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.

 

 

Do the Right Thing

It’s a fine line that we walk as physicians. 

I went into medicine because I wanted to learn about the craft, become proficient at healing disease and easing suffering, and because I genuinely liked getting to know more about my patients and hearing their stories. These reasons for going into medicine as a career and staying in medicine as a vocation have not changed significantly through the last three decades. 

The problem we are faced with pretty often nowadays is this: the demands that patients (and through them insurance companies, pharmaceutical companies, families, and other third parties) make are often at odds with what we were taught to do. I’ll give you a few examples. 

Patients will come to me and ask for a specific diagnosis. Why? Because sometimes their insurance will not pay for a less severe diagnosis (an adjustment disorder versus a major depression, for example), they do not want to be perceived as being in treatment for an alcohol or other substance abuse problem (no matter how valid it is), or they need to be seen as having a particular problem because their attorney told them that it “would look good” for their disability case or other lawsuit. 

Patients will come to me asking, or sometimes outright demanding, that I prescribe a particular drug for them. Telling them that I do not presribe narcotic pain medications in a mental health clinic is easy enough. When they ask for benzodiazepines like Xanax, Ativan, Valium, Librium or Klonopin, the area might be grayer. Some patients might benefit from those drugs or even need to be on them long term, but they are the exceptions nowadays. “If you won’t given them to me, then I’ll just go to Dr. Jones down the street!” they exclaim, thinking that this is somehow a threat to me. Or, “I know that you give them to Ms. X from across town. Why won’t you prescribe them for me too?” 

Direct to consumer advertising on television has not made this any easier, since patients will come in asking to be prescribed powerful antipsychotics for insomnia or pain medication for panic attacks. What they are asking for often makes little sense clinically, but of course since they saw it on television it must be true and I should get out the RX pad. 

Some patients come in demanding a particular kind of treatment that they think makes the most sense for them. Aunt Sara may have told them to ask for it, since of course she took Psychology 101 in college and has the power of the Google search behind that vast amount of training, or they have read about it in Vanity Fair, or a friend of a friend of a friend had the particular treatment years ago and it worked for them. Some will want long term therapy when it makes little sense to drag things out for years when weeks or perhaps months will address the problems at hand. Some will want outpatient treatment when it is quite clear that they need to be admitted to the hospital. Others, already on an inpatient unit, will want to stay there for weeks, when the right thing clinically is to discharge them to an outpatient clinic. Some will ask for “counseling” when it is imperative that they enter drug rehab for a heroin problem that they do not want to acknowledge.  

Some patients want a specific kind of relationship, that is, they would like to consider the doctor their special friend, not their physician. Others like to consider themselves the medical, diagnostic and therapeutic equal of their physician, since they can and do research everything online, sometimes in real time on a smartphone while they are sitting in the exam or consulting room! Some of course want a clinical relationship to move to a friendship and then perhaps an even more intimate relationship, which is never appropriate in my opinion. I was taught, once a patient, always a patient, and I still subscribe to that maxim today. 

It is hard to do the right thing, in medicine and in life.

So what is a conscientious and well-trained and compassionate doctor to do?

Establish a professional doctor-patient relationship first, before doing anything to treat any malady. This means seeing the patient, getting a thorough history, doing an examination as indicated, establishing a diagnosis and coming up with a treatment plan. No shooting from the hip, sidewalk consulting and doing something for a friend. These will come back to bite you. Although some would not agree with me, I have not made a practice of treating my own family over the years either. If my children were ill, I figured a well-trained, trusted pediatrician was a much better option than a slightly frazzled, worried parent who happened to also be a doctor. 

As far as medication treatment goes, I have always been very conservative. If a mother is pushing for a three year old child to be put on stimulants for “ADHD”, I will balk. If a woman pregnant in her first trimester is pushing for Xanax to help her deal with the marital conflict with her husband because of the pregnancy, I will recommend counseling, not benzodiazepines. If someone who is not psychotic is having trouble sleeping, I will be much more likely to give them a two week course of a sleeping pill than put them on the small dose of a major antipsychotic that they heard about on television. What you’re treating, and not treating, is important. Efficacy and potential side effects are important. 

It is very important to tailor the treatment to the illness diagnosed, the symptoms that are being targeted and the outcome that is expected. 

Lastly, as alluded to above, the relationship between doctor and patient must be held to the highest standard of all. It should be professional, respectful, and collegial. We are partners, but by definition we are not equals in the process. You know yourself better than anyone in the world. You have information that you must impart, and I have decades of experience and learning and training that I must share with you in order to help you get better. 

If we are honest and work together, treatment happens, illness is managed, and patients recover. 

It is only then that it is much easier to do the right thing. 

Would You Like Sides With That?

SIde effects are weird things. 

Now, when I prescribe medications for patients, one of the things I always do, after talking about the reason for the med, the dosing, the cost and the the like, is to discuss the most common side effects that I expect they might experience. Why? Because they are likely to have one or more of these obnoxious effects, and if I predict them in advance it makes me look like a smart guy. 

I was taught in medical school that “if you hear hoof beats, look for horses, not zebras”. Or, stated another way, “common things are common”. 

I always tell patients NOT to go home and Google the drug I have prescribed for them. They will be hit with every side effect in the book, legalese out the wazoo, and they will come away afraid to take not just that medication, but any medication that anyone might prescribe for them in the future, ever! I ask that they trust me to give them the lowdown on how the medication should work, how long it will take, and what very common side effects they are likely to see. 

Dry mouth, dizziness, weight gain or weight loss, hair loss, dry skin, sedation and confusion are all side effects that I might mention to a patient. 

Note that these are side effects of the medication itself

But what about side effects of another kind? Side effects of the treatment as a whole? 

By this I mean, what if the patient, after adequate treatment, starts to evidence behavior that he or his spouse or family is not expecting, and even dislikes? What do I mean by this?

Well, if a very depressed woman starts to get better, feels like going out and demands that her couch potato husband take her to dinner and a movie once a week, when he’d rather stay at home, that might be a problem. Her treatment has been very successful, she is more energetic, her interest in doing things has picked up and she is more assertive in asking that her spouse accompany her to do these things that she wants to do. He got used to the “old” her, the person who was lethargic and passive and never made demands on him. He does not like this “new” less depressed wife he now has. This is a side effect of the treatment that is unwanted, in the husband’s opinion.

What if a young woman who has schizophrenia is put on medications and in therapy groups that begin to slowly help her get out of her social isolation and enjoy being around others, even members of the opposite sex? Once again, her parents have gotten used to her being at home,  watching TV on the couch all day, for the last decade. Now, she wants to get out and go places, see people and even date. They are worried that she might even want to have (gasp!) sex! To them, she seems manic, out of control, hyperactive, when in fact she is now able to act like a normal young woman her age and experience things that she never expected to again. 

Side effects can come from medications, from the treatment as a whole, and sometimes can be seen as negative, even when to the patient thinks things are going much better. 

As in many aspects of mental health care and treatment, communication about these kinds of effects and behavioral changes should be attended to early on so that doctor, patient, and family are all on the same page. 

Repeat Offenders

I don’t like being told what to do. 

Those of you who know me, know that about me. ( I was told by a friend today that I have mellowed considerably in the last several years, but bear with me for the sake of this post, please)

Talk to me, give me the information I need, reason with me about it, let me think it over, then get the hell out of my way. 

I will make my own decision, I will make it on my own way and in my own time. And yes, I will own it. The consequences, whatever they may be, are mine and mine alone. I get that. 

Huh. 

Funny.

The theme for the day was readmission. 

Like, how many times can I possibly get myself admitted to the hospital, sometimes the same hospital, in the shortest amount of time? How many times can I stop my medication, the same medication that got me stable the first and second and third times I was admitted to the hospital, and relapse? How many times can I threaten to attack a police officer, kill my uncle or threaten to poison my family with kerosene-tainted food before someone either takes me out or locks me up and throws away the key? ( no fear of the latter, at least in the state of South Carolina-we no longer have enough long term hospital beds to do that to people)

Most of the eight patients I saw today for probate court evaluations had issues with noncompliance, or nonadherence in politically correct speak, relapse, not taking medications, lack of insight, or just pure stubbornness. 

Huh.

Funny.

Patients come to see me complaining of many kinds of symptoms, including depressed mood, anxiety, insomnia, hallucinations, paranoia, suicidal thoughts, and lack of energy. We talk. We brainstorm. We swap ideas. I advise. They question. We compromise. We devise a treatment plan that we can both live with. In my case, that plan often involves the prescription of medication therapy. I prescribe it. They agree to take it.

And then they don’t.

Even though they still feel miserable. 

They get admitted again.

Huh.

Funny.

Maybe my patients don’t like being told what to do. 

Maybe they want to tell me, “Talk to me, give me the information I need, reason with me about it, let me think it over, then get the hell out of my way. 

I will make my own decision, I will make it on my own way and in my own time. And yes, I will own it. The consequences, whatever they may be, are mine and mine alone.”

I get that. 

Maybe that’s exactly what I need to do with more of my patients.

Discuss.

Empower.

Support.

Repeat.

Disorderly Conduct

My friend Jordan Grumet wrote yesterday about a house call, a visit on someone else’s turf, as he put it. Read this short but poignant post, The Home Visit, here. 

This post stirred something in me, as Jordan’s posts often do, especially in light of my own recent thinking about the new year and what it means to me and how my life is run. As I have recently written, at this time of the year I think about putting things in boxes, into their proper places, just as his cancer patient had her home arranged just so, everything in its place. I pride myself on keeping a tightly orchestrated to do or reminder list, following it, organizing it by date or priority, and not letting things fall between the cracks. Everything in its place. Everything with its appointed timeframe and due date and project goals mapped out for me. This usually works pretty well. I feel comfortable with my work load, how it flows, and my ability to get things done. 

However, I practice medicine, and a type of medicine that can be very unpredictable just by its very nature and the type of illnesses I see and deal with every day. Just when I think that I have my schedule mapped out for the day, a code blue is called as a teen is having a seizure out front on the bench in the freezing cold. I excuse my self hastily from the present appointment and patient in my office, walk briskly towards the front of the building, and deal with whatever I find when I get there. When the paramedics and ambulance arrive and the child is safely loaded up for transport to the local hospital emergency room, I go back to my appointment, shifting gears quickly as my pulse comes back down to normal range. 

I carefully orchestrate my schedule for the first month of the year, coordinating two jobs that usually mesh together tolerably well, filling up each patient slot for the next six to eight weeks ahead. There is little room for error, few slots for extra duties, and very little wiggle room in general. Funny thing, that, because my third grandchild is due in the next forty eight hours, and I don’t think he or she will care much about what my schedule looks like on Tuesday or Wednesday or whenever the delivery date turns out to be. I will juggle and reschedule and make time for the trip to be with my family because that is most important to me. I will make it all work somehow. 

I will do my best this year to advise my patients on the best treatments available for their presenting complaints, utilizing the available evidence base and my own experience and crafting the best treatment plan I can for each patient who asks for my help. The problem with this is that mental illness is insidious, chronic, and debilitating. It affects mood, judgment and impulse control. No matter how diligent I am, no matter how good the plan is, sometimes it will fail. Like Jordan’s patient with cancer who decided not to have surgery or chemo or other “disorderly” treatments, my patients will decide to stop their oral medications, not come in regularly for their injections, forget to get blood drawn for lab work, and decide not to attend AA meetings after all. 

Medicine, again by its very nature, has a certain amount of built-in entropy. We schedule and plan and scheme against it, but to no avail. Sometimes things just don’t go our way. We doctors are trained to diagnose and fix things, to problem solve and make decisions and move logically from one problem to the next to the next. When this happens, we feel smart and happy and powerful and in control. When it doesn’t, we get irritable and angry and depressed and then we are not at the top of our game. 

Like Jordan, even if things don’t go exactly my way, I would still rather they are clean, crisp and orderly. The patient with schizophrenia may not live as long a life as I wish he would live, since he does not take care of his diabetes, he drinks too much and he goes off his medications every few months. The patient with bipolar disorder will get manic at intervals and spend too much money, end up in jail, or take a cross-country trip that has family and friends worried sick about her. These things will happen. 

I will still see them when they come back, get them back on track with a reasonable treatment plan, write the prescriptions for medications that should help them, and schedule them to come back to see me the next time, wanting to believe that this orderly way of doing things will keep the disorderly conduct of illness and infirmity at bay for just a little longer. 

In this new year, I hope that Dr. Grumet and I, and all of our colleagues, are successful at doing just that.