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From the title of this chapter, and from the direction of this book so far, it may seem I am making an assumption – namely, that all suicidal people suffer from some form of mental or emotional disorder. But I’m not making that assumption.
A rapidly expanding literature on the relationship of mental illness to suicide strongly suggests that 90 percent to 95 percent of those who complete suicide are suffering from some sort of disorder in brain function at the time (Goldsmith et al. 2002). This impaired functioning may be due to changes in neurotransmitter mechanisms secondary to brain dysfunction or insult, major life stressors that interact with genetic vulnerabilities to produce specific psychiatric illnesses, drug and alcohol use or abuse, and/or other physical conditions, including those associated with a primary physical illness, the side effects of medication, or disease processes. Because we know so little about those few apparently mentally healthy individuals who end their lives by suicide, my focus here is necessarily on the vast majority of suicidal people whose self-destructive thoughts, feelings, and actions are the consequence of untreated or undertreated brain disorders.
While this book is not the place to address a complete systems approach to suicide risk reduction in care settings or in community settings, it is important to look at some of the fundamental issues. In a clinical setting, a comprehensive suicide risk assessment entails more than simply asking a patient whether he or she is considering suicide and, if so, why. It also includes a thoughtful examination of questions such as the following:
This is not an exhaustive list of the items to be covered in a good workup. But whatever the specific questions that are asked, they must address such factors as personality traits that might predispose someone to suicidal behaviour, acute psychological stressors, and the possible presence of a psychiatric illness, including co-occurring disorders, or of a genetic vulnerability to such illness. If a psychiatric illness appears to be present, its severity must also be assessed.
Anyone who suffers from serious, chronic psychiatric illness is at a high lifetime risk for suicide. People with co-occurring disorders are at especially high risk – particularly when the second diagnosis is alcoholism or drug addiction. The good news about suicidal crises is that adverse life events of the sort that can aggravate a pre-existing brain disorder and precipitate such a crisis are usually of limited duration. To the degree that symptoms of depression are related to stress-spectrum forces, for example, it is possible that the sufferer will pass through a suicidal crisis without benefit of professional care.
The bad news is that, despite the availability of effective treatments, the majority of people who become suicidal are never diagnosed. The failure to identify and then accurately diagnose an underlying psychiatric illness or addiction or to acknowledge the gravity of such an illness can lead to no treatment, inadequate treatment, or the wrong treatment – all of which can have tragic consequences for both the suicidal person and his or her family.
One of the greatest challenges in suicide prevention, then, is ensuring that those most in need of treatment get the help that could save their lives. The chronically ill must have access to affordable and professional care provided by people skilled in the assessment and subsequent treatment of those at high risk for suicide. When you consider that most people who die by suicide are not in treatment at the time of their death, the question must arise: Had they gotten the help they needed, would they be alive? Many of us in the field of suicide prevention believe the answer is yes.
Each of the terms treatment, management, and therapy has a distinct meaning. The management of suicidal patients is not the same thing as the treatment of the disorders out of which suicidal thinking and behaviour arise. Good management creates a safe environment and establishes sound procedures for the delivery of appropriate treatments, thereby lowering the risk that a patient will die by suicide – both during treatment and after treatment is delivered. Treatment can include medication, socialisation programs, and job training, as well as case management; therapy, or counseling, has to do with how we use ourselves – our brains and our hearts – to help others heal. The cold and officious nurse in Ken Kesey’s One Flew Over the Cuckoo’s Nest may be a good manager, one who is able to deliver appropriate medications on schedule. But she does not provide warm, empathic care. To ensure the best outcome for suicidal patients, we need good therapy as well as good management and good treatment.
Good Management: Outpatient Care
It is difficult (if not impossible) to provide good treatment in the absence of good management. Good suicide risk management begins at the top of a healthcare organisation, when leadership establishes a culture of safety. This culture is evident in patient-safety education, staff training, and clear and effective policies and procedures.
Increasingly, most of those who suffer from chronic psychiatric disorders and are at high risk for suicide live in the community rather than in inpatient facilities. If we hope to save lives, we must make sure that these individuals have easy access to long-term, community-based case management services of high quality. These services should include aggressive outreach programs aimed at high-risk groups and persons who might be unlikely to self-refer. For a number of reasons, though, comprehensive service and treatment centers for the mentally ill are often either in short supply or else non-existent, and those that do exist are often poorly funded. And yet nothing is more likely to save lives than access to first-rate outpatient services delivered by well-trained, culturally sensitive staff working out of a fully funded mental health center. Enlightened, affordable, and accessible systems of care offer what is perhaps the most important ingredient of all: hope.
In a nutshell, good outpatient management means installing a community safety net while ensuring that a patient who is potentially suicidal receives appropriate treatment and therapy. In an outpatient setting, a responsible risk management and treatment plan includes the following elements:
In addition, a good outpatient management plan takes into consideration the patient’s connections in the community (a religious affiliation, for example, or membership in a local organisation) and the commitments he or she may have to others: Duties and responsibilities can serve as buffers against suicide. It also pays attention to any changes in care providers. If it is not clear with whom professional responsibility for the suicidal person’s welfare lies, tragedy can result.
Perhaps above all, prompt and courteous follow-up is essential. Suicidal people who have reached out, whether to a referral agency or a clinic or a single practitioner, are not given hope by statements like, “Someone should get back to you by Monday.” After an assessment interview or an initial contact with someone who ought to be able to help, suicidal people need to feel that they have made a genuine human connection with a person who cares and who can and will help them save their own life. In the absence of this sense of personal connection, all the work of others can go for nothing.
For many years, with the assistance of several devoted colleagues, I directed a suicide prevention hotline staffed largely by volunteers. Our main training message to the many wonderful people who gave us their time and energy was: “Unconditional caring inspires hope, and hope saves lives.”
Good Management: Psychiatric Hospitalisation
In case of chronic psychiatric illness, relapses are to be expected. It is important that neither the patient nor the provide interpret an episode of acute illness as a “failure” of some sort. A sound case management and treatment plan should therefore make episodic inpatient hospitalisation or entry into crisis respite shelters an effortless matter.
As we saw in our discussion of intervention, determining whether a suicidal patient should be admitted to the hospital is often the first major decision faced by an outpatient professional. When it comes to chronically ill patients who are already receiving treatment, a similar question can arise. Under what circumstances does something need to change? If not now, then when?
This is not always an easy question to answer. Especially because the prospect of hospitalisation sometimes aggravates a crisis, the decision to hospitalise should be a shared one. The patient’s primary care physician should be consulted, and, if you are part of a treatment or emergency response team, so should others on the team. Provided this seems helpful, family members can be included in the decision, and, as far as it is possible to do so, the suicidal person’s wishes should also be respected.
It is often useful to think of hospitalisation as a way to buy time for the suicidal person – time to think things over, to get some sleep, to allow a crisis to cool down, and to talk about his or her predicament with others so that healing can begin. Hospitals can also be the best place for a suicidal person who is not yet in treatment to receive a comprehensive medical and psychiatric assessment, to begin needed medications, and to make plans for outpatient care.
That said, it is well to remember that rarely does a single episode of psychiatric hospitalisation solve the fundamental problem. Hospitalisation is not going to prevent the recurrence of a cyclical depression, for example. Rather, long-term attention to stress management, outpatient therapy, and, in all likelihood, a monitored medication regimen are what will restore the sufferer and reduce the risk of suicide over the life span. Hospital stays are short, but the problems of those who are vulnerable to suicidal thinking are long-standing. The race to healing will be won by the tortoise, not by the hare, and more often by the outpatient therapist than the inpatient nurse.
It is also wise to remember that no one person or treatment facility or hospital can guarantee perfect safety. Even in the security offered by an inpatient setting, suicides do occur. Patient safety is a major concern among inpatient and residential healthcare organisations and their regulatory agencies (see, for example, Fawcett 1997), and creating the safest possible environment for suicidal people is a collective mission. In 2006, the Joint Commission specified suicide prevention as one of its patient safety goals for 2007, and we have reason to hope that even greater attention will be paid in the future to the issue of inpatient suicides.
Moreover, for some patients, hospitalisation could be a poor choice, one that might actually make things worse. For example, where a series of brief hospitalisations has produced no lasting benefit, not putting the patient in the hospital might be the best option. However, such a recommendation should be preceded by a careful risk-benefit analysis, preferably one carried out in consultation with other professionals. When someone appears to be seriously suicidal, the decision to forgo hospitalisation should always be thoroughly deliberated and documented.
Good Treatment
As I noted above, people suffering from mental disorders account for the overwhelming majority of completed suicides. Each of the major psychiatric diagnostic categories, including schizophrenia, bipolar disorder, major depressive disorder, and alcohol dependence or addiction, presents a different treatment challenge, which in turn has implications for both management and therapy. For the chronically ill, good treatment includes careful diagnosis, complete physical, neurological, and psychological workups, and the use of psychotropic medications.
An unanticipated loss or other personal tragedy, or the recurrence of binge drinking that leads to conflicts in a marriage or other close relationship, or the ordinary and progressive downward spiral of health and happiness that accompanies addictive disorders – all may trigger a suicidal crisis. What those who counsel seriously suicidal people must understand, however, is that, regardless of the precipitating factors, a thorough medical assessment and prescribed medications may mean the difference between life and death.
Replicated research from several countries has, for example, shown that, in comparison to patients suffering from other major psychiatric illnesses, persons who suffer from bipolar, or manic-depressive, disorder have the highest rates of completed suicide. Unless properly treated, one in five manic-depressive people will die by suicide. But as the same research demonstrates, when these patients receive ongoing treatment, especially with lithium carbonate, the likelihood of death by suicide drops dramatically (Tondo and Baldessarini 2003).
Similar studies testing the impact of other medications on suicidal behaviour are under way. Our job as healers is to know this literature and to use evidence-based interventions, both pharmacological and psychological, to help those at risk of suicide. We also need to remind both suicidal people and their families that new medicines are constantly being developed, one of which may turn out to work for someone who has not responded to the medications currently available. We are living in an age when the neurosciences re making dramatic contributions to our understanding of mental illnesses and suicidal behaviour. We have reason to hope, and we have reason to infect others with hope.
This text is not intended to address all of the treatments for psychiatric disorders currently available. Rather, I wish to emphasise three key issues for those who work with suicidal people. The following observations apply to individuals whose level of symptomatic distress – the intensity of their anguish or anger or despair – and psychiatric disability would be rated as moderate to severe by any competent and conscientious mental health professional.
Counseling is not enough. Modern psychotropic medicines that, when taken as prescribed and in sufficient doses, have been shown to be safe and effective in reducing symptoms of distress and improving brain function must be considered the first line of treatment for seriously suicidal people. Indeed, in such cases, relying on counseling or psychotherapy alone is tantamount to malpractice. This means that a medical consultation with a qualified physician, preferably either a psychiatrist or a psychiatric nurse practitioner, must form part of the treatment plan. Whether the patient will take the medication as directed is another issue, one that pertains to management, but clearly the first step is to make sure the medications are prescribed.
Aggressive treatment is always indicated. Seriously suicidal people are often living movement to moment, with the prospect of relief, in the form of death, just around the corner. It is therefore essential, during a suicide crisis, that action be taken immediately to reduce acute manifestations of distress. Insomnia, agitation, anxiety, incessant rumination, irritability, hallucinations, and other such symptoms must be targeted and treated definitively. An overly cautious approach typically results in medications being prescribed in inadequate dosages. Does half a does produce half a cure? No. Half a dose is more likely to produce a treatment failure. What is worse, half doses can lead patients to believe that medicine won’t work, which may in turn increase their sense of hopelessness to lethal levels.
Consider what happens when a promising medication fails to reduce a patient’s symptoms because less than a full therapeutic dose was prescribed. If a drug cannot reach a therapeutic level in the blood, the patient will receive no benefit from the treatment and so will continue to suffer. This failure could easily lead the patient to conclude: “Even medicine doesn’t work, so nothing can help, and so I might as well get it over with.” At least if you are suffering without medications, you can still cling to the hope of a magic pill and, on the strength of that hope alone, endure a bit longer. But once you’ve tried the magic pill and it fails, the promise is gone, and with it the hope of a cure.
In short, too little medication is often worse than none at all. Postmortem studies of blood toxicology have repeatedly shown that people who had been prescribed antidepressant medications and who went on to die by suicide very often did not have therapeutic levels of the drug in their bloodstream at the time of their death. Similarly, when someone appears to be at high risk for suicide, the professional should not worry about prescribing sleeping pills or minor tranquilisers on a short-term basis on the grounds that the person might become addicted. As one patient put it when I evaluated him following a life-threatening overdose, “Either they give me enough medicine to get to sleep, or I will. Permanently!”
There is no safety without sobriety. Good treatment demands assessment of the role, if any, that alcohol or drugs may be playing in the suicidal person’s life and, if need be, appropriate intervention. Intoxication impairs brain function, clouds judgment, and decreases inhibitory controls. To provide state-of-the-art antidepressants medications and supportive counseling while the suicidal person binges on alcohol between therapy sessions is like treating someone for a cold instead of the cancer that will kill him.
In conclusion, there is no substitute for good treatment. Talk therapies, by themselves, are not enough. Self-help books and self-help groups can’t do it alone. We need to get suicidal people into treatment – by raising public awareness, breaking down stigma, and making treatment and support services readily available. Until we accomplish this much, we cannot expect to substantially reduce the base rate for suicide in our communities.
No-Suicide Contracts
I firmly believe that a good-faith commitment to life (if not necessarily to a particular healer) can go a long way toward reducing the imminent risk of suicide. As we saw in chapter 1, convincing a patient to seek further treatment is an essential step in the informed consent negotiations that frame healing alliances. I have heard many patients say, after agreeing to a safety and treatment plan, that they feel much relieved – that affirming their desire to stay alive and to find a way to feel better has given them newfound hope.
And yet, having reviewed dozens of suicide cases, and having talked with other experts, I know that apparently well-intentioned patient promises not to attempt suicide, including written no-suicide contracts, have preceded many an act of self-destruction. I have read far too many medical records of people who completed suicide while under professional care wherein the provider had written of the last contact: “Denies suicidal ideation, contracts for safety.”
In a no-suicide contract we ask patients for a written promise, made in good faith, that they will not attempt suicide. As is the case with verbal safety agreements, if a suicidal patient refuses to sign a no-suicide contract, then we know that our therapeutic alliance is not in place and that, in all likelihood, the person is at greater risk than one who is willing to commit to safety.
Like verbal safety agreements, no-suicide contracts have certain limitations. Such contracts cannot responsibly be used with patients who are exhibiting symptoms of acute psychiatric illness or who are experiencing extreme distress, agitation, and anxiety or who are using or abusing intoxicating agents. Nor are no-suicide contracts appropriate for use with patient who have little or not impulse control. As a result, they may be of mixed or limited value with children and adolescents, especially those who are highly impulsive or unusually immature. In addition, certain cultural groups hold written agreements in low esteem.
But if no-suicide contracts must be used with due discrimination, those who favour such contracts argue that they offer a number of advantages. Quite apart from furnishing information about a patient’s relative willingness to make a commitment to safety, written agreements:
Some practitioners prefer to make a “no-harm” as opposed to a “no-suicide” contract. Such language perhaps makes sense in the case of someone who may be highly distraught and is engaging in self-injurious behaviour, such as cutting, but who is not intending to die. Because a no-harm request is not as specific as a no-suicide request, however, in the case of a patient who genuinely is suicidal, such language may appear evasive. A no-harm contract is timid, whereas a no-suicide contract is bold. As one teenage boy I saw early in my career explained to me when I asked him for a no-harm contract: “Get real. I don’t intent to harm myself, I intend to kill myself!”
As critics of the contractual approach to risk management have pointed out, a signature on a contract cannot possibly hope to substitute for a thoughtful and thorough clinical assessment of risk or the work needed to establish a genuine emotional bond between therapist and patient, which is the cornerstone of an effective therapeutic alliance. And yet counselors are sometimes tempted to rely on no-suicide contracts in place of something more difficult and time consuming. A written contract may also serve to provide a therapist with a comforting sense of security. Our culture places great faith in the written word. We assume that if we have it in writing, it must be true. The fact that a patient has signed a no-suicide contract can thus lull a counsellor into believing something that is simply not true – that suicidal people are actually going to call for help when they are in the middle of a life-threatening crisis or otherwise keep a promise that they are emotionally unable to keep. I remember once asking a patient of mine whether he would call me if and when he again found himself in that dark tunnel of despair. “You don’t know what it’s like,” he replied. “Once you’re in there, you don’t think of anything but stopping the pain. Call someone? Forget it.”
The popularity of no-suicide contracts probably has something to do with the connotations of the term contract, which suggests that an agreement is legally binding. But a contract is a two-way deal. In legal terms, a contract is a set of mutual promises, a meeting of the minds in which each party gives something to get something. Both minds in this meeting have to be legally competent. That is, they must have sufficient cognitive capacity to be able to understand the nature and consequences of the proposed agreement. A contract is automatically void if either party suffers from a serious “mental illness or defect.” Therefore, a no-suicide contract with an eight-year-old is suspect, as is one with someone who shows severe symptoms of a psychiatric disorder.
Moreover, precisely because a contract is a two-way relationship, it imposes an obligation on both parties. In the case of no-suicide contracts, a commonly overlooked question is, “What is it that you, the healer, are offering in trade for the patient’s offer?”
And do you find yourself getting a bit uncomfortable trying to answer these questions? Good! After all, you probably didn’t intend to make all these promises. However, even though the contract your patient signs makes no mention of such offers, your patient may believe that promises of this sort are implied. So unless you wish to specify, in writing, all the many possible offers you are not making to the fragile, recently suicidal person in your care, you may break your promises without even realising what you’ve done.
What happens to the contract if you unwittingly violate your implied promises or if, perhaps for reasons beyond your control, you cannot keep up your end of the bargain? The contract is void, for both you and the suicidal person. Every contract has its terms: I give you this, and you give me that. Any change in the terms of agreement – any deviation from the understanding on which the contract is based – is tantamount to a counteroffer. A counteroffer requires a new contract, one that is subject to approval by the other party. If you, as a healer, somehow fail to abide by your half of the agreement, the contract terminates, and a new one must be negotiated.
One serious problem, then, is that our no-suicide contracts with patients are typically one-sided. The patient gives up a lot while we give up almost nothing: We offer in exchange only what we owe to every other patient we serve. Most of what the therapist or doctor is or is not willing to bring to the table is omitted from consideration, and it is what these contracts do not say that is dangerous to the patient.
Too many counsellors have given little thought to their end of the bargain, and to the degree that they do not understand what they are promising, their patient’s promise of safety is only as good as the therapist’s first misstep. In other words, if the patient expects you to be a miracle worker, and all you do is pull the occasional rabbit out of a hat, your failure to deliver “as promised” can quickly negate the no-suicide contract and plunge the patient into a crisis.
It is probably too late to scratch the term no-suicide contract from our professional lexicon. But if you are going to use the word contract with suicidal people, please understand that legal language is very precise. A contract is a two-way street, and if one party in the arrangement fails to live up to what was promised, the contract is void. So never bet your patient’s life on a contract you can’t keep. And remember, there is no evidence that any signed, witnessed, and legal document ever prevented someone from attempting or completing suicide.
Screening for Specific Disorders
As we have seen, the prompt detection and treatment of underlying psychiatric disorders is critical to preventing suicide. Sometimes making a firm diagnosis is a relatively easy matter. But more often it is not. Your patient’s symptoms are likely to suggest certain possibilities, but because the same symptoms can be associated with several different disorders, you may be in doubt as to precisely what is going on. If in doubt, seek consultation or a second opinion.
Screening for specific disorders accomplishes two main things. First, it provides you with an independent assessment of the patient’s symptoms and their severity, which you can use to confirm or adjust your diagnosis. Second, it offers you an opportunity to confer with your patient about the diagnosis.
Depression
Let me say at the outset that I am not fond of using the word depression to describe the medical condition – the disordered brain and body chemistry – that produces the array of symptoms that made up the syndrome known as major depressive disorder or clinical depression. Depression seems to me too bland a word to do the descriptive heavy lifting this illness demands. Dr. Kay Redfield Jamison captured the true threat posed by this illness when she said, in a radio interview, “Depression is endlessly wicked in its ability to convince us to do things we wold not do if we were well.” People need to recognise that depression is a life-threatening condition. If we could devise a name for this condition that conveyed something of its agonies and its potentially fatal impact, our work would be a lot easier, and we would surely save more lives.
Not every depressed person experiences suicidal thoughts and feelings, but the majority of people who experience suicidal thoughts and feelings are depressed. For that reason, anyone who is suicidal should immediately be screened for depression. Various methods of screening for depression are available, and every counsellor should have some of these diagnostic tools in his or her office. Free depression screening is also available on dozens of Web sites, including that of Mental Health America (formerly the National Mental Health Association: www.mentalhealthamerica.net). In general, the higher the score on these instruments, the greater the indication that some sort of antidepressant medication may be in order.
The current standard of care in cases of clinical depression, especially if it is diagnosed as moderate to severe, is to give due consideration to the use of antidepressant medications, which may require arranging for a psychiatric consultation. To fail to consider these medications as a first line of treatment for a seriously suicidal person is to ignore a remedy that any reasonable and prudent practitioner would pursue under similar circumstance and and with similar patient. In fact, modern antidepressants are so important to the treatment of depression that if you apparently never explored the option – if you never explained the risks and benefits of such medications to the patient and/or the patient’s family – and your patient subsequently dies by suicide, you could be sued for failing to meet the current standard of care.
I don’t mean to frighten you, but you absolutely must understand that these medicines effectively reduce the major symptoms of depression in the majority of patients who take them. The most recent edition of the Diagnostic and Statistical Manual lists nine major symptoms of depression, and recurrent thoughts of death or suicide is one of them. The presence of persistent suicidal thoughts and feelings – even in the absence of other clear symptoms of depression or signs of mental illness – is reason enough to consider a psychiatric evaluation for the possible need for psychotropic medications. Do not be overly alarmed by reports of an increased risk for suicide following the implementation of antidepressant therapy. Research suggests that the benefits of such treatment far outweigh the risks (Simon, Savarino, Operskalski, and Wang 2006). All the same, the issue remains controversial, and it is a professional’s job to stay abreast of the literature.
A great many antidepressant medications are not available. This book is not the place to discuss them in detail, but two broader points deserve mention. First, the newer SSRIs (selective serotonin reuptake inhibitors) are generally preferred to the older TCAs (tricyclic antidepressants), primarily because the former are seldom dangerous in overdose, whereas the latter can be fatal. That said, the most effective medication for a particular patient may be one of the older antidepressants. This is why only a qualified medical provider should make decisions about which medication to prescribe, following which he or she will monitor the patient’s response.
Second, antidepressants work only when taken as prescribed. Far too many patients neglect to take their medication at the times and/or in the doses prescribed. As a result, they derive little, if any, therapeutic benefit from the drug, much as happens when a doctor fails to prescribe a medication in an effective dosage. As we saw earlier, the failure of a drug to provide relief can cause patients to become even more hopeless about their future, thereby increasing the risk for suicidal behaviour rather than lowering it. Just like half-measures in medicine, half-hearted participation in treatment on the part of patients is dangerous for everyone concerned. The fact that depressed patients often stop taking their medication as soon as they start to feel better poses an additional problem, as discontinuing medication can precipitate a relapse.
More often than not, depression is a chronic illness. As with any chronic condition, taking good care of oneself over time requires learning as much as possible about the illness and about how to manage one’s life in such a way as to minimise the risk of getting sick again. It is your job as a healer to make sure that patients suffering from depression understand how deadly serious this disorder is and to help them come to terms with it and manage its symptoms.
Anxiety and Panic Disorder
As research – notably that of Dr. Jan Fawcett, one of the nation’s leading experts on suicide – has demonstrated, untreated anxiety disorders, panic attacks, and panic disorders are associated with an increased risk of completed suicide, especially when these disorders co-occur with depression. Fawcett and his colleagues have described a number of suicide profiles, two of which are characterised by agitation, recurrent ruminative anxiety, and obsessive worrying (Fawcett et al. 1990). Research further suggests that a careful screening for the presence of anxiety symptoms and recent or remote panic attacks should be a routine step in the assessment of suicide risk and the planning of appropriate treatment (Busch, Fawcett, and Jacobs 2003).
In addition to a thorough patient history and direct observation, The Beck Anxiety Inventory has proved a very helpful and efficient tool in screening for anxiety problems (Beck, Epstein, Brown, and Steer 1988). Even in the absence of specific suicidal thoughts, reports of an inability to sleep and a torturous preoccupation with things a patient believes are inescapable, unfixable, and/or unendurable should alert the counsellor that the risk of suicide may be very high.
The prompt and aggressive treatment of anxiety disorders appears to be associated with a decreased risk of suicidal behaviour (Fawcett et al. 1990). There are many effective treatments, both psychological and psychopharmacological, for anxiety, panic attacks, and panic disorders, and these are often used in combination. If you are not licensed to prescribe medications, do not hesitate to refer a suicidal patient for psychiatric evaluation with a view to possible pharmacotherapy.
Alcoholism and Drug Abuse
Studies have repeatedly found that alcohol dependence and drug abuse are major contributors to death by suicide. Because therapists typically see a patient only once or twice a week, symptoms of alcoholism or drug abuse may not be apparent to them – and yet alcoholics and addicts are at high risk for suicide. Consequently, it is essential to screen for these problems as part of your initial assessment.
One of the simplest and most reliable methods of screening for alcohol and substance abuse problems are the four CAGEAID questions (Ewing 1984). (The mnemonic “CAGE” refers to key words in each of the questions, which are italicised below, and “AID” stands for “Adapted to Include Drugs.”) As the interpretive notes provided in parentheses suggest, these four simple questions are a remarkably effective means of diagnosing alcoholism and addiction.
C: Have you felt you ought to cut down on your drinking or drug use? (Normal drinkers feel no need to control their drinking, so a yes answer to this question can only come from someone who is worried that his or her pattern of alcohol or drug use is abnormal.)
A: Have people annoyed you by criticising your drinking or drug use? (Society generally defines substance abuse problems in terms of the inappropriate behaviour of those who are intoxicated or high. Anyone who is in trouble with a parent or a significant other over his or her drug or alcohol use will likely answer yes to this question.)
G: Have you felt bad or guilty about your drinking or drug use? (Nonpathological users seldom do things while intoxicated that they will later feel guilty about. Abusers and addicts do such things all the time.)
E: Have you ever had a drink or used drugs first thing in the morning, as an eye-opener, to steady your nerves or get rid of a hangover, or to get the day started? (A yes answer here means that someone is experiencing fairly severe withdrawal symptoms and so may signal middle- or late-stage alcoholism or addition.)
Two yes answers to these questions should make you suspect that a substance abuse problem exists. Three yes answers suggests that, with the benefit of some additional probing, a formal diagnosis can very probably be made. With rare exception, four yes answers signals that the person is in need of aggressive treatment for substance abuse.
Psychotic Disorders
As noted earlier, most people who die by suicide are suffering from a psychiatric illness of some sort. The following questions have proved useful in the detection of psychotic symptoms:
Positive responses to some or all of these questions clearly indicate the presence of a major mental illness, although the precise diagnosis will vary, since, in addition to schizophrenia, several other psychiatric disorders can produce psychotic symptoms. For example, manic-depressive illness, or bipolar disorder, may manifest itself through the appearance of psychotic symptoms, including severe symptoms of depression or mania or both.
Individuals whose thinking is seriously disordered may be unable to exercise control over suicidal impulses, which places such persons at significant risk. The lifetime risk of suicide for persons with schizophrenia has long been reported to be 10 to 15 percent. However, a recent meta-analysis of multiple studies found that the lifetime risk of dying by suicide for people with chronic schizophrenia is closer to 4.5 percent, with most deaths occurring at the onset of the illness (Palmer, Pankratz, and Bostwick 2005). As we have seen, those who suffer from manic-depressive illness are at an even greater risk for suicide. If you detect psychotic symptoms in an patient, then consultation with or referral to a psychiatrist or qualified nurse practitioner is imperative.
Alternative Remedies
Before you embark on standard approaches to treatment, it is important to learn whether a patient has been pursuing some sort of alternative remedy for his or her symptoms. If so, then the doctor who will be prescribing medication must be informed of this. Many people who have struggled with depression know something about the herbal remedy St. John’s wort and about omega-3 fatty acids, and they have probably heard about light therapy (or phototherapy) as well. Even Hippocrates was aware that exposure to sunlight could help to lift a depressed mood.
But how well do such alternative remedies really work? Our evidence is somewhat limited, partly because those who pursue such cures typically do so without benefit of clinical supervision. Moreover, the clinical studies that do exist have yielded mixed results. In particular, with the exception of omega-3 fatty acids, we know almost nothing about whether these treatments effectively target and reduce suicidal thoughts and feelings or discourage suicide planning or lessen the incidence of suicide attempts or completed suicides.
In 2002, researchers conducted a randomised clinical trial in which St. John’s wort (Hypericum perforatum) was compared to a well-known commercial antidepressant and to a placebo (Hypericum Depression Trial Study Group 2002). The herbal remedy was found to be nor more effective than the placebo in reducing symptoms of moderate depression. In contrast, it is at this point fairly well established that phototherapy can reduce the symptoms of depression associated with seasonal affective disorder. More recently, studies have shown that light therapy may also be of value in treating mild to moderate nonseasonal depression. We know nothing, however, about the effect of such therapy on suicidal behaviour. All the same, used under clinical supervision, light therapy is unlikely to be harmful. In conjunction with other interventions, it is possible that a trial of light therapy would yield some benefit even to a severely depressed patient.
Similarly, mounting evidence suggests that omega-3 fatty acids – found in flax seeds, ocean fish, and certain nuts – have antidepressant and mood-stabilising effects. Low blood-plasma concentrations of these essential fatty acids have been correlated with low concentrations of the very neurotransmitters associated with mood. In other words, insufficient quantities of omega-3 fatty acids in our diets may be contributing to the impaired brain functions one finds in depression and other mood disorders. As Joseph Hibbeln, a researcher at the National Institutes of Health, has argued, deficits of these fatty acids may play a role in our high rates of depression and suicide.
A seventeen-year-long study of fish consumption in a sample of 265,000 Japanese adults revealed that the suicide rate among those who regularly consumed large amounts of seafood high in omega-3 fatty acids was 19 percent lower than the rate among the group who ate relatively little of these foods (Hirayama 1990). A study published in Lancet found that patients treated with mood-stabilising drugs plus fish oil supplements high in omega-3 fatty acids had fewer recurrences of depressive episodes than those patients treated with medication alone (Hibbeln 1998; see also Parker et al. 2006). According to yet another study, which appeared in the American Journal of Psychiatry, omega-3 treatment may be effective in reducing symptoms of depression in children and could thus provide a much-needed alternative to drugs that have been approved for use only with adults (Nemets et al. 2006).
Although such findings are not conclusive, research into omega-3 fatty acids continues, and it makes good sense to keep up with the results of that research. The Web site of the National Institute of Mental Health is a useful source in this regard. Eating plenty of seafood or taking omega-3 fatty acid dietary supplements can’t hurt, and, like light therapy, could provide some added help to a patient who is depressed and feeling suicidal. But, especially in the case of someone who is seriously suicidal, to rely solely on omega-3 treatment (or on light therapy or on herbal remedies) would be a serious mistake.
People often assume that natural treatments for depression, such as herbs or fatty acids, are somehow safer and less toxic than prescription medications – but this is a foolish assumption. Natural does not equate to safe. The fact is that the chemical agents we use to combat depression, bipolar disorder, and psychotic symptoms are powerful in their effect. They’re supposed to be. Used ineptly and/or without competent medical supervision, however, any of these agents, whether natural or manufactured, can be dangerous. Consider that lithium carbonate is a naturally occurring salt. And yet it is lethal in overdose. For that matter, drinking ten quarts of water at one sitting is likely to kill you. Just because a product is natural doesn’t mean it isn’t potentially fatal. It also doesn’t mean it works.
Another alternative treatment for depression, although not a natural remedy, is vagus nerve stimulation. In VNS, a small, battery-powered generator, which is surgically implanted, sends electrical impulses to the left vagus nerve. We do not know precisely how VNS works, but it appears to influence certain neurotransmitters, including serotonin and norepinephrine, that play a role in depression. First approved for use in the treatment of epilepsy, in 2005 VNS was approved by the FDA as an adjunct treatment for depression. Nonetheless, the evidence in support of VNS as a treatment option is far from conclusive. And, again, we do not know whether such treatment has any significant impact on suicidal behaviour.
Am I saying, then, that we should essentially rule out alternative therapies? No. But before recommending alternative remedies, we should first consider conservative, proven approaches to the treatment of mental disorders. We might make an exception if a patient absolutely refuses to take prescription medications, or if the patient has been prescribed effective doses of well-known antidepressant medications, has taken them as directed, and has failed to receive any benefit. As a general rule, though, we should always recommend what we know works best – and this is doubly true when it comes to serious disorders of mood. Dramatic and powerful studies exist, for example, to support the use of lithium in the treatment of bipolar disorder, among them studies that demonstrate its effectiveness in reducing the incidence of suicide. Compared to that, we have almost no evidence to justify the use of other remedies. As one of the finest psychiatrists I’ve had the privilege to work with once told me, “We work with these medicines every day, all day long. Just about everyone we see is at high risk for suicide. It’s what we do for a living, and while it’s not exactly like treating the common cold, it’s pretty close.”
So, if you are not yourself licensed to prescribe medications, make sure your suicidal patient gets competent medical treatment for any serious mood or thought disorder. Psychiatrists do this best. It’s their specialty.
Let me also add that, even as i write these words, new evidence-based treatments are being developed, and further breakthroughs can be expected from the neurosciences. Research, including research that focuses on suicide, is ongoing, and much of it is on a fast track. Powerful new drugs that are safe to use dot the horizon. What constitutes effective treatment today will be outdated a decade from now, and perhaps a lot sooner than that. Hope does spring eternal, not only in the human breast, but also in the laboratories of dedicated scientists around the world.