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Suicide: A surprisingly ambivalent topic


It’s National Suicide Prevention Week (Sept. 10-16, 2017) and few psychiatrists would disagree that suicide is a bad outcome, that it is often preventable, and that the loss and pain that follow an untimely act are nothing short of tragic.

It’s also an epidemic on the rise, with more than 40,000 deaths a year, half of those by self-inflicted gunshot. Because 90% of those who suicide suffer from mental illness, one target becomes clear: We need to identify those at risk and make it easy for them to get help. Still, treatment is not a clear panacea; in the decades since selective serotonin reuptake inhibitors have become so readily available, suicide rates have risen, and many who die have gotten help of some type. The issue is a complicated one that reaches well beyond the arena of mental health.

Dr. Dinah Miller, a psychiatrist who practices in Baltimore.

Dr. Dinah Miller

Still, the suicide of a patient, friend, or family member is shattering, and psychiatrists hope to see this trend reverse. While to many of us, it’s an all-bad thing, society at large has become a bit more ambivalent, if not conflicted, as to how suicide is considered.

Paul Nestadt, MD, a postdoctoral fellow in the Johns Hopkins Psychiatric Epidemiology Training Program, is a researcher on a study that correlated rural suicide rates with the availability of firearms (Am J Public Health. 2017 Oct;107[10]:1548-53). “Suicide can happen when ambivalent suicidal thoughts dip over the threshold into behavior. In those key moments, the lethality of the nearest available method may determine whether someone dies, as illustrated in the United States by the predominance of firearms in the use of completed suicides.” Yet it is not unusual for those who are against gun control to note that most firearm deaths are suicides, and therefore unlikely to be changed with gun regulation; they believe that individuals who want to die will find another way, despite research that indicates otherwise. At moments, it feels like they are saying these deaths don’t count; people who have impulses to harm themselves will do so, and gun control is not an answer. Others, like Nestadt, contend otherwise, and say that limiting access to lethal means will make a difference.

Let’s also consider the words we use. While the familiar term is to “commit suicide,” the current thinking is that this is stigmatizing – people “commit” crimes – and family members of survivors often prefer the phrase “died of suicide.” Is the change necessary? It is true that people commit crimes, but they also commit to relationships, and to any number of positive activities. I had not previously associated the word with criminal behavior, and the now-favored term changes suicide from an active event to a passive one. If changing the words helps lessen the pain of the survivors, then I am all in favor, but the loss and shame remain regardless of the phrasing.

Stigma may be a mixed thing when it comes to ending one’s life. We would all like to see suicidal thoughts and intentions destigmatized so that those who suffer won’t hesitate to get help. It’s not clear, however, whether stigmatizing the completed suicide might serve as a deterrent to the behavior for some. When patients talk of wanting to die and are considering a method, they often add that they could not do this to their families. If suicide is just another nonstigmatized way to die and end an individual’s suffering, perhaps even more people would choose this option? And the question moves to media portrayals where suicide is not only not stigmatized, it is sometimes glamorized, and the deceased becomes the focus of positive attention, especially for young people, and inspires copycat deaths.

Anita Everett, MD, the chief medical officer of the Substance Abuse and Mental Health Services Administration and president of the American Psychiatric Association, notes, “Suicide is a significant problem of national concern that every part of the health care system can play a part in addressing.” Yet in our societal ambivalence, the topic of physician-assisted suicide has become a subject of much contention in our state legislatures. Six states and the District of Columbia allow for “physician-assisted suicide” – also called “aid in dying” or “death with dignity” – terms that distance the association with either suicide or euthanasia. It is available for people with terminal illnesses and a projected life expectancy of less than 6 months. In this scenario, a physician prescribes a lethal dose of medication at the patient’s request, and the patient then obtains the medication and self-administers it. The death is not reported as suicide, but rather as a consequence of the underlying disease, thereby eliminating any concerns with stigma for the family survivors. While this is not obviously an issue for psychiatry, members of our profession have been outspoken about it, and in one state, the issue came to such a head that two district branches of the American Psychiatric Association with differing views could no longer continue to employ a single lobbyist.

Ambivalence is not limited to the United States. Belgium and the Netherlands have extended physician-assisted suicide to include patients with psychiatric illnesses deemed to be intractable. In these countries, the patient may choose to have a psychiatrist administer a lethal injection.

Mark Komrad, MD, is the ethicist-in-residence at Sheppard Pratt Health Systems. Earlier this month, he visited Belgium to speak on the topic. Komrad noted: “The Belgian professionals were quite aware that the majority of the world disagrees with the euthanasia of psychiatric patients. It seemed almost a point of honor that they differed in this way, as if they are on higher moral ground in a bold new era of medical ethics.” It strikes me as tragically ironic that, as we struggle to prevent the blight of suicide, we have colleagues in Europe who are ushering it along and stretching the practice of euthanasia to what many of us might classify more simply as the murder of physically healthy patients who may not have exhausted every possible psychiatric treatment, or who may spontaneously recover in the future.

Finally, I wanted to touch on a rather unusual case of two teenagers in Massachusetts. Michelle Carter was 17 years old when her boyfriend died of suicide from carbon monoxide poisoning. Sometime after the young man’s death, it was discovered that Carter, a troubled young woman with her own psychiatric illnesses, had known of his suicide plans. By text and phone call, she encouraged him to go through with it, although she was never physically present at the scene of his death. The boyfriend had been suicidal prior to meeting Carter and had spoken to her about his wishes to die. The defense contended, unsuccessfully, that the young woman was propelled to such evil because she was taking antidepressants. Carter was convicted of involuntary manslaughter in a juvenile court and sentenced to 15 months in jail for her reckless conduct that was deemed to have caused the young man’s suicide. The case was obviously quite complicated, but I found it to be one more example of our society’s ambivalence about suicide, in that a teenager would be held responsible and incarcerated for inciting another person to die with her words alone.

As suicide rates rise, we are still finding our way here. We don’t know what propels it, and we don’t know how to cure it. We vacillate between trying not to stigmatize suicide and trying not to glamorize it. And we struggle with whether it is the role of the physician to prolong life and continue to proffer hope or to end life when suffering is deemed by the individual to be unbearable.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

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