A Primer on Depression and Bipolar Disorder

II. MOOD DISORDERS AS PHYSICAL ILLNESSES

D. Suicide

No discussion of severe depression is complete without a mention of suicide. Let us first ask ``Why do people suicide? Why do they want to die?''. Many studies of this question have been made through interviews of people who have attempted suicide, but failed (or were ``rescued''), and people who intended to commit suicide, but found a compelling reason not to. The very clear answer that emerges is that people who suicide do not actually want to die, but rather have reached a point where their present life is unendurable any longer, and they see no way to change it. Under these circumstances suicide is viewed as the lesser of two evils: a quick, clean, relatively painless death in the face of death by a slow, grim, grinding misery. Let me emphasize again that suicide cannot be viewed as a ``positive'' act fulfilling a ``death wish'', but rather as a final, abject, act of despair and defeat. There are hundreds of known cases where a suicide failed either because what the victim did didn't work (it is actually not very easy to kill oneself painlessly!) or because someone else intervened in time; almost always the person who made the attempt will say ``Thank God. I'm glad it didn't work; maybe I still have a chance.'' I remember lying on the Kona beach of Hawaii in the first week of January 1988, thinking ``Hey! This is pretty nice! I'm really glad my plan to shoot myself two years ago didn't work out! I would have missed this!'' And now I quietly, but happily, observe the anniversary of that event every year.

Of course, severe depression fits the description given above perfectly. If depression becomes severe enough, for long enough, there comes the day when anyone will think ``I can't stand this any longer. And I'm not going to get over it ever. I'm a failure at everything, and I'm a drag on my family and friends. There is really only one sensible way out.'' If this line of thinking is followed to its logical conclusion it represents certain death. It also represents a terrible defeat both for the victim, and for society, because in the case of depression, in particular, there is a good chance that his/her life can be improved, with treatment, at least to the point where it is no longer unendurable. For this reason, when a depressed person starts talking about suicide, he/she should be considered to be in a medical emergency, and medical intervention is urgent! If you ever find yourself considering suicide, and you don't have a regular doctor, and you don't know how to get help, call the crisis line in your community; almost all communities have one; if one doesn't exist, then when all else fails call 911. But get help. Fast! The same applies if you are in the person's family or are a friend.

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One of the first lines of defense against suicide is the crisis line. The dedicated people who man those lines lead a difficult life. They know that they are fighting to save someone's life, often when that person is unable or unwilling to provide straight answers to questions and may even be fighting against the process of rescue. This is a difficult job and a terrible responsibility. We should all remember crisis line workers as people who routinely perform ``above and beyond the call of duty''. There is no question that these services save many lives every year. The service provided by a crisis line isn't just superficial talking with the caller, trying to reassure him/her. If the caller is talking suicide, the person taking the call will try to make an assessment of how acute the emergency is: is the caller just feeling very bad, and needs to talk about it, or is he/she ready to do the act now? The methods vary from place to place, but in our community the caller will be asked a series of questions, each probing the next higher level of emergency. It goes something like this:

1. Do you have a plan for how you will kill yourself? If the caller doesn't even have a plan, then it is unlikely that the emergency is extreme. Clearly he/she still needs help, but maybe not this very minute.
2. Do you have the means to carry out your plan? That is, do you have the gun, the pills, the garage you can close and run your car in, the bridge to jump off, ....whatever. If the means exist, then the plan can be executed. The next thing to establish is whether it will be executed.
3. Do you know how to use the means you have selected? That is, do you know how to load the gun and pull the trigger, do you know how many pills are lethal, and so on. If you don't, then the plan is less likely to work; but if you do, we have a crisis.
4. Do you have the will to do it? Some people can get everything ready, but at the last moment can't bear to think of themselves covered with blood, crumpled and broken, or whatever.
5. Is there anything that can change your mind? Sometimes people attach ``contingencies'' to the plan of death: e.g. if some loss can be recovered (girlfriend, husband, job, etc.) Or sometimes they won't carry out their plan until some other event occurs (e.g. ailing parent dies). The existence of such a condition buys time: time to get help to the caller.
6. Are you ready to do it now? This is the bottom line. If the conversation has gotten this far, the crisis is extreme, and help should be on the way. This will often be a police car and an ambulance. The person answering the call now has two tasks: (a) keeping the caller talking, no matter what, and (b) telling him/her that help is on the way, describing what will happen when it gets there so that the caller won't panic and pull the trigger when someone knocks on the door.

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