Why Do We All Want to Die?

I use an ongoing spreadsheet to keep track of and to report my demographics and stats for each telepsychiatry consult shift I do.  I’ve done thousands of consults in over two dozen South Carolina emergency departments over the last half-dozen years. We have now gone over thirty thousand consults as a group.

It never ceases to amaze me, as I fire up my computer, log on to my systems and bring up that spreadsheet for the shift ahead, that one column is remarkably uniform and consistent, sometimes for days at a time. It is the column that asks for an abbreviated reason for the consultation request. It usually looks like this:

SI

SI

SI

SI

SI

SI

SI stands for suicidal ideation, and that is one of the most common chief psychiatric complaints that we see in the emergency department.

Sometime I am simply so busy trying to see all of these people (there was a multi-day stretch recently that we had up to thirty different consults queued up waiting for one of us to see them) that I cannot afford the luxury of slowing down, looking for trends, trying to analyze why we might be so busy during that particular weekend, and the like. There is just not time. However, it is hard not to see the obvious pattern created by the number of people who come into the EDs and state to a staff member that they want to kill themselves.

Why do we all want to die?

Sure, the world has its ups and downs and stresses, but there seem to be so many people who are bent on their own destruction lately that it is mind-boggling.

Allow me to posit some reasons for this disturbing trend.

We do not feel that we belong.

I heard something on the way to something else the  other day that stated that folks who are forced to check that box called “Other” on standard forms do not feel special when doing so. They actually can be made to feel apart, cast out, cut off from the mainstream, in that they do not fit any of the standard groups listed on such forms. To be “other” is to be different, odd, not a part of the group. It is socially and emotionally ostracizing. It means that we do not belong. That hurts.

We do not feel loved.

Okay, okay, I know that is shrink talk and too touchy feely for some of you, but hear me out. I hears over and over from folks in the ED that they do not feel loved by their parents, their spouse, their children, or anyone else. Once again, whether it is feeling like the “other” or not loved by anyone at all, it is a massive cause of self loathing, isolation and hopelessness that will drive someone towards not wanting to exist at all.

Everything seems too hard these days. Nothing is guaranteed.

It used to be if you went to school, graduated, kept your nose clean and played by the rules, you would almost certainly succeed in life. You would be able to find a job, you would have a place to live, you might find love and even raise a family. Today, it seems that none of this is guaranteed, and that for some it all seems just out of reach. Sometimes, people who appear at first blush to be lazy are just depressed, unmotivated, not well-trained, not educated, and simply down on their luck. They see little hope for success no matter how hard they try, so they don’t try. It is sometimes easier to just give up, find someone or something to blame, and give up, rather than really working to make things better.

We feel hopeless.

Hope keeps us getting up in the morning. Hope keeps us going to school, working our way up the ladder, doing the jobs that no one else wants to do, taking on challenges that we are afraid of. If we lose hope, we have lost our will to challenge ourselves. We have lost our dreams for the future. We have lost our ability to see ourselves in the distance, happy and healthy and successful.

What exacerbates these core states and feelings? What makes it hard to fight back and move past them? What do I see most often in the emergency department when someone has come in after cutting, swallowing a bottle of Tylenol, or drinking themselves into oblivion?

Relationship problems are always in the mix. A teenager breaks up with the love of her life and now thinks that life is over. (She cuts herself on the arms and legs where no one can easily see her attempts to deal with her pain). A middle-aged man is a raging alcoholic but has no insight into how this is devastating his family. His wife leaves him, taking their three small children with her. He comes in with a blood alcohol level five times the legal limit. An elderly man has just lost his wife of sixty years to cancer. He is quite literally lost without her, and he does not want to go on. He is a retired police officer, owns several handguns, and knows how to use them.

Financial problems and reversals can produce high levels of anxiety that seem insurmountable. Some folks are almost paralyzed by just not being able to buy gas for the car or groceries for the kids this week. Others may be more well to do, but the shock of losing value in their retirement portfolios or not being able to make the mortgage payment on a huge house that they really cannot afford leads to guilt and shame and feelings of failure. Both can feel like the easiest way out is to simply not be here any more.

Some patients are dealing with chronic mental or physical conditions that they are simply tired of. The ups and downs of bipolar disorder, the pain of congenital spinal malformations, the physical and emotional trauma of cancer and its treatment can all lead to feelings that it would just be better to end things on your own terms rather than waiting on the  diseases to decide when it is time for you to die.

Perceived failures and disappointments (both disappointing yourself or others) often leads to the mistaken notion that if you kill yourself, the problem goes away for not just you, but everyone involved with you. The thing that most of these folks have not thought about to any degree is the pure devastation that is left in the wake of a suicide. The family members, spouses and friends who must live on after you are gone must ask all the hard questions, the “what ifs”, the whys. The guilt and emotional suffering they feel is tremendous and it never really, truly goes away.

Fear and anxiety drive many suicide attempts. Odd, in that most people think that only those who are severely depressed kill themselves. Anxiety, severe and unrelenting, actually leads more folks to actually successfully complete an attempt than depression. The underlying shame, guilt, or other emotions that drive the anxiety are often not discovered in time, or are so well hidden by the patient that it is only after the successful suicide that these are uncovered and better understood, often from the note or other communication left by the deceased.

What is the common feeling that weaves its way through it all? Hopelessness. If you think that there is no way out, that there are no viable solutions left, that you have exhausted all reasonable possibilities for making your situation better, then that gun or bottle of pills or telephone pole look like rational and logical answers for your unanswerable questions. You give up. You quit looking for answers. You feel lighter, happier, more confident because you have made that decision to just let it all go. If there is no intervention, swift and appropriate, you will die.

What are all these stresses and problems complicated by, as if it could get any worse?

One of the most common accelerants for suicidal ideation and attempts is intoxication with alcohol and other drugs. Decreased inhibitions, poor judgment, impulsivity and poor decision-making all lead to potential problems when one is already contemplating self harm. If you are already stressed, at the end of your rope, and contemplating ending it to escape the anxiety and pain you feel, reach out and get help. Drinking, smoking and popping pills rarely makes things look better.

Poor social support is another major deficit that exacerbates suicidality. I see countless patients who truly do not have family, friends, church or anyone else they can call on in time of need. They are really, truly alone. Isolation and disconnection from other people kills.

Lack of access to care also makes things worse just when the help is needed the most. The shrinking of available mental health resources in this county has lead to a dearth of programs that address acute illness and this does not bode well for someone who needs help now, not three weeks from now or at the next available appointment time.

Concomitant mental and physical illnesses can spell disaster. Those dealing with longstanding cardiac disease, severe diabetes, metastatic cancer, and other devastating illnesses may be overwhelmed with the emotional counterpart of the illness and if not noticed or addressed, it may steadily worsen and become malignant itself.

What to do if you find that you are one of those people who is thinking that death looks like your only option?

Call 1-800-273-TALK.

Talk to your family, your girlfriend, your husband, your minister or priest.

See a psychiatrist or other qualified mental health professional right away. If you are turned away when you call, call somewhere else. Don’t accept anything less than an option for immediate assessment. This is your life in the balance, and it is important.

Suicide kills over forty-four thousand people in the United States every year. For each completed suicide there are twenty-five attempts. On average, there are over one hundred twenty suicides per day in the US.

There are many reasons that many of us really want to die.

The job for the rest of us is to convince those folks on the edge that there is help.

There is treatment.

There is hope.

 

 

Death, Where Is Thy Sting?

In 2014, the suicide rate in the United States was 13 per 100,000 people, the highest recorded rate in 28 years. Over that year, 43,000 Americans killed themselves. The U.S. suicide rate also rose 24% over the 15 previous years (1999-2014), with the rise correlated to the period’s severe economic slump.



Wikipedia



I am getting ready to enter a five day stretch of work, during which time I will spend fifteen hours in mental health clinics, up to seven hours in probate court related evaluations, and thirty seven hours doing telepsychiatry consults in emergency rooms around South Carolina. If past history is any predictor of future trends, which it always is, then many of those hours in clinic and ED will be spent assessing suicide risk. 

Threatening to commit suicide can be a cry for help, a manipulation to control an estranged spouse, a last ditch effort to control debilitating anxiety, the only perceived way out of a drug addiction, or a gamble that one might be admitted to a secure hospital when one has no where else to go. It may also be, unfortunately, the successful ending of one’s life by one’s own hand. 

We see various forms of threats. Let’s me say right off the bat that ALL threats should be taken seriously. ALL. 

There are teens who cut themselves. Although some folks do indeed cut themselves seriously enough to to die, most of these self-identified cutters do so to control anger, stem impulsive and destructive urges, or to “just feel something”. 

There are others who have suicidal ideation, real thoughts about dying, without any specific plan or intent or mean to carry out the threat. 

Other groups have suicidal ideation, specific plans, and means to carry out those plans. These are often considered gestures if they involve non-lethal methods such as swallowing a small amount of household cleaner, burning oneself, or trying to drown oneself in the bathtub. Again, some of these gestures can be inadvertently lethal, such as when a preteen decides to take a whole bottle of a “safe” household drug like Tylenol, shuts down her liver and dies. 

Then there are the more serious attempts, such as overdose with a lethal amount of an antidepressant (one week’s worth of some such pills is enough to cause death), hanging (still one of the most common methods used in jails), and self inflicted gunshot wounds. I have seen patients who tried to hang themselves and succeeded only in causing anoxia severe enough to cause permanent brain damage. I have also seen a police officer, well trained in the use of guns, attempt to kill himself by pulling the trigger of a shotgun with his toe, only to have miscalculated the kick of the weapon, blowing his face off but leaving him very much alive. 

The most serious of suicide attempts, the ones who succeed, often give you clues to the act before they carry it out, but manage to succeed anyway. They are often middle aged to elderly men, divorced or widowed, with medical problems, a history of depression, substance abuse, taking antidepressants and who have made some contact with a healthcare provider within days of killing themselves. These men are disconcerting, because they are often resigned to the fact that they are going to die, are relieved and even happy about it, are firm in their convictions and plans, and are very likely to be successful. I have seen some of them leave all the bills paid, the financial and other documents neatly organized on desk or disk drive, and have a letter, will, and other documents laid out for easy discovery by their grieving families. 

Who kills themselves the most? 

Men. 

For every one completed suicide, there are about twenty five attempts. Often, these are women using overdoses, cutting or other attempts. Men tend to use guns, although women are catching up to them in that department. Firearms account for almost fifty per cent of all suicides. White males accounted for seven of ten completed suicides in 2014, and middle aged to elderly men are still the most at risk group of them all. 

Women attempt suicide three times more often than men.

Men die of suicide 3.5 times more often then women.

Obviously, suicide attempts and completions are still a huge problem in the United States. 

Suicide is the tenth leading cause of death in South Carolina, where I practice psychiatry. On average, one person dies by suicide in this state every 11.5 hours. Our telepsychiatry shifts cover eighteen hours per day. 

The rate of 15.13 suicides per 100,000 people is higher than the national rate of 12.93. 

I will go into this long working stretch knowing that the odds are stacked against us, but that we can make a difference if we listen, intervene, and try to catch those who feel that suicide is the only way out. 

If you or someone you know is suicidal, please seek help through your local emergency room, through your doctor, or by calling the National Suicide Prevention Lifeline at 1-800-273-8255.

Any Given Day

I love football.

There is one thing that I absolutely believe to be true about the sport I love.

Any given team can beat any other team on any given day. 

Sometimes my love of sports and the little metaphors that sprout from it spill over into my workspace as well. 

At the end of each shift I work in telepsychiatry, one of the last things I do is complete an electronic log of the consults I worked on and completed that day. I list the initials of the patients and the demographic information about them for the bean counters who hang out in Columbia making sense of what we clinicians do every day. I add a few diagnostic codes, and then I also look at a little drop down menu that allows me to describe in a few simple words why they needed to see me in the first place. The reason for the consult. 

On any given day, the pattern that jumps out at me is something like this:

Danger to self.

Danger to self.

Danger to self.

Danger to self.

Danger to self…

In other words, the vast majority of folks I see on any given day want to kill themselves. They are suicidal. They have tried to slit their wrists or overdose with pills or drink bleach or hook hoses up to car tailpipes or shoot themselves in the chest. 

Now, most days I am pretty circumspect about my job. I know that it is stressful. I realize that it puts me at risk myself to hear story after sad story about the woes and trials and tribulations that my patients bring and leave at my feet. Anyone who knows me, has had a conversation with me or reads me knows that I am a person who loves stories. I love to hear them. I love to tell them. I love to write them. I will go back to work at the clinic this morning because I know today, through stories, I will learn something that I did not know yesterday, something that I can use to help someone else tomorrow. 

On any given day, however, the stories can be so bad, so terrible, so hopeless and so horrible that they try their very best to not only beat me up, but to beat me. Finish me. Pummel me. Make me quit. Send me packing. Some days I feel defeated by them. Some days I am flat out of answers, suggestions and positive statements. Some days I slink out the back door, swiping my little electronic card to get out, half hoping that when I come back the next day it will malfunction and not let me back in. 

But you know, if this list of woe, this chronicle of misery can beat me yesterday, then today is a new day. It can be my time to come back, march down the field, score a last minute touchdown and win the game. On any given day, I can be the one who comes out on top, not the misery that the world would throw at me by way of my chosen profession. 

I saw a lady yesterday who is very, very ill. She is sick physically as well as emotionally. She knows this, and it torments her. She cannot do what she used to do, no, she will never be able to do those things again. She is depressed, sad, sometimes hopeless, sometimes suicidal. She has been in counseling. She has taken medications. She is only marginally better. She is worried that nothing is going to work, that she will never feel good again. 

I could sit there with her and commiserate, feeling sorry for us both, the defeated patient and her defeated doctor, helpless in the face of one of the illnesses that lead to more than thirty thousand suicides a year in this country. I could write her off as just another very, very difficult case that I don’t know how to solve, how to fix. 

That’s not why I went into medicine.

On any given day, my job is to be there for her, this lady who came shuffling in with braces and cane and aches and pains and depression to see me when she’d rather have stayed at home hidden away from the world. 

On any given day, my job is to be there with her, to listen to her story, find something in it that will guide me and teach me how to best help her. 

On any given day, my job is to try, and try, and try again, until there is no more time on the clock.

That is the only way to win, in football, medicine and life.