Talking About Suicide

I have written about depression, including my own experience with it, many times over the years, yet I have never written about suicide. But after a week in which there were two celebrity suicides, the CDC issued a report on the dramatic increase in suicide rates across the US, and people are talking about suicide on social media, I realized two things: first, there is a lack of understanding about the causes of suicide, probably the result of our natural aversion to talking about it. Second, as a mental health professional, I am guilty of avoiding the topic with my own patients.
 

Perhaps we need a #MeToo movement for depression and suicide, and maybe we’re seeing the beginning of that now. I believe it’s healthy for our society that people are talking about it, however I have heard from some of my patients that it hasn’t been easy for them – either to be reminded of what may have been an extremely painful time in their lives, or to read the ignorant things that people are saying about those who would consider, attempt, or complete a suicidal act.
 

Suicide, like rape, has been a mostly taboo topic in our society. To take one’s life is a sin in many religions, and even people who aren’t particularly religious can be very judgmental about it. If you haven’t ever felt suicidal, it can be difficult to comprehend what it’s like to feel that way. It’s frightening to face a friend or loved one telling you they feel such despair, and if you haven’t had training in how to talk someone off the ledge, you may feel powerless to help.
 

Also, our healthcare system works against people seeking help for suicidal thinking, because if you tell your doctor or therapist, you could be hospitalized against your will and prescribed some heavy-duty medications which may actually make you feel worse. So people learn to NOT tell their doctors or therapists – and we learn to not probe too much, for fear of alienating our patients.
 

So, this is a serious issue that we need to be discussing, yet it’s often an intensely uncomfortable conversation to have, about a complicated condition for which there aren’t clear and easy answers. In this article, l offer some answers to the “why?” as well as to the “what can we do?” (Apologies in advance for the length – I may be overcompensating.)
 

What is depression? 
Not everyone who attempts or commits suicide is depressed – but at least 80% are, so let’s start here. Depression is part of the human condition, and exists on a spectrum, anchored by suicidal thinking and behavior on one end, with ordinary moments of melancholy on the other, and a very wide range of symptoms and experiences in between. Everyone can relate to feeling sad, unhappy, or discouraged at some point in their lives. We might even have a random thought, “what’s the point of going on?” Yet most of us will never cross that invisible line from ordinary sadness to a mental disorder, or the line after that, into suicidal acts.
 

And yes, depression is a mental disorder, because it involves distortions of thinking and perception. However, it is also a physical disorder, because it affects energy, sleep, and appetite. And it’s an emotional disorder, because it affects mood and involves powerful negative emotions like sorrow and shame. Finally, it’s a spiritual disorder, because it involves loss of faith, hope, and meaning. We need to keep all of this in mind when we consider how to effectively treat it.
 

It’s an equal-opportunity illness – anyone can get it, as the recent suicides of celebrity designer Kate Spade and celebrity chef Anthony Bourdain have proven. It might be situational, developing out of grief over a significant loss; or it may be endogenous, existing in one’s genetic make-up. It can also be a learned response to stress and trauma. It often co-occurs with other disorders, like addictions, ADHD, and OCD. It can be temporary, lasting for days to weeks, or it can be a life-long condition. And it can show up differently in different people, or in different ways in the same person at different times.
 

Depression can be difficult to diagnose 
Often people who are depressed don’t know what’s wrong with them. Or they do know, but feel some shame or embarassment, because it’s still regarded as a weakness in our society. So it can be difficult to recognize, both for the person who is suffering with it, as well as for the people around that person. I myself experienced this in the past year – I failed to see the signs that I was sliding into a seasonal depression until I’d been in it for awhile, and no one around me saw it either.
 

If you don’t know what’s wrong, or you feel embarassed or weak about it, you’re not likely to seek out medical care. And even if you do go to the doctor, the doctor may not recognize that you’re depressed, or to what extent. Most MDs and other healthcare professionals don’t get a lot of education and training in how to diagnose and treat depression, so often they’ll simply write a prescription for an anti-depressant medication without exploring other treatment options.
 

And it can be difficult to treat 
Since the advent of Prozac in the 1970’s, we have developed an over-reliance on medications called SSRIs (selective serotonin re-uptake inhibitors) as the primary treatment for depression. This is one of the factors that has led to the increase in diagnosed depression as well as suicide rates.
 

Why? First, SSRIs don’t work for everyone – they may not work at all for some, or help just a little for others. Many depressed patients have to try multiple medications over months before they find one that helps. And these meds come with some pretty undesirable long-term side-effects, like loss of libido and weight gain, in addition to these commonly experienced initial effects: headaches, nausea, dizziness, jitters, irritability and insomnia. Is it any wonder that 50% of people either never start their prescription, or stop taking it without going back to their doctor to ask for other options?
 

Second, in some cases, taking an SSRI can actually increase suicidal thinking and behavior. The American Medical Association recently published a list of medications that may trigger suicidal symptoms, and every single antidepressant is listed!
 

Not everyone who experiences depression has suicidal thinking or behavior. I never have, and many of my depressed patients haven’t. But among those who have, there is a much greater risk that they will attempt or succeed at suicide during a depressive episode, so it is really important to identify whether a depressed person is having thoughts, mental images, or impulses related to suicide before recommending an SSRI. This means being willing to ask questions that most people, even doctors and mental health professionals, typically avoid.
 

The deadly combination of factors that leads to suicide 
Research on suicidal depression has identified three key factors that increase an individual’s risk of suicide: the first is having a strong “fear of losing control of emotions,” which is often present in people who are successful, perfectionistic, and used to being in control. The second is an inability to tolerate “emotional intensity,” or strong negative emotions like shame and despair. And finally, there is a “sense of urgency to take action” to relieve the emotional pain, which feels like it will never end. These factors intensify the feeling of being trapped in despair with no way out.
 

I recently saw Brian Copeland’s solo performance, “The Waiting Period,” about his own battle with suicidal depression. He tells the story of reaching a point where he could see no way out of his emotional pain and despair, and went to buy a gun, but had to wait the mandatory 10 days to pick it up. So he couldn’t act immediately, and by the time the waiting period was over, he had found enough reasons to live that he didn’t go back to the gun store. His story is a powerful one, and he’s been giving free performances at the Marsh Theater in San Francisco as a way of encouraging more people to talk about depression and suicide. He has started a GoFundMe campaign to support his outreach efforts, if you’d like to help – or go see his show!
 

The survivors and their stories 
Hearing directly from someone who has experienced suicidal depression and overcome it is one of the best ways to gain a better understanding. How about hearing from a guy who actually jumped off the Golden Gate Bridge – and survived? Kevin Hines did, 16 years ago, and went on to become a suicide prevention advocate, motivational speaker, and filmmaker. His is another powerful story, and his film “The Ripple Effect,” features suicide prevention experts and other suicide survivors.
 

Another survivor’s story that I came across uexpectedly, while researching resources for suicide prevention, is Stacy Freedenthal’s. Dr. Freedenthal is a psychotherapist, an associate professor at the University of Denver Graduate School of Social Work, and the author of “Helping the Suicidal Person: Tips and Techniques for Professionals.” She also wrote an essay in the New York Times about her own suicide attempt that she had kept secret for 22 years.
And she runs a website, SpeakingofSuicide.com, which has one of the most comprehensive sources of information and resources I’ve seen.
 

Treatment that helps 
Any effective approach to treating suicidal depression must address the distorted thinking and perception that leads someone to feel trapped, while also impairing their problem-solving ability. Cognitive therapy is very effective at this, as Judith Beck wrote in a recent New York Times article.
 

But simply addressing cognitive distortions is not enough. Remember? Depression is also an emotional, physical, and spiritual disorder in which people feel alone, ashamed, and trapped. So any treatment that offers social inclusion and support, compassion, and physical activity, along with concrete steps that can be taken to climb out of that pit, will help.
 

One of the simplest approaches is compassionate support in the form of listening without judgment, help to discern the difference between unsolvable and solvable problems, and offering concrete assistance toward solving the solvable problems in the person’s life. This is what happens in 12-step and other support groups. (For a list, go here.)
 

An effective approach to treating depression that I am trained in is Mindfulness-based Cognitive Therapy (MBCT). Adding mindfulness to cognitive therapy offers specific tools to address key factors in suicidal depression: the inability to tolerate painful emotions, and the impulsivity to act. Some of the psychologists who developed the MBCT curriculum have recently developed a more intensive curriculum for people at risk of suicide.
 

In summary – if you’re still with me – suicide and suicidal depression are serious and complex issues that we have to stop being afraid to talk about. Now that the conversation has started, we need to find ways to keep it going, so that we don’t let depression have the last word.
 

(The photo above is by Thomas Hawk, found on his Flickr site, and used with permission. To see more of his incredible photos, go to thomashawk.com)