COMMENTARY

Robin Williams' Suicide Had Nothing to Do With Demons

Jeffrey A. Lieberman, MD

Disclosures

September 04, 2014

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Hello. This is Dr. Jeffrey Lieberman of Columbia University in New York City, speaking to you today for Medscape.

Recently, the actor and comedian Robin Williams died by suicide, and this shocked and saddened the country. He has been mourned as a head of state or iconic national figure would be mourned, which is fitting, given his widespread fame and the way he was loved, admired, and respected by so many people. In the wake of his death and all of the media attention and commentary that it has garnered, and the many views that have been expressed, I want to share some thoughts with you about this.

One thing that has been said repeatedly is that Robin Williams "struggled with demons." This really burns me up. The use of that term, "struggled with demons," which is nothing more than a misguided colloquialism, is a throwback to the days when mental illness was regarded as some kind of supernatural phenomenon, when someone was said to be possessed or was somehow subverted by the devil or supernatural forces.

Rare but Not Random

The reality is that Robin Williams had many, many risk factors for suicide. It is true that suicide is a rare event, but it happens with alarming regularity in our society and in the world's population. And it does not happen randomly. It happens in individuals who have vulnerabilities or predisposing risk factors.

Ninety percent of people who commit suicide have a preexisting mental illness. The most common of these are mood disorders: psychotic depression, bipolar depression, nonpsychotic depression, and schizophrenia. In addition, there are other complicating factors, such as substance abuse, that can enhance the vulnerability. Family history, not just of mental illness but of suicide, is another critical factor.

We know that most people who commit suicide have a preexisting mental illness, but not all people who have mental illness attempt suicide. Thus, the person who commits suicide has something more that predisposes to the action of suicide beyond just the symptoms of mental illness. For example, suicide does seem to run in families, which suggests that there is a genetic contributor. Heart disease is known to be another risk factor for suicide. Heart disease and depression are intimately associated.

Risk Factors, Not Demons

Robin Williams had numerous risk factors. He had a long-standing history of depression, which he was public about. He had a long-standing problem with substance abuse of alcohol and cocaine, which he also had been very forthcoming and open about. Several years ago, he underwent heart surgery for valve replacement, and the media reported that he may recently have been diagnosed with early-stage Parkinson disease.

All of these factors made Robin Williams someone who clearly was at greater risk for suicide than the average person in the general population. Beyond these illness-related risk factors, he was also a 63-year-old man. That is the group at highest risk for suicide. We know that middle-aged and elderly men are among the groups with the highest rates of suicide.

In reality, Robin Williams had multiple risk factors, and as a result of that he should have been a person for whom there were adequate protections, or at least monitoring and awareness of the risk.

Let's look at an analogous situation. Suppose he had been at risk for heart disease. Let's say that he did not exercise, he was overweight, he smoked, he liked to drink, he also did drugs, and he had a family history of heart disease. His doctor would have been all over him, prescribing a statin, telling him to watch his diet, getting him on an exercise regimen, doing serial electrocardiograms, maybe even an exercise stress test or gated thallium scan to see to what degree he was at risk. Was anything similar done for Robin Williams as a possible measure to assess his risk for and reduce the likelihood of suicide? I do not know, but I would not be surprised if this was not done. We do not do the same kinds of monitoring for mental illness or for suicide, its most devastating consequence.

The fact that Robin Williams committed suicide is shocking and saddening but it is not so surprising. He had many risk factors that could have increased the likelihood of him taking that action.

Telltale Signs Too Often Ignored

We know more than ever about suicide -- from its neurobiology to its epidemiology, treatment, and prevention. We know that mental illness is an antecedent to suicide in the vast majority of cases and that treating the mental illness is highly effective, whether it is a mood disorder, a psychotic disorder, anxiety disorder, or addiction. We also know that if someone has suffered an adverse life event or has an illness that is associated with depression, these are factors that can be focused on and potentially acted upon, to try to reduce the risk.

We know that some telltale signs can emerge in individuals who are at risk during the period that may be imminent before a suicide. For example, making statements that life is not worth living; that others would be better off if the potentially suicidal person was not around; losing interest in things. There are a variety of telltale signs or indicators that suggest that someone may be thinking about suicide.

But individually, family, friends, and healthcare providers do not take action often enough, not as they would if this were heart disease and someone displayed manifold risk factors. As a society, we do not do enough to prevent suicide. We talk about it, especially when it affects one of our most beloved and well-known people, but again, we do not act on it. Why is this?

Too Uncomfortable for Words

I believe we do not act because we are not entirely comfortable with raising the topic. We do not completely believe that this is an actionable problem that has a known medical and scientific basis. But it does. I tell people who are concerned about a loved one that they should not feel timid about asking this person, "How are you feeling?" We need to ask whether he has had thoughts of ending his life and aggressively try to move him towards getting an evaluation and treatment. If we hope to make any progress in reducing the rate of suicide, we have to step away from our tendency to walk on eggshells, of being timid and afraid to raise an uncomfortable issue, because this is an actionable problem. It is a public health problem. It is caused by an illness.

What do we do when we have epidemics of other types of illnesses? We study them, we determine the best course of action, and then we act on them. But with suicide we are in a situation along the lines of Mark Twain's comment about the weather: Everyone talks about it but no one ever does anything about it.

If we can do anything to honor Robin Williams in the aftermath of this terrible event, because he was such a charismatic and beloved figure; if his death can galvanize us to act in a way that prevents other people, including their families and friends, from suffering this terrible fate, instead of just grieving and then forgetting about it, this will be a fitting memorial to him.

Speaking to you today for Medscape, I am Dr. Jeffrey Lieberman of Columbia University. Thank you.

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