COMMENTARY

Death Is Not an Acceptable Outcome for Mental Illness

Jeffrey A. Lieberman, MD

Disclosures

December 11, 2018

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

Mental illnesses are very serious. They cause great suffering and they can be extremely disabling to people, but they do not kill people directly like cancer does or like heart disease does. In some cases, such as anorexia nervosa, maybe they do. People with mental illnesses, particularly severe mental illnesses, experience excessive medical comorbidities, which shorten their survival by as much as 20 years compared with unaffected individuals or peers. Basically, the diseases that we deal with in psychiatry and mental health care are not lethal.

The greatest cause of mortality in people with mental illness is suicide, which is viewed as a complication of mental illness. In regard to this, and I don't mean to make light of such a serious subject, the quote [often attributed to] Mark Twain is apt: "Everybody talks about the weather but nobody ever does anything about it."

Sadly, that is the case for suicide in our society. That was brought home very clearly through a series of events that occurred in June. Although they occurred some months ago, and it was something that prompted me to want to comment on it, I didn't immediately because I wanted to allow the emotionality to subside and be able to talk in a more dispassionate way. Essentially, these events were two celebrity suicides. Kate Spade killed herself on June 5; Anthony Bourdain killed himself on June 8. Kate Spade, of course, was a fashion designer. Anthony Bourdain was a chef and a television personality. They both killed themselves by hanging.

The world was shocked because these were famous people, they were attractive people, they were wealthy, they were celebrated, and they seemed to have everything. Why would they kill themselves?

If that weren't enough, that same week, a report was issued by the Centers for Disease Control and Prevention (CDC) which indicated that the rate of suicide in this country had gone up in the past 20 years by 25% nationally and in many states by as much as 30%.

Close to 50,000 people a year die by suicide. If we talk about youth, it is the second leading cause of death. Moreover, apart from the fact that these national statistics are stark and troubling is that the suicide rate over the past century has been stable and nondiminished, and since 1999, as the CDC report indicates, has gone up by 25%-30%. This rate is in contrast to most of the countries in the developing world, where the rate has gradually declined.

The fact that suicide rates were constant over a century when medical science and progress have improved the morbidity and mortality for many public health diseases—cancer, cardiovascular disease, respiratory disorders—and yet suicide remains undiminished, is really an indication of a lack of interest, lack of attention, lack of evaluation, and lack of effort to try to address this problem.

Again, to quote Mark Twain, "There are lies, damned lies, and statistics." I've told you about the CDC report, which is incredibly sobering, but individual cases are what really bring you emotionally to tears. There are two cases that appeared in the news recently that were indications of such.

One of them was of a 61-year-old man. This was published in The New York Times on October 23, 2018.[1] A neighbor walking his dog in the East Village saw the man one night, sitting motionless behind the wheel of a parked car. Two days later, he was still there. The windows were up, the engine off—during an August heat wave. The neighbor called 911.

Soon the block of East 12th Street was busy with police officers and their bosses, the car roped off with yellow tape. The police released the name of the man who was in the car, dead. It was Geoffrey Corbis of Bridgeport, Connecticut. He appeared to have died of natural causes about 2 days before he was found there.

None of those initial findings would prove to be true. Not the cause of death, not the name, not the length of time the man's dead body was in the car, which was far longer than 2 days. It is now believed that the man was there for a full week—a week that his family spent in vain asking the police to look for him.

The chain of events serves as a stark reminder that even in 2018 Manhattan, a city that lives beneath the nonstop gaze of countless surveillance cameras—one that for years has urged its citizens that if they see something suspicious, to say something—it is still possible for a dead man in a parked car on a busy block to go unnoticed for days.

The events leading up to and following that August day also reveal a story about a distressed man's plight—his decline in fortune, his failure to raise fast cash. He was thwarted by circumstance and his grim resolve in his final hours was to end his life, all detailed in a farewell text message to his loved ones.

This shows you the pain that an individual goes through before they're impelled to take their life, and the effects it has on other people, most immediately their family.

Suicide has continued in this way, undiminished, because it hasn't been dealt with sufficiently and properly. There are many myths that surround this tragic and irreversible act. One is that suicide just happens. People snap at one point, they just end their life, and there's nothing you can do to stop it. Another is that suicide occurs because of an existential crisis of the postmodern Industrial Age that we live in. Another is that suicide seems to be glorified, and is somehow dramatic in the act of ending one's life in some fit of emotion and some grand gesture.

Suicide has had a ritualized role in some societies in history. In ancient Rome, it was a practice for defeated or failed civic leaders to kill themselves. There is the act of what we know as harakiri, or more specifically, seppuku, which is a Japanese ritual suicide by disembowelment that was originally reserved for samurai but also practiced by other Japanese people later on to restore honor to themselves or their family.

Those are extreme exceptions; the vast majority of suicides are simply a consequence of mental illness in which the symptoms become too severe and have not been effectively treated. In fact, over 90% of people who commit suicide have antecedent mental conditions.[2] The majority of them have not received treatment, or if they have, the treatment has been ineffective and inadequate. That would be understandable if there were no effective treatments, but that's not the case.

Suicide occurs as a consequence of a very small number of mental disorders, including depression, bipolar disorder, and schizophrenia. After that are conditions like post-traumatic stress disorder or anxiety disorders complicated by substance abuse. All of these are have some proportion of individuals affected who are at risk of committing suicide. All of these have effective treatments if they're administered properly and in a timely fashion, so there's really no reason for the suicide rate to not be going down, much less to be going up.

[T]here has been abject neglect to take this as a public health problem...

The only reason that that's the case is because there has been abject neglect to take this as a public health problem that needs to be addressed by providing mental health care, by having systems of mental health first aid, by having a ubiquitous means by which people who are in distress can reach out (or their loved ones who observe this can reach out).

Again, I don't mean to make light of it, but think of this: You have a life-threatening situation for which treatments exist that could prevent that from happening, but they're not used, available, or adequately provided. It's like saying that sexually transmitted diseases are a necessary consequence of sex, that they can't be avoided.

What's to be done? Suicide absolutely can be prevented. Zero tolerance is a pretty high bar to get to, but there's no question that if treatment were more widely available and provided to people with mental illnesses, particularly the ones that I enumerated, which are the ones at greatest risk for suicidal complications, that the number would go down. We know that the increases occur in specific demographic groups—late middle-age males, middle-age females, and also in youth and adolescents, but particularly adolescent girls.

Treatment needs to be provided, and that's the case for mental health care in general. In addition, the public, the layperson, you, your coworkers, your family, your friends need to be engaged. The adage developed for the age of terrorism, "See something, say something," applies here also.

There is another myth: that you shouldn't say anything about suicide to somebody who's feeling suicidal because you might prompt them to do something. That's absolutely not the case. In fact, the opposite is true. When you ask someone about how they're feeling, when you say, "Have you been having thoughts of life not being worth living? Have you thought about hurting yourself?", that helps to relieve them, to diffuse them, to bring to light something that they've been wrestling with.

You want to bring that out. You want to talk to them. And if they do acknowledge that they've had such feelings, you want to take any precautions or at least inform somebody—their family, their loved one, or significant other—that this is the case and they need to take precautions. Suicide may be a recurring or even a chronic thought that people have, but the action is only taken on impulse. If you can avoid the impulsive act of hurting oneself, you can avoid having this tragic event occur. You just have to get past those moments, provide them the initial support, and then guide them to the appropriate medical care.

There are also suicide hotlines. There are organizations that specialize in this, so there's abundant information for people to access.

I want to conclude by returning to a heart-rending example that was in the news more recently that just broke my heart. This is the case of Jane Doe Ponytail, published on the 11th of October, 2018.[3]

A woman begins to fall. With her long, dark hair in a ponytail and her black and red scarf loose around her neck, she's plummeting from the fourth-floor balcony through a neon-charged November night. Below awaits 40th Street, a gritty street of commerce in the Flushing section of Queens—Chinese restaurants and narrow storefronts, and dim stairwells leading to private transactions.

But before the pavement ends the women's descent, a few feet from a restaurant's glittery Christmas tree, imagine her fall; suddenly it was suspended—her body freeze-framed in mid-air, if only for a moment.

Jane Doe Ponytail toils in the netherworld of Flushing massage parlors, where she goes by the name of SiSi. Youthful, 38 years. She's in a platonic marriage with a man more than twice her age, harbors fading hopes of American citizenship, and is fond of Heineken, Red Bull, and chicken. Among her competitors, she is considered territorial and tireless.

It is the Saturday after Thanksgiving and SiSi is in a shabby building's top-floor apartment, for which she pays her "boss" a hefty fee. She has returned from a market with provisions. She has tried calling her younger brother in China but he is asleep. She has been on the phone with friends and clients, unaware that she is in the sights of a 10-member police vice squad team.

She heads downstairs to stand at the building's entrance, a necessity of her job. Soon, she is leading a man back upstairs—unbeknownst to her, an officer working undercover—as her closely held cell phone casts a glow about her face. Their awkward conversation in her apartment convinces him that SiSi has broken the law by soliciting him for prostitution, just as SiSi is aware that he is really an undercover cop. She pushes him out, closes the door—though not to the inevitable.

She knows from experience what comes next: more police, tromping through the dusky vestibule of her building, across the worn scarlet rug, and up the tiled steps. Past the Chinese sign that says, "If you're looking for driving school, you're in the wrong place," then right to her door. The handcuffs, the hurried escort to the police vehicle, the humiliation.

SiSi watches the officers ascend on the video monitor she keeps near the door. Under the fixed gaze of one of those lucky cat figurines perched on a table, its paw raised in a wish of good fortune, she begins to pace.

Now they're pounding at the door, shouting, "Police! Police! Open up!" SiSi rushes to the apartment's north balcony, with its panoramic view of the street hustle below. Day and night, sun or sleet, this is where she and her sister competitors sing their plaintive song to passing men, "Massage? Massage?"

On the narrow balcony, barely 2 feet deep, she keeps a broom, a bucket, a small blue stool. Up she steps. Then she jumps. Now she's falling, plunging toward the hard tenth of a New York mile that is 40th Street. Gravity prevails.

It's hard to know what SiSi's diagnosis was, but obviously it was the conditions that she lived under that drove her to this after enduring incredible mental distress. There was no help to save her. I wish there [had been help for her] and all of the other people who are victims of suicide.

Suicide and death should not be an outcome that is acceptable for people who have mental illnesses—it is preventable.

Thank you for listening. This is Dr Jeffrey Lieberman of Columbia University, speaking to you today for Medscape.

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