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 


  1. "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."

    Very wise decision. It's startling how awful and wrong a lot of the early psychological autopsies on Robin Williams were. Some of the rushed touchy-feely articles on Psychology Today and other sites are downright dumb, urging people to get rid of the stigma against suicide, as if that's the same as stigma against mental illness or stigma against mental health workers (the touchy-feely articles are not helping our image). Stigma against suicide is good, for the same reason stigma against murder is good. It's well known that Catholic stigma (I am not Catholic BTW) does seem to have some protective effect. Another thing I am seeing a lot is using celebrity deaths to argue for more mental health funding. That wasn't an issue with Spade or Bourdain though it may be an issue in general. (I am skeptical about just throwing money without understanding at complex problems). I think a lot of educated people who parrot platitudes and cliches think they are deep critical thinkers. I don't want to say anything specific about the recent celebrity deaths but I already have suspicions that the early reports may be wrong on some major issues.

  2. Kirsten Powers wrote the following link in USA Today yesterday, and offer it as an interesting read at least.

    She wrote this: "We exist largely disconnected from our extended families, friends and communities — except in the shallow interactions of social media — because we are too busy trying to “make it” without realizing that once we reach that goal, it won’t be enough."

    As always, there are multiple factors to suicidal risks being elevated, and these days, being lead by more Personality Disordered people in positions of power and influence, well, who can maintain a level head being around inflexible, rigid, and disruptive "leaders"???

    Add the growing prevalence of substance abuse in this country alone, wow, we are stirring a brew that is literally and figuratively lethal.

    Just some thoughts...

    1. There are always a lot of social theories. There was a series in the British Medical Journal many years ago linking suicide to unemployment and of course Durkheim's 1915 classic Le Suicide. If the answer was out there and that simple - somebody would have figured it out by now. Adding epidemiology and statistics has really added nothing.

      We are bouncing around between population limits rights now. We know the gross markers of those limits but not much else. As long as we are within those bounds - I don't see anything useful in speculating about the social causes. It is not an epidemic and Durkheim covered just about everything that I have read in the current press back in 1915.

      We need to move on to a new paradigm or these inaccurate theories will just keep churning until the end of time. In the meantime we have to implement every public health appraoch that has worked - specifically the ones we all learned in residency about restricting lethal means.

      Politicians remain a threat to everyone's health.

  3. What I learned from Psychology Today about the deaths of Bourdain and Spade:

    1. Gun control is necessary to stop these events in the future even though ropes and belts were the instrument of choice.
    2. Increased mental health funding in rural areas are necessary to prevent these deaths even though these two had plenty of money, had been in treatment, and about as New York as you can get.
    3. The stigma against suicide (not depression) is a terrible thing (actually Catholics and Greek Orthodox have a lower rate because of stigma).
    4. Hotlines are the solution to everything.
    5. Apparently most Americans aren't "aware" that suicide is a problem.
    6. Suicide is the LEADING cause of death in the US (it's tenth and not even close to heart disease and cancer).
    7. Experts are great at giving sage and wise insights even though they know none of the details.
    8.Hastily written articles by people of questionable credentials are all about selfless concern for humanity and not virtue signaling.

    1. These general articles are horrible and leave the reader more confused than anything. I have seen more evidence today that evidence I presented in the vignette above the deterrence can be turned into non-deterrence is a common problem. There are a mind boggling number of these combinations and only very clear knowledge of the person can be used to make these determinations.

      The best outcome would be for the stories to either go away at this point or present a rational article. I don't see the latter happening any time soon.

    2. We should go back to Latin, left is Sinister, and if people can't figure that one out, then we are screwed.

      How do people practice psychiatry in 2018?...

    3. Even early on, I realized that the training and temperament of many people in mental health was abysmal and it has only gotten worse. Basically if you can fake compassion and parrot platitudes you've got it made. They condemn judgment while passing judgment on those of us with a more balanced viewpoint. They believe their blanket compassion alone can save people, the Freudian "devouring mother", and it's a lot of male therapists too who have fallen into this. The idea of "analysis" at any level, using logic to make sense of emotions is frowned upon in some circles. I often point out that if emotion was a reliable guide, the study of psychology would be unnecessary. A lot of horrible and horribly miserable people have followed their hearts to terrible places. Let's see how this "passionate" Arianna Grande/Pete Davidson thing works out.

  4. Your article had more substantive information and reason than all those pop psych articles combined.

    The most obnoxious one I saw was an "open letter" from a therapist to Kate Spade's daughter. The comments were brutal. I actually like it when sleazy virtual signaling backfires.

  5. You mean that people are all different and the reasons for suicide are all over the place and many of them are often fairly unique to the involved individual? And you have to do a complete psychiatric assessment of a patient rather than just have them fill out a checklist, and even then they can still be exposed to unexpected stressors after they leave the office? And you can't do a good assessment in 15 minutes? And psychiatrists in a shortage specialty have no power to say no when administrators with no training in the field tell them how to practice? Will wonders never cease!

  6. Dr. Allen, I agree with you. Given the supply/demand economics of the field, I have no idea why psychiatrists in private practice don't tell them (and KOLs who encourage this including Collabocare Lieberman) go piss off and mind their own damn business. I suspect many of us are still mentally acting like obsequious PGY1s. Jordan Peterson talks about how agreeableness (the 5PF trait) in women leads to lower salary demands and my take is that agreeableness in physicians/psychiatrists leads to abuse, poor working conditions and poor mental health care. The core conflict in medicine/psychiatry right now is that we can't be both agreeable and conscientious at the same time anymore.