Saturday, June 9, 2018
Conscious States and Suicide.....
When I first starting writing this blog - I decided that I was not going to make the common mistake of using celebrity tragedies as a springboard for posts. I have been very pleased with that decision. Given recent events - it is evident that people who use that approach are speculating and either don't know enough of the details or make sweeping statements that they could have made without any specific reference to the person or their family. It is also evident that in some cases, the potential for damage to the survivors is great and should be avoided at all costs. The only rationale that I hear is they were celebrities and the people want to know.
I will comment on the mystery of suicide. How is it that a highly accomplished person with ample resources and even supportive people and family in their life can make a decision to take their life? The press has settled on a couple of unsatisfactory answers that flow from the risk analysis approach to suicide. In other words, let's look at number of modifiable and unmodifiable correlates of suicide attempts and use those in an analysis of a specific death by suicide. After the fact it is basically a fishing expedition trying to fit the pieces together in a way that there is a logical and linear story about how the incident unfolded. If the person is famous enough there may not be a final judgment until the autopsy toxicology comes in many weeks later. Even if a coherent story is constructed, the story may be debated for years on cable TV shows that have medical experts second guessing real time experts.
Serious and intractable disorders and impulsivity is a big part of the current media story. I had somebody ask me today: "Is it true that people just make the decision and in 5 minutes they are dead?" People tell me stories about Golden Gate Bridge jumpers who survived to tell about it and that is what they reported. All of the stories are very linear - there is a precipitant and then depression with depressed moods and then an impulsive suicide attempt.
Psychiatrists are trained to recognize and treat all of the major disorders that are thought to increase risk for suicide including substance use disorders. We are also trained to be optimistic about the treatment and consider these diagnoses to be modifiable - if they are treated correctly they will respond to treatment and improve thereby reducing risk for suicide. Overall psychiatrists are successful in that approach as evidenced by reduced suicidal thinking and in some cases behavior that is directly observable in hospital units. Self report by patients is another valuable metric that is rarely talked about. Patients can at some point say: "I seriously contemplating suicide and had a plan to kill myself until I came here for treatment." or "During my last pregnancy - at one point I was going to kill myself. I don't want that to happen again. I want to have a plan this time to prevent that from happening."
From an epidemiological standpoint, psychiatrists in general treat people who are at much higher risk than the general population for suicide. The CDC, just came out with data to show that the suicide rate in the USA from 2014 was 13 per 100,000. Many of the disorders treated by psychiatrists have lifetime suicide rates of 10-15%. In a cohort of 100 people with the disorder, 10-15 are expected to die by suicide over the course of their lifetime. Suicides by people in active treatment by psychiatrists is rare relative to those numbers but they do happen. They are more likely to happen during transitions between care settings like hospital discharges or when care is fragmented. They are more likely to happen when there are destabilizing factors in the person environment and easy access to highly lethal methods of suicide - like firearms.
Even in the case where a person has survived a potentially lethal suicide attempt it may be difficult to piece together what has happened. Consider the following case. John M. is interviewed in his hospital bed by a consult psychiatrist. Three days earlier he shot himself through the left shoulder with a handgun and barely survived. He has extensive damage to the structure of his left shoulder and it will be a while before his surgeons can advise him on whether to not it can be reconstructed. It is clear that he has been depressed and somewhat paranoid for years. The psychiatrist asks him about the injury.
JM: "I guess I shot myself?"
PSY: "Can you tell me about the sequence of events?"
JM: "Well - I was feeling very depressed. I thought about calling my parents but they have done too much for me already. I started to think that I was not worthy of their help anymore. I feel worthless and like a burden to my family. I knew they would miss me - but at some point you realize sure they will feel bad for awhile, but they will get over it in a while and the burden will be lifted. At that point I thought I would get out my .44 and shoot myself in the chest..."
PSY: "Tell me exactly what you were thinking.."
JM: "Like I said I felt hopeless and like I was a burden. At some point I realized that I was pointing the gun at myself. I knew I did not want to shoot myself. I have a nephew and I wanted to see him again. And then the gun just went off.."
PSY: "The gun went off? Don't you remember pulling the trigger? Were you holding the gun in your right hand or your left hand?"
JM: "I am right handed. I was holding it in my right hand and pointing it at the center of my chest."
PSY: "Do you remember what you thought when you pulled the trigger?"
JM: "I don't remember pulling the trigger.... One minute I see my hand and wrist and the gun barrel and then it goes off and I am on the floor bleeding."
Further discussion of the incident does not provide any further degree of clarity. The psychiatrist has to come up with a diagnosis and a formulation as well as a risk assessment of future suicide potential. There are several diagnostic possibilities including mood disorders with or without psychotic features including substance induced mood disorders. Alcohol, stimulants, and opioids can all cause acute suicidal thinking during intoxication and withdrawal states. The suicide assessment is basically a collection of risk factors that at the time of this interview may not be entirely relevant. For example, the patient in this case did not have any suicidal thinking at all and was pleased that he had survived at the time of this interview. Irrespective of all of those considerations there may be some psychiatrists who would be comfortable discharging the patient at that point. I am not one of them. In this case I would opt for a more detailed assessment and period of observation and an attempt to restore the person to his baseline level of functioning.
In acute care psychiatry, we talk a lot about baseline and cannot always achieve it. People my not be aware of the fact that they are not at baseline, insist they are fine, and want to go home even if they are at high risk. People may not want to access help in the first place for the same reason. We can only assess baseline very indirectly. The best current way is an extended conversation with a person who knows them very well. Is their social behavior and personality the way it should be? How do they differ from that.
This baseline that we refer to and assess only peripherally is critically important when it comes to suicide risk. We are actually referring to the person's conscious state. There are no ways to assess baseline conscious states. All of our energy has been focused on extreme psychopathological states and the handful of criteria that are used to define them. By way of contrasts the human brain is designed to generate billions of unique conscious states - no two are ever alike because these billions of states have all had unique life experience to think about. There is no universal agreement -even among researchers about how to define conscious states - but discussing the contents of consciousness is a fairly universal approach. I typically ask students to imagine their own stream of consciousness and why it night be unique. But that is only part of what defines a unique conscious state. Subjective experience is another. Unique subjective experience is diametrically opposed to the usual methods in psychiatry of trying to index disorders based on a handful of common features. A person's unique experience is much less likely to be recorded anywhere in today's era of rationed psychiatric care and poor documentation. Conscious states are also subject to perturbations that are transient based on internal and external conditions. In the case of suicidal thoughts, in my thousands of interviews of people the most common reply I get is: "Yeah - I have had a few suicidal thoughts -hasn't everybody?"
In this era of inability to assess and essentially predict a person's conscious state it should not be surprising that we have only the most basic knowledge about the assessment and treatment of suicide potential. We are generally using a very crude risk assessment and many of the variables may be unchanged for years. It is not like an actuarial assessment for insurance purposes where the outcomes and statistics are not that dynamic. In the case of suicide assessment, we don't know all of the variables, the number of variables is large, and we may not even know the person's baseline conscious state unless we have known them for years. To further complicate matters - they may not be able to tell us about their baseline state until they have recovered it and recognize that they have changed. The change we are interested in is going from a state that would never consider suicide to one that would.
The media storm around recent events, will seem to provide a number of pat answers based on society, culture, pop psychology, and special interests. They seem to ignore the fact that in any given society, these rates rise and fall. The current rate was the same in 1950 and 1970. Moreover American society is intermediate relative to the rest of the world when it comes to suicide rates. Some countries with more psychiatrists per capita have higher suicide rates.
On an individual level, suicidal thinking especially if it is combined with of other psychiatric symptoms is a red flag. It suggests that a person should try to obtain professional help. There is no easy way to discuss the consciousness issue on more than a fragmentary basis at this point. I do try to discuss it with people as a risk factor, but if they are in an altered state they may not be able to hear what I have to say. The current practical approach is to listen carefully to people who know that person well and have their best interest in mind.
A reasonable pathway to assessment and treatment is paying attention to any changes that a concerned third party may have noticed and if that person with the problem can't see it - get a neutral third party professional involved and give them all of the information.
George Dawson, MD, DFAPA