Tag Archives: suicide prevention

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)


Suicide Prevention: In The Real World

By Dr David Laing Dawson

Marvin and I have written blogs about the failure of current and proposed “suicide prevention programs”, the crisis line, the gatekeeper programs, the public awareness programs. He points out these programs make us feel like we are doing something, at least, but are a waste of money.

I would go further. I think they actually increase the number of people who use “suicide threats” as negotiating tools, and then through the intervention of family, counselors, and teachers find themselves in the Emergency Department of Hospitals being assessed by nurses, emergency doctors, social workers, and often the psychiatrist-on-call over a three hour to three-day period. This uses up our resources and poses the risk of inuring these front-line professionals to true suicide risk.

The number of people who actually kill themselves each year is remarkably stable. We know it goes down in wartime, increases in peacetime, and poor economic times. We know the demographics of suicide. We know the high-risk groups.

We know that a few of these suicides constitute rational, understandable, reasonable, sane and logical decisions to end one’s suffering in the face of incurable disease and disability. Hence the current move toward allowing some physician assisted suicides.

We also know that the suicide of someone in other circumstances (temporary distress, intoxication, treatable illness) can be devastating to family and friends. It may in fact be an event from which a sibling, a parent, a child never fully recovers.

We know that many social factors put people at higher risk:

  • inadequate housing,
  • inadequate support systems,
  • social isolation,
  • bereavement,
  • joblessness,
  • addictions.

These factors have no simple solutions but can be gradually improved through well-funded social programs, retraining programs, affordable housing.

We also know that many suicides occur in the population suffering from severe mental illness especially when:

  1.  Discharged from hospital prematurely,
  2.  Unable to be hospitalized in a timely fashion,
  3.  Drop out of treatment or go off medication,
  4.  Their illnesses are not identified nor adequately treated.

We also know a particularly tragic circumstance is the suicide of a teenager, often responding on impulse to something they see as catastrophic, life impairing, hopeless, even while we adults know the situation is transient and will get better.

So what should we do if we want to spend our money on programs that will ultimately make a difference to that completed suicide statistic?

I don’t think I can answer my own question in a blog, but I can start a grounded discussion.

  1. Easy access to family friendly mental health resources including hospital beds.
  2. Hospitals return to somewhat longer hospitalizations with discharge waiting until true stabilization and a good discharge plan. Stop the fast turnover and length of stay pressure.
  3. Better comprehensive outpatient programs for the seriously mentally ill (including PTSD), ensuring the best possible treatment and compliance with that treatment.
  4. Training, organization of services, physical environments that allow optimal detection and response to depression, anxiety and psychosis by family physicians and emergency doctors.
  5. Continue improving our alcohol and addiction programs.
  6. If there are to be government sponsored public education programs they need to counter the very loud voices denying the existence of mental illness, and denigrating medical treatment. They need to focus on parents monitoring their adolescents’ online activity. They need to focus on parents ensuring their adolescent does not have access to lethal weapons and substances.

As for the horribly high rate of suicides on our reserves and among our first nation peoples: I do not think they suffer from a higher rate of actual mental illness than the rest of our country. But all those social factors that increase risk are ubiquitous on many reserves:

  • Alcohol and drug abuse
  • Poor housing
  • Poverty
  • Severe unemployment and underemployment
  • Poor rate of attendance and completion of school.
  • Easy access to lethal weapons and lethal drugs.
  • Social disintegration and corruption.
  • The hopelessness and anger fueled by dependency.

We should study the reserves that are successful, and then work with the leadership of the first nations people to recreate these factors within less successful reserves. Throwing money at the problem does not help. Sending in more “mental health professionals” does not help. Responding to political whims and self-serving demands does not help. We need to help the leadership of these reserves find clear-eyed solutions or improvements to each of the social problems listed above.


Suicide Prevention – Thoughts For Practitioners

By Dr David Laing Dawson

I have written a blog before about suicide prevention, about many of the things we do that don’t really make a difference, and about where we could and should put our resources if we want to make a difference. But this is a blog about suicide prevention on the ground.

We can talk about suicide prevention in general terms but the one and only time a health care clinician can actually prevent a suicide is when an at-risk individual is sitting in front of him or her. Your patient, new or known to you, at your office, in your clinic, at the hospital.

Some emergency and rapid response services have mandatory checklists. Most clinicians are taught to always ask the question. Many family doctors are fond of using a self-test for depression with questions like “Do you think of suicide?” with check boxes ranging from “all the time” to “never.” And many clinicians contract with patients – that is they extract a verbal agreement from their patients to not harm themselves, at least not before calling.

My suspicion is that these activities provide a false sense of security for the clinician and do not necessarily make any difference to the outcome.

  • While asking and focusing on the checklist questions and filling in the boxes, and taking notes, a clinician may well miss what I will discuss later.
  • The direct question about suicide intent and suicide ideation yields far more false-positives than useful and truthful answers, to say nothing of a few false negatives.
  • How we answer those self-test questions depends more on how we want to present ourselves to the doctor than a realistic appraisal of mental state, especially when it comes to the question of frequency and future behavior.
  • And contracting with patients poses two problems: one is that it does not work. The other is a logical fallacy: If the clinician truly thinks that the only thing preventing his or her patient from killing himself is a private promise that he won’t, a promise that he won’t let the clinician down, then that patient should be in hospital. And clinicians who contract in this way should think hard about the boundaries, the limitations, the nature and impermanence of the professional therapeutic relationship.

But day to day,  mental health clinicians are faced with the difficult decision to act or not, with the anxiety of predicting human behaviour, in this case with a lethal outcome if they get it wrong.

Let me share with you what both good and bad experiences have taught me:

Rule 1: Be present when seeing a patient, be there, in the room, focused and attentive.

This may require, in many situations, a clearing of the head before entering the room, making sure other loose ends have been taken care of and are not nagging you. It requires an ability to be present in that room no matter how slow, painful, distasteful, or even boring the encounter is, or how many distractions  insinuate themselves . And it requires you to stay away from your computer screen, not take notes, and be quiet.

Rule 2: Talk less. Empathy, the ability to experience what the other is experiencing requires silent observation, watching the eyes and mouth, the movement and posture, listening to the tone, the cadence, the intensity, the timbre, the intention of the spoken word as much as the content.

Rule 3: Without directly asking, listen for the presence or absence of future references in your patient’s words, something he or she plans for next week, next year, tomorrow.

Rule 4: And lastly, watch for, listen for, let yourself experience, the presence of two emotions, the congruence of these two emotions if they are present:

Despair/hopelessness plus  dread/anxiety.

If both of these are present this patient is high risk for suicide. And to know these are both there, residing in your patient today, you have to be there yourself, attentive, present, open, receptive.

On the Efficacy of Suicide Prevention

David Laing DawsonBy Dr David Laing Dawson

In the past decade, make that two decades, we have witnessed a plethora of mission statements, lectures, programs, public health campaigns, TV ads, crisis services, anonymous telephone answering services, crisis lines, websites, information initiatives, task forces, white papers, all aimed at suicide, reducing the suicide rate in our communities, preventing suicide.

Yet the rate of suicides in Canada, completed suicides, remains statistically unchanged.

All of the above activities make us feel we are doing something about the problem. We are trying. But that is all they do.

The problem with a public campaign to prevent suicides is that it is akin to a public campaign to prevent heart failure. Both are end stages of other processes, but in the case of heart failure we know enough to target smoking, cardiovascular disease, obesity, hypertension, diabetes, rather than “heart failure”. We do not say, “Call this number if your heart is failing.”

We know the demographics of completed suicide. We know the risk factors. We know the specific and usually 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 treatment of those specific conditions so often responsible for suicide:

  • Some suicides are bona fide existential decisions, a choice to end one’s life of suffering: terminal illness, intractable pain, total incapacity.
  • Some suicides are the result of chronic complex social factors: unemployment, divorce, poverty, loss, alcoholism, addictions, isolation, and chronic illness. We can chip away at these factors with better support and rehabilitation services, improved minimum wage, retraining – but there is nothing we can do quickly and easily.
  • Some youth suicides are the result of impulsivity, intoxication, and an available instrument of death. Impulsivity comes with youth. Parents can keep an eye on intoxication. But we can make sure no instruments of death are available. Guns. Pills. Cars. Get rid of the gun(s) in the house. Lock up the serious drugs. Driving the family car is a privilege, not a right.
  • Some teen suicides today are the result of public shaming, bullying. Watch for this. Chaperone the parties. Monitor Facebook, Snapchat. No cell phones or internet in the child’s bedroom. It bears repeating: NO cell phones or internet in the child’s bedroom.
  • And then we have the specific mental illnesses that all too frequently, especially when undetected or under-treated, lead to suicide. These are Depression, Schizophrenia, Bipolar Disease, Severe Anxiety, PTSD, and OCD. And if we really want to make a dent in that suicide statistic then our programs, our money, our resources, should be directed to detection, comprehensive treatment, and monitoring of these illnesses.