In one week, five of my patients were considering suicide.
Winter and darkness are coming, and the holidays don't help, but most of the folks I see have been thinking about death for decades. Suicide is configured very early in life. I see suicidal patients who are in their teens and have already tried to kill themselves. Parenting has to do with instilling hope in children, and without hope and nurturance, kids grow up to be despairing adults. Some of the adults have managed to pivot their emptiness to professional accomplishment, yet there exists within a quiet desolation that pulsates on weekends when structure is lacking. Others describe feeling hollow, like a scarecrow.
There are men and women who fondle guns or save up lethal supplies of pills or examine the exhaust tailpipes of their cars or buy a length of stout rope at Home Depot. Or they travel to the tops of tall buildings or overpasses or bridges and gaze down at mother earth. The despairs that spawn these behaviors can't be fully eradicated by Prozac, even though textbooks and conferences teach us that if we are pharmacologically aggressive enough, blackness will lift and ginger ale will replace beer or wine or a martini. But self-destructive urges ooze back into consciousness.
Thoughts about death are one of the few valid reasons for hospitalization these days, but the insurance companies have little truck with suicide. Reviewers ask on the second day of hospitalization if suicidality is still present, as if a raging fever has suddenly subsided. Five days in the hospital doesn't cure suicide. It takes months and years to work this out and repair the deficits in esteem, and I don't know a good way beyond the steadfast work of talking, which has never really been reimbursed in medical culture and never will be.
I recently heard an old-fashioned lecture in which the psychoanalytically oriented therapist spent years reconstructing a depleted human being. A wonderful talk, but archaic, of course. On the horizon is the promise of the anesthetic agent Ketamine abolishing suicidal thinking in mere minutes, but the effect doesn't last. Maybe someday bench scientists will find a long-acting form, or some substance to identify and coat the brain circuits responsible for feeling lousy. Sometimes I still recommend electroconvulsive therapy (ECT) to bring someone out of a severe melancholia, but that's more a beginning than an end. There remains the formidable problem of eradicating the defects in worthiness. The same is true for bipolar illness. Starting the patient on lithium is a mere prelude to the work of monitoring and maintaining mood. Indeed, I think that bipolar illness is one of the most difficult diseases to treat. It's a real long term task.
The American Psychiatric Association regularly travels to Capitol Hill to get money for mental health, so the organization champions the treatability of depression as if the entity were a broken ankle that just needed casting. Legislators can buy into these sales pitches and send big bucks down to NIH without ever considering that rehabilitation of something like drug addiction requires more than lifetimes of chemical agonists and antagonists that reduce cravings but don't touch the core of neediness.
I read about the military's struggle with post traumatic stress disorder in returning veterans who are not furnished the years of therapeutic effort needed to erase corrosive imprints and imbue these folks with a sense of purpose. Time is the enemy in a world of haste and hurry. And the fact that depression is more chronic than acute is particularly distasteful to those who construct health plans predicated on cure. So there exists a double burden for patients, one overcoming the disease process itself, and another an expectation that a full recovery is easily attainable.
Meanwhile, patients who are swept into the catechism of rapid cure vow to be happier in the new year. They say they will be more content and less disappointed with their lives and will aspire to be more fulfilled. Such longings require an extensive process of mending that prevents relapse and strengthens immunity. Nothing about it is a fast fix. I like the repair work. Patients like it less, of course, but they are ones on the upward sloping treadmill. If they can stay on it, most get better.
Dr. John R. Lion is a physician and psychiatrist based in Baltimore; his email is firstname.lastname@example.org.