Williams' Tragic Death a Reminder Suicide Risk Is Pervasive

Pam Harrison

August 14, 2014

The death of actor/comedian Robin Williams at age 63 is a tragic reminder that the risk for suicide is pervasive, particularly among white, middle-aged men, experts say.

"There are good data available that show that baby boomers — particularly white males between the ages of 55 and 64 — have the highest rates of suicide of any demographic in this country," Prakash Masand, MD, president, Global Medical Education, New York City, told Medscape Medical News.

According to the Centers for Disease Control and Prevention (CDC), in 2011, there were more than 28,000 completed suicides among white males vs 7600 among white females and fewer than 2000 among black males.

"If you tried to create a profile of someone at high risk of committing suicide, one likely example would look like this: A middle-aged or older white male toward the end of a successful career who suffers from a serious medical problem as well as chronic depression and substance abuse, who recently completed treatment for either or both of those psychological conditions and who is going through a difficult period, personally or professionally," write Lenny Bernstein and Lena Sun in the Washington Post (August 12, 2014).

Deadly Diagnosis

Robin Williams fit that profile perfectly. Reportedly a heavy cocaine user at least up until the death of friend and fellow actor John Belushi and a relapsing alcoholic, according to Mark Breslin, cofounder of the Yuk Yuk's chain of comedy clubs who knew the former comedian well, Williams was also apparently bipolar, according to a number of news reports.

Harry Croft, MD, a psychiatrist in private practice in San Antonio, Texas, told Medscape Medical News that even if that diagnosis has not been officially verified, "you just had to watch Robin Williams and wonder whether he wasn't bipolar at least sometimes."

And bipolar disorder (BD) can be a deadly diagnosis — literally. According to an expert interview conducted by Medscape Medical News, on average, 1 suicide occurs for every 30 attempts in the United States.

"In bipolar patients, it's 1 suicide for every 3 attempts...so in patients with bipolar disorder, their attempts are 10 times more lethal," Jan Fawcett, MD, professor of psychiatry, University of New Mexico School of Medicine, Albuquerque, told Medscape Medical News.

"The combination of depression and substance abuse is a particularly lethal one and is associated with a much higher rate of suicide compared to depression alone," said Dr. Masand.

At least one explanation behind the high risk for suicide in middle-aged white men might be the way men in general express depression.

"Men in particular self-medicate, especially with alcohol," said Dr. Masand. Men also deal with depression differently than women. For example, studies have shown that men are more likely to become angry and irritable in response to depression compared with women, who are more likely to feel sad, hopeless, and worthless.

Treatment Gap

Recent evidence also suggests that because men do not meet standard diagnostic criteria for major depression, they are likely to go undiagnosed ― and untreated. Even if Williams had been correctly diagnosed with BD, both physicians concurred that bipolar depression is probably one of the most difficult illnesses to treat in psychiatry. "Bipolar patients simply require a lot more 'TLC,' " said Dr. Croft.

This is borne out by the fact that in the United States, there are only 3 Food and Drug Administration (FDA)–approved drugs for the treatment of bipolar depression compared with perhaps 40 or 50 FDA-approved drugs for the treatment of unipolar depression.

"Antidepressants in general do not work in bipolar depression, they only work in unipolar depression," Dr. Masand cautioned.

Despite this, most patients in the United States with bipolar depression are treated with antidepressants, he added. "So there is a huge gap between what's happening in the real world and what evidence says we should be doing," Dr. Masand said.

It is not clear whether Williams was receiving treatment — appropriate or not — at the time of his death. But, Dr. Croft noted, news reports about the actor's suicide indicated that Williams was revisiting Hazelden, a highly prestigious addiction treatment center, around the time of his suicide.

"Hazelden is probably the best treatment center in the country," Dr. Croft observed. And although Williams apparently was going there to maintain his sobriety, "I'm not sure what that means," said Dr. Croft, "but part of what's going on in my mind is, maybe he went there because he was depressed or was in bipolar depression."

If Williams was seeking medical care, even if disguised as seeking treatment for addiction, he was again smack dab in the middle of the usual pattern of people who commit suicide.

"After a certain age, a very high percentage of people have seen a medical professional within 1 to 3 months of committing suicide," Dr. Croft said. "And particularly amongst the elderly, this is especially true. Many have seen their primary care physician within a month of killing themselves.

"What this is telling us is that there is an opportunity to do something about it."

Important Reminder

Williams may have slipped through the cracks, but his death serves as an important reminder to physicians to be on the lookout for patients who may be suicidal, said Dr. Croft.

"I’ve been in practice for over 30 years, and I learned long ago not to ask about suicide directly, so I don't ask, 'Are you suicidal? Are you thinking about killing yourself?,' because the answer is generally, 'No.' "

"A lot of the elderly assume that if they tell their doctor that they're going to kill themselves, the first thing the doctor will do is put them in the hospital in a locked unit, and they won't want to be in the hospital in a locked unit," he added.

What Dr. Croft now asks is, "Have you ever felt so down or so despondent that you felt that life wasn't worth living anymore?"

If the patient acknowledges that they sometimes they feel that way, the clinician should ask follow-up questions, including the following:

  • Have you ever actually thought about killing yourself?

  • Have you made a plan?

  • Have you done anything to make that plan come to life?

"That way, people start opening up," he said. "And I think that's because they believe you really care. Most people don't really want to kill themselves. They are just tired of the pain, the despondency or the stress, whatever it is, and they want that to end.

"So it is always appropriate to ask about despondency, and if you get an answer that makes you think, 'Wow, this sounds like ideation and a plan,' then I would say, 'I’m really concerned about your feelings and what you’re telling me' and ask them if we can't do something together to help them get past this."

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