By Dr David Laing Dawson
The problem with a public campaign to prevent suicides by identifying suicide ideation is that it is akin to a public campaign to prevent heart failure. Both actual heart failure and actual suicide are end stages of other processes, but in the case of heart failure we know enough to target cardiovascular disease, obesity, hypertension, diabetes, smoking, rather than “heart failure”. We do not say, “Call this number if your heart is failing.”
It is not a perfect analogy but one can imagine what would happen if we established dedicated phone lines across the country to respond specifically to people who felt “their hearts were failing”. And then what would happen if each of these callers were instructed to go to an emergency department.
Curiously the authors of the original article that surrounds the four graphs I included in Part 1 of this series, summarize by emphasizing the importance of identifying suicidal ideation and going to the emergency department for assessment. More of the same. Stay the course. Double down.
We do not easily give up our cherished beliefs. And as with many human endeavours, it is often politically and personally more important to appear to be doing something about a problem than to actually do something effective.
We know the demographics of completed suicide. We know the risk factors. We know the specific and sometimes treatable illnesses that all too frequently lead to suicide. So if we truly want to reduce the actual numbers of people who kill themselves (not threats, small overdoses, passing considerations), then we need to stop wasting resources on “suicide prevention programs” and put them into the detection and continuing treatment of those specific conditions so often responsible for suicide.
Let’s break that down.
There are some basic demographics that contribute to risk. These are older and male. This does not help us.
Then there are all the social factors that increase risk: poverty, unemployment, social isolation, divorce, living alone, alcoholism, drug addiction, chronic pain. Each of these can only be addressed by specific social programs (minimum wage increase, income equality, safety nets, affordable housing, retraining, community support systems) and focused treatment programs for alcoholism and addictions.
But there are specific high risk groups we can identify and for which we can increase accessible treatment and continuity of care. And these account for the majority of completed suicides. They include:
- Recently discharged psychiatric patients.
- Unrecognized developing serious mental illness.
- Under treated serious mental illness.
- Stopping treatment for serious mental illness.
So to put a dent in the actual suicide rate we should be putting our resources in:
- Recognizing and making treatment available for Depression, Anxiety, Bipolar disorder, schizophrenia, severe OCD, PTSD (not for or identified by “suicide ideation”)
- Providing good continuity of care, especially after discharge from a treatment center.
- Using all the tools available including involuntary commitment and community treatment orders to ensure the seriously mentally ill are adequately treated.
- Working hard with our patients to keep them in treatment and on medication.
We know, for example, that people with bipolar illness are very high risk for suicide when not receiving treatment. We know they continue to pose a risk for suicide when receiving treatment. But a very important study found this: Those with bipolar illness who were thought to be receiving treatment and who still killed themselves, were found, at autopsy, to not have psychiatric drugs in their systems. They had all stopped treatment.
Hence bullet point 4 above.
To be continued.