More on ECT and Other Treatments

By Dr David Laing Dawson

Throughout medical history, every treatment that actually works becomes overused.

Examples today include treatment for high blood pressure, statins, mastectomies, arthroscopies, opioids for pain, antibiotics, aspirin…..

When a treatment is found to work, the criteria for use informally expands until large studies find this to be either detrimental or unhelpful and then the practice shrinks. The current opioid crisis is a good example. The struggle to control the overuse of antibiotics is another.

ECT was first used in 1938 and found to be dramatically effective for patients with very severe depression, intractable mania, and some forms of psychosis. This at a time when there were no other explicitly effective treatments. This at a time when most of these cases were thought hopeless and all other treatments constituted a mix of hocus pocus and wishful thinking.  The very first patient to receive ECT was a man found by police wandering in the Rome train station muttering gibberish to himself. After this first rather unrefined ECT treatment the patient was discharged from hospital fully oriented and talking sensibly.

ECT was also introduced at a time when depression could reach a point of severity to justify the adjectives “stuporous”, “vegetative”, “retarded”. People died in this state from the consequences of malnutrition, starvation, unrecognized infections, and all the problems associated with total immobility. For this subset of severe depression ECT is a miraculous and dramatic (sometimes temporary) cure. It similarly had stunning results with intractable mania and catatonia, and pretty good results with something called “agitated depression”.

Hemingway was hospitalized with a form of psychotic depression (severe depression with agitation and some paranoia), was treated with ECT and returned home to work. For eight months or more he wrote at his standup desk somewhat unsuccessfully, drank too much, relapsed, and was readmitted to hospital. This time he talked his way into being discharged without treatment. And then he killed himself.

Through the 40’s, 50’s, and 60’s ECT became overused, both excessively used for single intractable cases, and used to “treat” many problems that simply don’t respond to ECT. Then our new drugs began to replace ECT, attitudes changed, One Flew Over the Cuckoos Nest hit the big screen, and, perhaps more significantly, with our new drug treatments, very few people got to the late stage of depression and psychosis we called, “stuporous”, “vegetative”, “retarded”, “agitated” and “catatonic”.

Over the years I have received heart felt thanks from a few people for whom I recommended ECT.

And it seems clear to me that all or most of those people who complain of the barbarity and after-effects of ECT are victims of that overuse mentioned above.

There are many human conditions for which ECT is not helpful, but, in some of those cases, once used, ECT becomes the perceived cause of all succeeding problems.

In reality ECT remains a very safe and effective treatment for serious depressive illness. Today it is mostly used when trials of medication have failed. Curiously, though pilloried and thought to be barbaric by some, ECT is actually one of most dramatically effective and safe treatments in all of medicine.

On ECT and The Variability of Bodily Experience

By Marvin Ross

ECT or shock therapy has to be the most contentious treatment in all of medicine, in part, due to its depiction in films which is highly negative. My initial view of it was coloured by my favourite aunt when I was a kid. She had what in those days (1950s or 1960s) was a nervous breakdown. Her husband had died and then her brother (my father) died suddenly of a heart attack.

One of her symptoms was unusual pains in her chest and back for which no organic cause could be found so her physician nephew had her admitted to a private sanitarium rather than the infamous Toronto Hospital for the Insane at 999 Queen St W ( actually the Ontario Hospital and now the Center for Addiction and Mental Health). She underwent a series of ECT treatments and was eventually discharged.

After discharge, she confessed to me that after each treatment, the staff asked her how she felt and if she was still experiencing the pains. She told me that if she said yes, she got more shocks so she told them she was fine, the pain had gone away and she was discharged. But, she told me, she still had the pains. I can’t recall how long after but she died of a stroke. I’ve always wondered if they had missed atherosclerosis as diagnostic skills were quite primitive in those days as was treatment for heart and stroke compared to today.

Fast forward to the late 1990s and I was a regular visitor to the psych unit at our local hospital. One of the patients was a young mother with schizophrenia who, I was told, attempted to kill herself and her young children. She was getting ECT. A few months later, I was picking up a coffee at the hospital snack bar when an attractive woman said hello to me.

“You don’t recognize me, do you” she said.

“I’m so and so and this is the new me post ECT. I was discharged, I feel really well and I’m here for an outpatient visit with my psychiatrist”

Psychiatric Times just ran an interview with the author of a new book called Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy by Jonathan Sadowsky, PhD. The one question he was asked that I found very interesting was this:

“Patients have both attested to damage it has done and expressed gratitude for the relief and hope it can provide.” How do you explain this seemingly paradoxical disparity in the experiences and opinions of patients?

The answer was what I have tried to say about medical treatments and recovery in schizophrenia in general but not as elegantly as this author. This is what he had to say:

“The human body is not a mass-produced machine, where given inputs such as therapies produce automatic and predictable results. Most clinicians and lay people know this but often act as if they don’t. One result of this mechanistic conception is resistance to the variability of bodily experience. But this variability is easy to show.”

And so, some people do well and others do not just as some drugs work well for some people and in others not only don’t work but have horrific side effects. We are all different and good clinicians have to recognize (and do) that trial and error is required to find the correct treatment for any given individual.

In a recently released study out of the Karolinska Institute in Sweden, it was found that there is considerable variability in the efficacy of anti-psychotics to prevent relapses in patients with schizophrenia. This study involved 29,823 patients aged 16 to 64 years with a median follow-up of 6.9 years. It was also a naturalistic study where each patient served as his/her own control to avoid selection bias. Long-term injectable antipsychotics, paliperidone and zuclopenthixol and the oral clozapine had the lowest risk of rehospitalization.

Going back to ECT, another recent study found that remission rates for patients with severe mood disorder are lower among those who have had ECT as inpatients. Earlier studies had shown that ECT leads to better remission rates in people with major depressive disorder and results in reduced mortality.

The bottom line is that despite the bad press that ECT and other treatments may have in the media or among the general population, many will experience positive outcomes. Keep an open mind.

“Is Donald Trump Human?”

By Dr David Laing Dawson

Men in Black, from 1997, with Will Smith and Tommy Lee Jones, is full of good moments. The particular moment that came to mind, for reasons that will become apparent, follows the recruitment of Will Smith to the very small and select team. Tommy Lee is showing Will Smith the ropes. He suggests they “check the hot sheets”. They stop by a News Stand to pick up a couple of tabloids, each with a lurid headline.

“These are the hot sheets?” asks Will.

“Best reporting on the planet,” says Tommy. “Go ahead, read the New York Times if you want. They get lucky sometimes.”

Smith spells out the gag: “I believe you are looking for tips in the supermarket tabloids.”

Their headlines include: “Pope a Father”, “Top Doctors baffled, Baby Pregnant”, “Man Eats Own House” and “Alien Stole My Husband’s Skin.”

The scene is played straight.

It is a very funny moment, I thought.

And I have always assumed that anyone reading these yellow sheets is engaging in a guilty pleasure. They are titillating themselves with implausible stories. Today those titles would be called ‘click bait’.

The publishers of these magazines, when they deal with celebrities, are marketing to our schadenfreude. Ah, how we enjoy reading that the lives of the rich and privileged may be as fraught with conflict and unhappiness, sin and regret, as our own.

But we know that when the story is not an outright lie, a gross exaggeration or invasion of privacy, it is still merely trivial. At least I thought we all understood that.

Hence the entire audience in the theater watching Men in Black got the joke.

But not, apparently, Donald Trump.

It is very distressing to learn that he and the publisher of The National Enquirer are good friends who influence one another. And that this publisher is thinking of buying Time Magazine.

There is a strange slippage afoot. I’m not sure whether we should be boning up on George Orwell or Lewis Carroll.

And I notice another thing entirely by accident. These Men in Black, American enforcement officers for true aliens, extraterrestrial aliens, of all shapes and sizes, some cute, some grotesque, some “legal” and some “illegal”, treat these aliens with much more decency and respect than Donald Trump and ICE treat human “aliens.”

Racism

By Dr David Laing Dawson

At least three times per week every week, between editorials in my local paper and the CBC I am made to feel guilty about any vestiges of prejudice I might have, or even my ancestors might have had, toward people of a different race. I often get to the point where I mutter, “Enough already”.

A fan of Star Trek has a vanity license plate with a form of “Assimilate” on it, the demand of The Borg. Someone objects for it is reminiscent of an attitude some of my ancestors had toward First Nations People. But we all know it is more complicated than that. To begin with The Borg are (or is) villain(s) in that Sci Fi series. And, despite the sense of loss felt by several generations, we all assimilate eventually, while retaining some ceremonial cultural practices and artifacts.

But perhaps we need to be scolded three times per week. For deep within the current political theater in the USA lurks the unmistakable venom of racism. Even the rush to a new health care bill is quite obviously being driven more by a wish to remove “The Stain” of having had a black president than any fervently held ideological position or humanitarian hope. It is there in the language used. It is there in the faces of the proponents of “Repeal and Replace”.

It is there in the stroke of Trump’s pen and the triumphant faces behind him when he signs off on orders to stop anything Obama started, no matter how innocuous, or, for that matter, no matter how obviously good it was. It is there in the tendency to excoriate anything achieved during the eight years Barack Obama was president. It is there in the ignoring of Sally Yates’ wise counsel. It is there in the attitude toward Sanctuary cities and Urban police. It is there in the sea of old white male faces standing behind Trump in the Oval Office. It is there in the soft and reluctant criticism of white supremacist groups. It is there in the activities of ICE.

When Trump claims the world “was laughing at us” this is code for “the world was laughing at us because we elected a black president.”

So, despite my first paragraph, despite my occasional irritation with excess political correctness, keep scolding us please, keep reminding us. It looks like we all need this if we are not to willfully or accidentally step on that slippery slope back to tribalism and contempt for those unlike ourselves.

 

Dump Trump

By Dr David Laing Dawson

If a doctor, teacher, manager, administrator of 70 years of age emailed, announced, or tweeted what Donald Trump just tweeted I would immediately suspect alcohol or frontal lobe dementia. Besides being relieved of his office, or license, his family would take him to a family doctor who might then refer him to either an addiction service or a psychiatrist/neurologist. It would be a striking failure of judgment only plausibly explained by frontal lobe impairment.

With Donald Trump though, this kind of behaviour is not new or unusual. But even a narcissistic misogynistic sociopath might recognize that in the context of being POTUS such a tweet would bring only shame upon his head and reduce, not enhance, his status.

So we have to conclude that either Donald Trump is the same Donald Trump he has always been plus he now has some early dementia, or, his personality disorder is so severe, his ego so fragile, that he cannot stop himself from engaging in a playground (age 14 maybe) retaliation, even when it would be so obviously damaging to him, his family, and his country.

Either diagnosis bodes poorly for the safety of our planet. Please, Republicans, understand this man will take you down with him. It is time to act.

Although, while Trump may be a threat to all things good and sane, from what I see and read, the Republican party in its current form may be an equal or bigger threat to democracy.

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.”

The Doctor gives us one hundred years.

By Dr David Laing Dawson

What an interesting time to be alive. I had grandparents who drove some of the first mass produced automobiles; parents who listened to the radio, took penicillin, and flew in planes; I grew up among a generation of boys who dismantled cars and rebuilt them to drive when we got our licenses at 16; we watched television going from black and white to colour, and analogue to digital, from large boxes to thin screens; we bought 64K computers; watched the first messages pass through the internet and modems; watched portable phones, libraries, laptop computers, arcades, cameras, pagers, slide rules, and calculators merge into this ubiquitous instrument we call a smart phone; we learned to say double helix, and then genome; we saw small amounts of data stored on microfiche evolve into terrabytes of data stored in something smaller than a thumbnail; my son and daughter work in the high tech industries; my grandson is studying artificial intelligence at University; and Stephen Hawking tells us we need to colonize another planet or two within 100 years or risk extinction.

If he is right, then the generations alive today are humans who have links to the early days of mass production in the industrial revolution, to the beginnings and early evolution of modern science, medicine, and agricultural practices, right though the digital age, space travel, and on to the destruction of the planet.

Our dramatic success over the past few generations (give or take some stupid wars, genocides and catastrophes) is leading directly to the demise of our species, all within a dozen generations. That is impressive if sad.

Hawking includes possible “acts of God” in his list of destructive forces (direct hit by a large meteor) but most scenarios include one form of suicide or another (pandemic spread around the globe, nuclear holocaust, the consequences of over population, and global warming).

Biologically our evolution has spanned millions of years. Until the industrial revolution our social evolution had been almost as slow and incremental. Capitalism, democracy, science, medicine, and technology have jet propelled (literally and figuratively) this social evolution the past 150 years.

Before then we were creatures surviving within a complex ecology, our population very slowly increasing, subject to the whims of weather, drought, wars, and pestilence. We had minimal effect on our planet. We could build a boat, a city, a canal, and a damn, but the oceans and forests continued, the rivers, deserts, and most of our earth’s life forms persisted. To survive through those centuries we needed to expand, explore, conquer, and exploit.

Not now.

Now quite suddenly we are the shepherds of our own destiny as a species, a life form. To survive we must all cooperate. We must give up notions of magic and Gods and competing feifdoms. We must stop population growth through all humane means of birth control. We must husband our planet’s resources rather than exploit them. We must have in place an international program ready to act instantly when the next pestilence arises. We must stop talking about economic growth and replace this with equitable economic distribution. We must stop destroying our oceans and forests. And of course we must either reduce our CO2 emissions or figure out how to capture them.

A tall order. Especially when some leaders of our fully industrialized nations want to pull us back to an age of competing xenophobic fiefdoms. A hundred years is but a blink of a galaxy’s eye.

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.

Kim Jong-Un Goes to the White House

By Dr David Laing Dawson

In our histories there were times the mad arrogant king could demand that his subjects, especially the Lords and Ladies of his court, prostrate themselves in obedience and offer unlimited praise of his highness. They would do this because to refuse brought about death for themselves and a life of penury or slavery for their families.

To my knowledge Donald Trump does not have such powers (yet). But still his cabinet engaged in such a ritual display before the world. As if from a script they each in turn offered the same words of honour and subservience, rounding off with a fantastical account of the state of the nation, the world, and their particular spheres of influence, and indebtedness to his majesty.

I could only listen to a few of these and perhaps, maybe, someone in the circle diverged from the script later. The last to speak I listened to described such a delusional world view I could watch no more.

This is not something we should be watching in a democracy. Perhaps North Korea, or Saudi Arabia, not America. The penalty for not complying, of thinking for themselves, of being principled and honest is not death. At least not yet. Where is their pride? Where is their courage?

More importantly, if they do not find this courage soon, the day may come when the penalty for disobedience will be death and a life of penury for their children

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.