Category Archives: Suicide

More on Families, Privacy And Suicide

By Dr David Laing Dawson

Much of psychiatry is about convincing people to do things that will improve their mood, their health, and their lives. Exercise, better diet, overcoming fears, taking necessary medication, stop taking harmful substances, go to bed earlier, turn off electronics, find balance in your life, join something to overcome loneliness, stop procrastinating, call a relative, tell your husband, plan your day, stop worrying about things you cannot control, take baby steps, take medication regularly as prescribed, go for blood tests, enjoy small pleasures, scream at someone rather than cut yourself….

It is not in the DSM V (I think) but we know “no man is an island”. We are social beings. Maybe not to the extent of bees and ants, but no less than chimpanzees. We are never fully independent life forms. Even a hermit has a relationship (albeit a distorted and contrary one) with the community and family he or she is rejecting.

We also know that the quick impulse to say to the doctor, “Don’t tell my family.” or “I don’t want my family involved.” is often derived from shame, guilt, a sense of failure, and sometimes the opposite, a genuine wish to not burden the other. This is further complicated in the teen and youth years by an ongoing negotiation with respect to power, control, individuation, responsibility. We also know in these years the adolescent often says, in the same breath, “I hate you. Give me a hug.” “Get out of my life. Drive me to the mall.” “Don’t tell my dad. Please tell my dad so he can protect me.”

And we also know that persons suffering from severe anxiety and depression develop a sort of tunnel vision that excludes broad levels of social awareness and understanding. “Leave me alone.” And people suffering from a psychotic illness often harbour delusions about family members. “She’s controlling me.”

So, absolutely, when the young person says, “Don’t involve my family.” professionals should explore this, and then convince the patient otherwise unless there is good evidence that keeping the family (parents, sibs) away will be ultimately better for this patient.

Families, Privacy and Hospital Suicides

By Marvin Ross

One of the constant themes in my writing of mental illness is the need to involve the family. And so, when I read a lengthy account of the suicide of a young 20 year old girl that appeared in my local paper, what jumped out at me was that she had requested that her family not be involved with her illness or treatment. She wanted to spare the family grief and, it seems that the doctors went along with her.

The young girl had a number of suicide attempts while in hospital and the family was told none of it. Dr Peter Cook, one of the psychiatrists, told the newspaper that “We were obligated to protect the privacy of Nicole. She was an adult.” The other shrink said that confidentiality between patient and doctor is “sacrosanct.” Nicole did not want to share her medical information with her family.

Sadly, this young lady is not the only suicide in the past little while at this hospital. There have been 9 – 3 in hospital, 2 of patients on leave and 4 outpatients. To its credit, the hospital did commission an external review to see if things could be improved. One of the recommendations was for “closer collaboration with families.”

Now, maybe the outcome would not have been different if the family was involved but we don’t know that. And, the privacy legislation is pretty confining but there are ways to get around them if the medical staff really care. The hospital recently established a family resource centre as the result of a donation from a philanthropist friend of mine. It was difficult to get them to accept the gift but they did and it is being used and it is being well publicized to families.

At the time we were negotiating for a family resource centre at the hospital, I wrote an op ed for the local paper on the need that families have for inclusion with staff when their loved ones are being treated. Aside from pointing out the anger that families have towards being ignored, I mentioned the very sensible guidelines that were produced by the Mental Health Commission of Canada for family caregiver inclusion. And I mentioned this:

“Very few, if any, mental health facilities have adopted these recommendations despite the fact that about 70 per cent of those with serious mental illness live with their families according to the Mood Disorders study. And family caregivers spend 27 hours a week caring for their ill relative according to the EUFAMI survey. That is five hours longer than the average in other countries surveyed by EUFAMI.”

I don’t know if St Joes ever did adopt these recommendations and I do know that the Privacy Act is very restrictive. But, with a little effort, it can be sidestepped as I pointed out in a Huffington Post Blog.

I was basing what I had to say on an excellent paper on the topic that had recently been published by Dr. Richard O’Reilly, a professor of psychiatry, Dr. John Gray, an adjunct professor of psychiatry along with J. Jung, a student in the Faculty of Health Science at Western University.

I said this in my post:

They point out that clinicians often don’t even bother to ask their patients if they have permission to involve family.

If they do and the patient refuses, then they should take the time to explore the reasons for this refusal. Many patients don’t understand why it is important and do agree to allow their families information once it is explained to them. In some cases, there is some information they do not want shared (like sexual activity and/or drug use) and the staff can ensure that this information is not shared. Staff can also inform families of pertinent facts in meetings with the patient present. This often allays patient fears and is similar to the approach recommended in the UK and by the Mental Health Commission of Canada.

In those cases where no consent is given, the staff can give general information to the families and receive vital information from the family. The family can tell the doctors about new emerging symptoms, worsening of symptoms and medication side effects, all of which should be crucial information.

Until such time as political jurisdictions reform the privacy legislation, mental health staff can do far more to open the channels of communication with families for the betterment of their patients. It is time they do so.

I was pleasantly surprised that at a meeting with St Joes staff just after this was published, one of them told me that this blog was being read by staff and was being circulated within the hospital.

It seems that not sufficient attention may have been paid to that. I hope that more attention is paid to involving families so that these tragic events can be minimized going forward.

Suicide Prevention. Part Five. First Nation Youth on Reserves

By Dr David Laing Dawson

All that I have written in parts I, II, III and IV apply to this population as well. But the overall rate of suicide on some reserves is tragically high.

There are several factors that lower the threshold for suicide. Some of these, I think, are inherent in the dependent and isolated nature of reserves and the impossible cultural stew that one finds on these reserves.

Many years ago, even before the internet, I was walking through Kenora in Northern Ontario  one evening when I saw three boys practicing break dancing on an empty lot. They were first nations kids with a boom box, possibly from the White Dog reserve. If so, these were boys who lived on a reserve two hours north of Kenora in the wilderness and they had adopted a dance form that originated on the street corners of the South Bronx within the African American and Hispanic community.

In that same time period a shaman invited me to attend an exorcism he was soon going to perform on a woman possessed by an evil spirit. He suggested I bring some holy water with me for protection. When I asked him why he wanted me there, he answered, “You might bring some of those pills of yours.” So here we have native spiritualism, an Ojibway healing ceremony, Catholic holy water to guard against evil, and anti-psychotic medication just in case.

Another man I saw because his son was in jail explained to me that within his culture children were not raised with the kinds of discipline and control that people of European descent expect. They run free within the village.

At the time I suggested that might have worked well a hundred years ago, but now with alcohol, drugs, firearms, television, cell phones, internet….

I thought of the cliché that “It takes a village to raise a child.” And I can well imagine a village of First Nations People raising a successful child one hundred, maybe five hundred years ago, the boys learning skills and being inducted into the hunting and warrior cultures of the men, the coming of age ceremonies, the girls learning skills and being inducted into the world of women, of gathering, sewing and cooking, of childbirth and babies.

I attended a band council meeting on one occasion to discuss the problem of their teens and youth getting in so much trouble. They constituted a high percentage of the population of the Kenora jail. During the meeting one councilor said he almost wished that they could still send their teenagers off to residential school to learn some discipline. He went on to say it is the parents’ fault. The kids roam the village at night, out of control, looking for drugs or alcohol or trouble or excitement.

It is easy to see why the threshold for violence and suicide is low. The structure, rituals and meaning of growing up in a hunting gathering village have been lost, and the structure, meaning, rituals, rules, organization, expectations of an industrial society (or even a post-industrial society) have never quite taken. The first has been lost (or badly damaged by my ancestors, by politicians, the church, the merchants) despite attempts to hold onto language and rituals. The second never quite accepted. An elected band council is superimposed over a traditional tribal politic. Survival now depends on negotiations for food and housing, clean water and medicine with two levels of Government, not on hunting, gathering, planting, building, making, preserving.

Caught in this the teenagers easily become lost. Many now see little future for themselves. Or to put it another way, it is especially hard for a teenager living in a small, isolated northern community to imagine a bright and satisfying future for himself or herself in a larger world, a larger world that is very visible to them on television. The threshold for suicide pacts, for the contagion of suicide, and for a lethal impulsive action is much lower.

We can fly in mental health resources, improve the local school, try a number of different programs to help youth in those communities, but ultimately I think this will continue unless and until we find a way of ending the reserve system. This kind of chronic dependency is not good for anyone, least of all teenagers.

Or we could study the successful reserves, of which there are a few. And by we I mean government, first nation leaders and organizations. Can this be replicated elsewhere? Is it possible to retain and preserve these ancient cultures and languages without creating an artificial existence and a pathological hostile dependency?

A native friend once told me when we were working together that there were no swear words in Anishinabek languages. Then, on an evening when I was having dinner with a chief, I asked him, the chief that is, what he and his people would say when they were angry.

He smiled slyly and answered, “You must remember that the Indian had no reason to be angry before the white man came.”

As I write this a third 12 year old has killed herself on a small isolated Ontario Reserve. The photo of her in the newspaper shows a sweet child standing before a decorated Christmas tree, a large ginger bread man, and an enormous candy cane. She is clearly within puberty at this early age, and she smiles with innocence and charm. There is talk of money, of mental health workers, of safety plans for the tweens and teens of this two thousand person community.

But this is a band aid on a slow hemorrhage. Our system of reserves is a trap. It is a pretense at preserving a way of life, a culture. It works for those on the payroll, and perhaps for those whose jobs entail preserving and teaching the traditions and languages, and representing their people. But the children and teens? Netflix, a ginger bread man, a Christmas tree and a totem, clothes and packaged food from the stores, alcohol and drugs, video games, occasional attendance at school, and long winters with little to do.

I don’t have a solution. But I do know some advice for leadership applies equally well for the parents of children and teens: “Give them purpose. If you can’t give them purpose give them hope. And, above all else, keep them busy.”

Suicide Prevention. Let’s Talk. But Let Us Talk Truth. Part Four

By Dr David Laing Dawson

Part iv

Special populations

Teenagers

Juliette is shy of her 14th birthday and Romeo perhaps 16.  Shakespeare knew this tragedy would not play had these “star-crossed lovers” been much older.

The brain has not fully developed until age 22 to 25. Yet the years before that involve an intense social learning curve, a testing out and practicing, competing, comparing, shunning and sharing. The prizes are belonging, achieving, competence, prominence, intimacy, self-esteem and sex.

Our brains are also uniquely forward looking. We listen and scan for the minute and hour and day to come. We perceive and select from our environment information that informs us of what is coming. Even when we retrieve memory we shape it for tomorrow. We reform, reinvent the memory to serve our needs for today and tomorrow.

It is no surprise to me that when I ask a teenager what really happened at school yesterday or last week they respond with at least three versions that support their wishes for tomorrow, with total disregard for logical narrative. I have to fill in the blanks to get the true story, or at least a plausible facsimile.

And as teenagers they have limited perspective, limited sense of a world beyond themselves, limited sense of the many years and experiences to come. They live in the now, anticipating only tomorrow. Only a teenager could mouth the words, “If I’m not invited to the prom my life is over.”

And today teenagers live within this cauldron of social competition 12 to 20 hours per day every day of the week. Even when they reject it, as some do, they are defining themselves by rejecting their peers.

So, along with the risks for suicide listed in Part II teenagers also pose the risk of concluding – on the basis of what we adults know is a temporary setback but they see as life defining – that they should kill themselves: the posted naked picture, the rumour at school, the rejection, the betrayal, the public or gossiped accusation….

As I was writing this a Washington Post article popped up on my Blackberry Passport. A girl in the US is on trial for manslaughter. She had encouraged her boyfriend to kill himself through a flurry of texts. When he was parked in his pickup truck filling with carbon monoxide he stepped out and texted her. He wasn’t sure. He had second thoughts. She told him to get back in. This he did. She was 17 when she explained to him that a better life awaited him in heaven.

Apart from anti-bullying initiatives are there ways we can reduce this risk unique to teenagers and youth? Maybe.

  1. Ensure they have reprieve from the adolescent peer cauldron. Electronics off by 9 pm at the very least. Holidays totally away from this. Family time without electronics. More of their time with peers spent in supervised skill building activities.
  2. Know what is happening in your child’s bedroom.
  3. Know what is being posted on your child’s facebook and instagram account.
  4. Know what they are texting to one another. At least check on it occasionally.
  5. Never, ever let them have access to lethal weapons. And there are times a car or a truck can be considered a lethal weapon.
  6. Understand what I have written above about the adolescent brain.

And for teenage and youth counselors, therapists, psychiatrists and family doctors. Please, please, always see these kids with a parent. Make the time you see a kid without a parent an exception for a good reason. Not the kid’s reason, but a good adult reason. And the only good adult reason for not having a parent present is that you have seen the parent(s) and he or she is hopelessly drunk, violent, stupid, immature or in jail.

You see, it is seldom you (therapist, counselor) who can provide an alternative reality to a teenager drowning in his peer group, at least not for much more than an hour a week. But a parent might be able to with some encouragement, instruction, and advice. Just simply having a parent in that consulting room with his or her son or daughter may empower a parent to be a parent, may assign responsibility where it really belongs, and open the window for a teenager to see that there is an adult world with a broader and longer perspective.

Suicide Prevention. Let’s Talk. But Let Us Talk Truth Part 3 Suicide Ideation

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.

  1. 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……
  2. Misuse of relatively scarce medical resources.
  3. Support for and reinforcement of the “suicide threat” as being a legitimate way to negotiate with others.
  4. The emphasis shifts from patient care to safeguards against legal liability.
  5. 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.
  6. 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.
  7. With mental health workers, nurses, doctors, so focused on people expressing “suicidal ideation” they can miss far more important indicators of high risk.
  8. 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.

Suicide Prevention. Let’s Talk. But Let Us Talk Truth. Part Two

By Dr David Laing Dawson

Part 2

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.

Suicide Prevention. Let’s Talk. But Let Us Talk Truth.

By Dr David Laing Dawson MD

A Five Part  Series

1. Background (Reality)

Over the last 20 to 30 years we have all witnessed an increasing emphasis on “suicide prevention”. This has included TV spots, public health announcements, and the development of crisis lines. Most major emergency departments now have some form of mental health team available to them. Many police departments now have mental health teams, psychiatric nurses, or social workers working with them. All doctors, mental health workers, school counselors, school nurses have been encouraged to ask the question. The phrase “suicide ideation” has become part of our popular jargon.

Fair enough. Though some suicides result from competent and rational choices to end one’s suffering from incurable disease, many others are tragic, tragic both to the victim and his or her survivors. And it always seems even more tragic when the victim is young and the suicide unexpected or unfathomable.

One of the obvious results of this heightened awareness of suicide, “suicide ideation”, and the behaviours that are called “suicide attempts”, has been a dramatic increase in the numbers of people seen in emergency departments for the identified problem of “suicide ideation.”

Below are four graphs showing just how dramatic this increase has been. An increase of 11 to 14 percent per year for six years is quite astonishing. These are American figures but I am sure the trend would be the same in Canada.

From: HCUP Overview. Healthcare Cost and Utilization Project (HCUP). April 2017. Agency for Healthcare Research and Qualityfigure1sb220

Now, at first glance this would imply that the new “awareness” and alertness with regard to suicide, and especially suicide ideation, is working. It means, doesn’t it, that far more people are being identified as “at risk” and coming to, or being brought for, an emergency assessment. Which in turn would mean that the actual suicide rate should be declining.

But it isn’t.

The suicide rate in Canada for the years 1950 to 1960 averaged about 7.5 deaths per 100,000 people.

The suicide rate in Canada for the years 2000 to 2009 averaged about 12 deaths per 100,000 people.

In the United States the suicide rate increased 24% between 1999 and 2014 to 13 deaths per 100,000.

I cannot scientifically claim there is a cause-effect relationship here, only an association, but I can certainly claim that the awareness of and the alertness to “suicidal ideation” has NOT decreased the rate of actual suicide in any age group.

But I do think that by focusing on, advertising, talking relentlessly about, “suicidal ideation” we have dramatically increased the use of “suicidal thinking” and suicidal threats as interpersonal negotiating tools, while making no difference to, and certainly not preventing, actual suicides.

What we have been doing is not working. It may even be exacerbating the problem. Yet every month or two I hear more of the same being promoted. We have not reduced, we may even have increased, the incidence of the very personal and often tragic act of suicide. And we may have simply caused or grown another public health problem unnecessarily straining our resources.

(continued in parts II through V)

 

Understanding Youth “Suicide”

By Dr David Laing Dawson

Our assumptions and the language we use, that we so quickly use, often hinder a fresh and more useful way of viewing a problem. The word “suicide” and the phrase “attempted suicide” are examples of such assumptions and language.

This word and this phrase carry assumptions of intent, a formed intention, an intention to engage in an action that will achieve a goal. With the word “suicide” we imply that the goal is death, the ending of a life.

In the newspaper, and equally in medical charts, the phrase “attempted suicide” is poorly applied to many behaviours that were not “attempted suicide”. For many “attempted suicides” by teens, and some adults, the goal is not death, but …. Well, many things: payback, “they’ll be sorry”, negotiating power and control, making a point, taking a break, sleeping for a while, avoiding, revenge, punishment, getting someone to care, stopping the emotional pain…. Even when the goal is “death”, for a teenager, this can be a very ill-formed concept of death (complete with the idea of being around later to watch other peoples’ reactions), or a very drastic solution to a relatively small and temporary problem.

When the goal is not “death” and yet we call it “attempted suicide”, our interventions will be ill formed and misguided. In fact, I will make the case that when we mistake a teenager’s “getting someone to care”, or “punishing a boyfriend” for a “suicide attempt”, we mental health professionals find ourselves ratifying self harm as a legitimate tool of social discourse and problem solving.

But what is “death” to a ten year old, to a 14 year old? What is “death” to a Catholic or a Moslem?

Some years ago the uncle of a young boy killed himself by hanging. The boy was taken to the funeral of his uncle; he was privy to the conversation and distress of his own parents. And then the boy hung himself.

The community was understandably distraught. His teachers, family, friends, and the social workers working for the school board.

I was asked why an 11 year old would commit suicide? Was it a suicide? Could they have prevented it? I gave it some thought and reassured them that it was “an accident”, a tragic accident, not suicide.

For is it possible for an 11 year old to formulate a goal of being dead? Meaning “dead, dying, and death” as adults mean these words? No. For the boy in question we can never know how much was curiosity, imitation, how much distress, how much distracted parents, what he imagined he was actually doing. I am sure, that at 11 years of age, he did not have in his mind a clear and mature sense of the finality of death.

I am writing about this because of recent news reports of deaths of children age 10 to 14 in two northern Saskatchewan Communities. The reports are labeling these deaths “suicides”. They are also saying many other youth have “attempted suicide.” The responses have apparently been to send in mental health counselors, and to fly one or two out for psychiatric assessment. And these responses go along with the assumption that these children did in fact “commit suicide” and are in fact “attempting suicide.”

Now no doubt they are engaging in behaviours that have the potential to kill them, and that did so in four cases, including the most recent 10 year old. But that is what they are actually doing, these children; they are engaging in behaviours that can result in death. They are too young to know what that actually means for themselves, and for their families.

We do need to send a team in to investigate, but without the assumption that these behaviours constitute either “suicide attempts” or “suicide”, in an adult sense. We should investigate without the assumptions carried by those words.

Exactly what behaviours are these children engaging in, where, how, and why? And then, how can it be stopped. Or what needs to be done to change these patterns of behaviour?

 

A Subjective Unscientific Analysis of Anti-Psychiatry Advocates

By Marvin Ross

Many of my Huffington Post Blogs attract some very nasty comments from the various anti-psychiatry adherents. The same applies to the blogs by my colleague Susan Inman and we get some on this blog. The Boston Globe award winning Spotlight Team featured in the film Spotlight, just did a series of articles on the sad state of mental health care in Massachusetts. Wanting to foster dialogue, they set up a Facebook Page for comments. And did they ever get comments!

I’ve been looking at more than my fair share of these comments over the years but decided to try to categorize them. So here goes.

1. I was badly treated, mistreated, misdiagnosed therefore all of psychiatry is evil. In some cases, this alleged mistreatment occurred over 50 years ago. I do believe that this happened in most cases and it should not have happened but it did. Personally, I’ve run into (or family members have) some very incompetent and inept treatment by doctors and/or hospitals. This has occurred in inpatient stays, visits to doctors or in emergency rooms. And some of these misadventures have been serious but I do not spend my time denouncing all hospitals, all doctors or all Emergency Rooms. What I have done is to complain to the appropriate authorities. And most of the time I’m successful.

As my English mom used to say, “don’t throw the baby out with the bathwater”

  2. The other very common cry is that I got help and recovered therefore everyone can recover and if they can’t, it is because the docs are bad or are trying to keep people sick to make money and peddle drugs. I’m sure there is an error term in logic where you extrapolate your particular situation to everyone. That is what these critics are doing. It is like saying I survived prostate cancer which has a 5 year survival of 98.8% so that someone with pancreatic cancer can too. Pancreatic cancer only  has a 4% 5 year survival rate. It is not the same nor is say mild anxiety comparable to treatment resistant schizophrenia. Stop mixing apples and oranges.

3. Involuntary treatment for those who are so sick that they pose a danger to themselves, others, or will deteriorate further without involuntary committal means that the state will lock up, drug and keep everyone indefinitely. None of these fears are true so learn what is entailed and get over it. And when I post a video or an article by someone like Erin Hawkes who went through about a dozen involuntary treatments till a pharmaceutical agent was found that removed her delusions, stop insulting her as some have done by calling her a victim and that she is suffering from Stockholm Syndrome.

How will you learn if you refuse to listen to other opinions?

What I suspect that these involuntary opponents do not understand is that people are not locked up without just cause or forever. There are safeguards in place to ensure regular reviews and appeals. In Ontario a few years ago, a group of so called psychiatric survivors challenged the constitutionality of community treatment orders and supplied the courts with affidavits from people who found them to be bad. This is what I wrote about that in the Huffington Post:

Justice Belobaba only had to look at the affidavit that the plaintiffs filed as part of their attack on CTOs to get an idea of how well they can work. Amy Ness had, prior to being put on a CTO, been involuntarily committed for showing violent behaviour in 2004. In 2007, while hospitalized, Ms. Ness kicked her mother in the back and hit her repeatedly. Then, in 2009, Ms. Ness grabbed a large kitchen knife and marched upstairs toward her mother after discovering a magazine about schizophrenia. In another incident, Ms. Ness kicked and punched the emergency department psychiatrist. By the time she was given a CTO in 2009, she had five hospitalizations.

Since then, while on a CTO, the judge pointed out, she takes her medication and sees her case worker on a regular basis. She has not been hospitalized, she maintains her housing and she works as a volunteer, has a job and takes courses. She does think, however, that the CTO is an attack on her personal dignity.

Herschel Hardin, a civil libertarian once wrote that:

“The opposition to involuntary committal and treatment betrays a profound misunderstanding of the principle of civil liberties. Medication can free victims from their illness – free them from the Bastille of their psychoses – and restore their dignity, their free will and the meaningful exercise of their liberties.”

A psychiatrist I know who is a libertarian (someone who believes that people should be allowed to do and say what they want without any interference from the government) told me that when your brain is immersed in psychoses, you are not capable of doing or saying what you want. Therefore, he was fully supportive of involuntary treatment so that people could get to the position where they had the capacity to do what they want.

4. And then we come to what Dr Joe Schwarcz on his radio show, Dr Joe, calls scientific illiteracy. He used that in his July 10 interview with my colleague, Dr Terry Polevoy, in a discussion on EM Power + and the conviction of the Stephans for failing to provide the necessities of life for their child who died of bacterial meningitis. They refused all conventional medical care, gave him vitamins, herbal products and echinacea till the poor little toddler stopped breathing.

There was a case of scientific illiteracy in that the parents are totally opposed to vaccinations and work for a  company that encourages people with mental illnesses to go off meds in favour of their proprietary vitamins. They had no idea why they were convicted, lashed out at the jury who convicted them and then, at their sentencing hearing, the wife shocked even her own lawyer when she told the court that the Crown had used a phony autopsy report as evidence.

Other examples are that anti-depressants cause violence and suicide. Violence possibly in those under 24 according to a large Swedish study but not in adults. However, the authors state that these findings need validation. There is no definitive proof of this and no evidence of increased violence in adults.

As for anti-depressants causing suicide, a warning that this might be a concern was posted on the labels. Doctors were advised to be cautious when prescribing these for depressed young people.Consequently, this resulted in an increase in suicide attempts.

“Evidence now shows that antidepressant prescription rates dropped precipitously beginning with the public health advisory in March 2004, which preceded the black box warning in October 2004. Since the initial public health advisory, antidepressant prescriptions for children and adolescents decreased, with a consequent increase (14%) in incidence of suicide in these populations.”

On my to-read list is Ordinarily Well The Case for Antidepressants by psychiatrist Peter D Kramer. Kramer is the author of Listening to Prozac and, in this new book, he continues with proof that antidepressants do work and are not simply placebos. Not only do they work, but they are life savers.

In the New York Times review by Scott Stossel, the reviewer points out that when Kramer first began visiting psychiatric wards in the 1970’s, they were filled with people suffering what was then known as “end-state depression”. These were depressed patients in what appeared to be psychotic catatonic states.

Patients like that have not been seen for decades which he attributes to the aggressive use of antidepressants.

And, lest we forget, there is also the common view that the chronicity of psychiatric disorders are caused by the drugs that doctors force on their patients. People love to quote the work of Martin Harrow in Chicago but I suspect that many have not actually read his studies. Some people, he found,  did better after going off anti-psychotics over time than those who continued with their use but that is not surprising. It has always been known that some people improve while others have chronic problems and still others are not able to be helped with anything.

What they do not realize is that in Harrow’s study, 79 per cent and 64 per cent of the patients were on medication at 10- and 15-year follow ups. And that Harrow points out that not all schizophrenia patients are alike and that one treatment fits all is “not consonant with the current data or with clinical experience.” His data suggests that there are unique differences in those who can go off medications compared to those who cannot. And he points out that it is not possible to predict who may be able to go off medication and those who need the long term treatment. Intensified research is needed.

So stop with the reference to Harrow that no one needs meds. And stop also with promoting Open Dialogue when, first, it has never been empirically validated and second, many of their patients are on medication.

5. Regrettably, many of these people lack any civility whatsoever. People are entitled to offer their comments but they should not do so anonymously. And they should show some respect for those who have different views. I’m told that some have been banned from the Spotlight Facebook page and I’ve just banned one anonymous person who posts here for his/her personal attacks. I mentioned above that Erin has been called a willing victim and one who suffers with the Stockholm syndrome for her video and her article. Refute the points she makes but leave the insults aside.

And, one post that I removed from the After Her Brain Broke page on Susan Inman in response to he video What Families Need From the Mental Health System claimed that Susan keeps her daughter locked up and ill and that she likely suffers from Munchausen by proxy.

 

On Adolescent Suicide

By Dr David Laing Dawson

Adolescent suicide is a tragic event. It can have a devastating and life long impact on others: parents, siblings, teachers, relatives, counselors, friends.

Five Woodstock, Ontario  teens have taken their own lives since January this year. A very high number for a small community.

If this were a cluster of deaths from respiratory causes we would surely investigate with a team comprised of a respirologist, an epidemiologist, and the public health officer.

Thus our first step here should logically be an investigation by an epidemiologist, a  psychiatrist, and the public health department. Let us first see if these deaths are a result of undetected, untreated mental illness, if the teens know one another in real life or through social media, if they are all browsing the same toxic websites, or if each has been the target of bullying or something worse, or a combination of these. Let us try to understand before rushing into awareness programs, school assemblies, more crisis lines.

There are several good reasons to not rush to “talking about it” as the answer. These are teenagers, not adults. We know from anti-smoking programs, when we gathered our high school students into the auditorium to talk to them about the horrors of smoking and showed them videos of cancer-ridden lungs and COPD sufferers gasping for breath, the number of teens taking illicit puffs at the local smoking pit increased. Increased. Not decreased, increased.

We are also living with the paradox of contemporary times when kids are inundated with suicide awareness programs, when every school counselor and nurse asks every troubled kid the question, when each community has an advertised crisis line, when the question “do you ever think of harming yourself?” is asked on countless questionnaires and surveys, when our teens are communicating with each other around the clock, when information on any and every subject is as available as the nearest smartphone, and when we are in the midst of public discourse about assisted suicide. It is in these times, not in the 50’s, 60’s, or 70’s ( when the word suicide would only be said in the same whisper as syphilis), that clusters of teens are committing suicide.

Or so it seems.

But what I am trying to say is that we should investigate these phenomena before we rush to “solutions”, especially with teenagers. They are not adults. They often do things just because they have recently learned those things are possible to do. They are often more intrigued when adults bend over backwards to warn them of danger.

The adolescent brain has lost some of the intuitive avoidance and fear of the child’s brain. It is developing some reasoning and analytic processes to replace these. But it does not have the breadth and depth of experience of the adult brain, nor the ability to consider the distant future and the effect on others. The adolescent brain tends to live entirely within its present context.

“Would you swim with sharks?” When a child is asked this question he or she will answer with an emphatic NO. An adult will also offer a very quick negative, though with some adults and a few adolescents the questioner may need to add that ‘sharks’ is meant in a literal sense. But the teenager. Ah, the teenager. He or she asked that same question will ponder it. You can see and sometimes hear the analytic reasoning kicking in: “Well, humans are not the sharks’ natural prey, so….and though I am not a good swimmer….and depending on…”

So far, with teens, my own informal survey has resulted in answers of “yes or maybe or I’d consider it” 100 percent of the time.

I am not saying we should downplay suicide and it’s tragic consequences. I am saying that we should treat an increase, a cluster of suicides like any other serious outbreak of illness. We should study it without pre-judging. And when teens are involved we should take into account their contrary minds.

The Woodstock cluster may be a problem of inadequate resources; there may be a contagion factor at work;  there may be a local stigma about seeking help; there may be some cyber bullying occurring; the means to kill oneself may be too readily available; there may be untreated mental illness involved; they may all have been fans of the same toxic Web site; they may know one another, or not; they may be using or misusing the same drugs; they may be all attending the same counselor; or this cluster might be simply a statistical anomaly…

We should help family and friends cope with these tragedies, but we should investigate before we plan a preventive intervention.