black community, where people played “Russian roulette” with their lives, and said, “I believe that more people are dying of depression than are dying of AIDS, heart trouble, high blood pressure, anything else, simply because I believe depression brings on all of those diseases.” The audience was stunned, but according to association director Anita Sheldon, none of the people who came up to Wilson afterward talked to him about his illness.

  Wilson became increasingly strange and morose in public appearances, but most people att
ributed his behavior to his customary moodiness. In his final taping of a TV show he hosted on D.C. cable, Wilson was alternately laughing, stuttering and rambling … he concluded the monthly show by saying, “We’ll be back next week, I guess.”

  At a May 12 hearing on Capitol Hill on the D.C. budget, he discarded his prepared speech—“the people who wrote this would die if I didn’t read it, so they are going to die”—and proceeded to ramble extemporaneously before the House District of Columbia appropriations committee: “Mr. Chairman, I am at the end of a political career, I am arriving at the end of a political career and I have served this government, I think, well for 18 years.… So, Mr. Chairman, I come to you today as a tired, weary old man, who is losing his hair, who is becoming extremely, extremely frightened to death of the District of Columbia’s financial situation.… I am frightened. I don’t know what to do anymore.”

  The day before he killed himself, Wilson presided over a crowded city hearing; he was intermittently lucid and volatile. At one point, in front of television cameras and a room full of people, he exploded with rage and stalked out of the hearing room. Later he returned to the meetings but was rambling and incoherent. Despite this, at least one close friend remarked that he had looked upbeat and jovial, “like he didn’t have a care in the world.” The next day, when he did not show up for work, his chauffeur and his wife drove to Wilson’s house, where they found him hanging dead in the basement.

  A superb politician and a prominent civil rights leader, the ambitious and wildly successful son of a porter for the Baltimore & Ohio Railroad was dead by his own hand. He was dead from depression, dead from his concerns about how the public would respond if they knew of his mental illness or if they knew that he had been hospitalized for it. Dead, too, because the illness he had made it difficult for others to know how to reach out to him: no one knew how to deal with a public figure who was unstrung and unpredictable. Dead because psychiatric commitment laws protect civil liberties but not necessarily lives. And dead because we as a society fail to deal in a tolerant or informed way with serious mental illnesses, addictions, or suicide.

  What could society have done to have made it acceptable to sign into a hospital, and what could it have done to make it unnecessary and unimaginable to throw a rope over a pipe?

  DOCTORS, WHO ought to be in the best position to help the public, are not distinguished by their own ability to help one another or themselves. They are, to start with, twice as likely to kill themselves as other people are. Psychiatrists and anesthesiologists are especially vulnerable, and women physicians even more so; in fact, women doctors are three to five times more likely than the general public to kill themselves. (Women psychologists and chemists, but not teachers, have similarly elevated suicide rates. Men in these professions do not. It may be that there is a selection factor—high energy and volatility, with an associated mood disorder—for women who go into, and succeed in, highly competitive and male-dominated fields. Women also probably experience greater levels of stress due to the demands of bringing up children, the prejudice of colleagues and patients, and loyalties torn between personal and career lives. Those in medicine and science also have a familiarity with, and access to, highly lethal methods of suicide.)

  Doctors, more often than not, are left alone to struggle with their suffering. Many find it hard to ask for help or, indeed, to acknowledge needing it: they are trained to be independent, to be accountable for decisions that cost or save lives, and to assume an undue portion of the miseries of others. They function within a closed system that too often discourages seeking treatment and has, as well, the power to deny or rescind medical licenses and hospital privileges and to affect the flow of patient referrals. Highly addictive and lethal drugs are readily available, stress and depression are common, and sleep deprivation—a source of fatigue and bad judgment, as well as a potential precipitant of mental illness—is pervasive. Self-medication with alcohol, drugs, or mood-altering medications can be, and often is, disastrous.

  Doctors must recognize and take care of their own problems and those of their colleagues, in addition to those of the patients they treat. They must attend to deeply ingrained attitudes and prejudices about mental illness and suicide as well. The compassion and scientific knowledge they bring to the care of other medical illnesses are not always a part of treating the mentally ill. Doctors confronted with suicide or suicidal behavior often find it incomprehensible or threatening. Yale surgeon Sherwin Nuland, for example, observes that for the family members or friends of someone who has killed himself, “things seem inexplicable.… But for the uninvolved medical personnel who first view the corpse, there is another factor to consider, which hinders compassion. Something about acute self-destruction is so puzzling to the vibrant mind of a man or a woman whose life is devoted to fighting disease that it tends to diminish or even obliterate empathy. Medical bystanders, whether bewildered and frustrated by such an act, or angered by its futility, seem not to be much grieved at the corpse of a suicide. It has been my experience to see exceptions, but they are few. There may be emotional shock, even pity, but rarely the distress that comes with an unchosen death.”

  Yet nearly a third of those who kill themselves visit a physician in the week before they die, and more than a half do so in the month prior to committing suicide. Most do not say they are suicidal, and most are not asked. Even for mental health professionals, as we have seen, recognizing and appropriately treating a suicidal patient are not always easy things to do. Some doctors remain skeptical that general medical practitioners can or should be put in the position of screening for or treating suicidal patients; others persevere in the erroneous belief that if they ask their patients about suicide, they will somehow encourage the act. Accumulating evidence suggests, however, that educating doctors about recognizing and treating depressive illness may have an impact on the suicide rate.

  In the early 1980s, the Swedish Committee for the Prevention and Treatment of Depression introduced an educational program for all general practitioners on the Swedish island of Gotland. The doctors attended comprehensive lectures on the causes, classification, and treatment of depressive illnesses; they also learned about more specific areas of clinical concern, such as the diagnosis and treatment of children, adolescents, and the elderly. Follow-up studies showed that the doctors who had participated in the intensive educational program were better able to identify patients with depression and were more accurate in the treatments they prescribed. The overall suicide rate on the island decreased more than did the rate for Sweden as a whole; specifically, the proportion of suicides due to depressive illness decreased. Although the methods used to determine changes in the suicide rate have been debated by some researchers, as has the durability of the change, the results have been impressive to many public health physicians. They have been encouraged by the potential of an educational program to make an impact on a problem that has remained more resistant to change than virtually any other major cause of death.

  Doctors who are in frequent and direct contact with very suicidal patients are in a more obvious position to prevent suicides than general practitioners are. Medical staff in emergency rooms, for example, treat patients who have attempted suicide and therefore are at high risk for eventually killing themselves. The American Foundation for Suicide Prevention has developed a poster to be placed in emergency rooms across the United States that highlights, for both nonspecialists and psychiatrists, the major clinical predictors of suicide, as well as minimal steps that should be taken by clinicians to decrease the chance of its occurring. Reaching out to those doctors and patients, it is hoped, will save at least some, if not many, lives.

  Widespread screening of patients in more general medical practices, however, has not been shown to be particularly effective; neither the Centers for Disease Control and Prevention in the United States nor the Canadian Task Force set up to study the feasibility of such a screening process recommends it. In the future, though, it may well be t
hat automated interviews conducted with a computer, which do not place a heavy burden on the limited time of general practitioners and which, research indicates, elicit more accurate reports of suicidal ideation and alcohol consumption than those obtained by clinicians, will be used routinely.

  Identifying and treating people at high risk for suicide involves not only doctors, of course, but many other individuals, organizations, and intervention strategies as well. National Depression Screening Day, which began as a pilot program at a local hospital in Massachusetts, has, since 1991, reached out to a more self-selected group of individuals from the public. In October of each year, in thousands of clinics, hospitals, libraries, businesses, and shopping malls across America, people fill out a brief depression checklist. If they request a referral for treatment, or if their depression score indicates they should be more thoroughly evaluated by a clinician, they are. (Twenty percent of those screened are severely depressed, but of those only one in ten is in treatment.) More than 400,000 people, many of them at significant risk for suicide, have participated in the screening program since it began. When a similar depression symptom checklist was published recently in nationally syndicated Parade magazine, along with a telephone contact number, more than 100,000 telephone calls were received within two weeks. Only a small minority of those who called were in treatment.