By Dr David Laing Dawson
At least every second night on television I can watch an ad for a pharmaceutical during which a calm mesmerizing voice tells me of all the possible side effects of the drug being promoted. It is a voice playing over reassuring music and a pastoral video. Often, for a certain class of drugs, the warnings include “may cause suicidal ideation in teens and youth.”
The SSRI medications (from Paxil to Zoloft) come with the same warning and patients going on these medications are cautioned to watch for “suicidal thoughts”.
This is nonsense, of course.
If we had actually found a drug that, when taken, could instill a specific thought, the CIA would be all over it.
Pharmaceuticals can affect our arousal systems, heightening or dampening; they can affect our physiological sensations; they can affect our energy levels, our pain, our comfort, our ability to think clearly; but they do not instill specific thoughts. The very idea is ludicrous. Even the ingestion of mescaline or LSD requires specific anticipation, context and guidance in order to provoke either ecstasy or horror.
There is a history of how those warnings came to be, and political and legal reasons for drug companies to continue them.
When these warnings were first published and doctors in those small northern European countries (that keep complete and excellent national data) stopped prescribing these medications for depressed younger people, the actual suicide rate over the following ten years went up in that population. So most physicians went back to prescribing these along with the caution to “watch for suicidal thoughts”.
But there is something very instructive in all of this. We are social beings. How we think, how we express our thinking, how we react, how we negotiate with each other, the language we use to express our unhappiness or anger – these are all socially and culturally determined. We learn what works and we use it. We are highly impressionable. Especially when we are young.
So it is not surprising that with the dramatic increase in public awareness of, and the exhortations to watch for suicidal ideation, both the experience of and the reporting of a “suicidal thought” have dramatically increased.
People are routinely asked that question on surveys, on screens for depression used in family doctor’s offices, on psychological testing and in most encounters with a mental health care professional. The question is asked of most distressed people.
SSRI medication is prescribed for people who have been at least identified as being distressed and the question of suicide ideation has been asked of them. In some cases, often.
As a medical test used for an assessment of risk of suicide, the question, “Are you experiencing suicidal thoughts?” (in whatever form it is asked), now yields about 95% false positives. All clinicians know that it also yields about 1 or 2% false negatives.
The truth is many people who answer yes to a variant of that question are brought to emergency (see charts in part I). In the emergency department they are assessed in various ways. And they are allowed to leave when their answer to that question reverts to “No.”
At that point they are often asked to “contract for safety”. This is a particularly silly intervention and amounts to the patient being allowed to leave after he or she has promised to not hurt themselves.
This has caused several obvious and a few less obvious problems.
- With the emphasis on that question, the actual cause or nature of the person’s distress may be missed entirely: e.g. relationship distress, abuse, anger, anxiety, guilt, teen drama, need for parenting, fear, loss, grief……
- Misuse of relatively scarce medical resources.
- Support for and reinforcement of the “suicide threat” as being a legitimate way to negotiate with others.
- The emphasis shifts from patient care to safeguards against legal liability.
- Unnecessary admissions to hospital of people whose answers don’t revert to “No.” until they have been on the inpatient ward for a few days.
- Reliance on that question produces the 1 to 2% false negatives who should have been kept in hospital and treated, not because they said yes or no to that particular question, but because they were agitated, psychotic, or severely depressed, and truly at high risk.
- With mental health workers, nurses, doctors, so focused on people expressing “suicidal ideation” they can miss far more important indicators of high risk.
- Finally, some people experience suicidal thoughts not because they are suicidal, but as specific obsessive thinking, and sometimes, as an intrusive or unbidden thought, and sometimes as an inserted thought, experienced as being put in one’s head. This thought can take the linguistic form of either, “I should kill myself.” Or “You should kill yourself.” The thought itself is distressing to the patient. In the case of this being an obsessive thought torturing someone with OCD, it is not an indicator of high risk of suicide. But it is treatable with the same drugs and counseling that work with other OCD symptoms.
When the thought is experienced as being put in one’s head, and as a command, it does indicate risk, as well as psychosis. It is a symptom of a psychotic illness requiring treatment. However this person is unlikely to answer yes on a screen for “suicidal ideation”. It is a command hallucination that this patient will only admit to experiencing, reluctantly, within a longer, slower, quieter interview.
I know I can’t, but I would like to ask all clinicians and counselors to stop asking the suicide question, at least not as routine, not as a survey. It is not preventing actual suicide.