Suicide
Your dog wishes you a long life
Russian proverb
Depression can and does kill. In Australia, one person ‘completes’ suicide every five hours. During those five hours, many others will have attempted suicide – 300 for the under 65s, and many of these will eventually succeed. If this figure were for road deaths, we would be galvanised into more effective action.
1. Sudden change of mental state or frame of mind
At the outset, there is one fact I want to emphasise.
If the patient who has been anxious, without hope,
desperate, seriously depressed or suicidal,
suddenly becomes happier or calmer for no apparent reason,
take extreme care.
Very often these unfortunate people are happier
because they have worked out a suicide plan.
Their dread will come to an end.
Three friends lost loved ones because they simply didn’t know
what an unexpected change in mental state might signify.
And so they mourn.
2. Entrapment and absence of hope
From time to time we read of depressed mothers or fathers killing themselves as well as their young children; murder-suicide scenarios. The world is so terrible for them – the patients – that they do not wish their dear children to remain alive in such a place, after they themselves have ‘gone’.
Often the community is outraged but having sunk to the depths myself, I can understand their illogical reasoning; why they act as they do. No miracle has taken away their pain, their terror, or fixed their problems, so they take matters into their own hands.
Of course these are very sad situations, but I can understand the unsound ‘logic’ of these patients who have come to the end of their tether – unlike an older woman I was speaking to many years ago.
She remarked to me that people who suicide are cowards.
I can remember being jolted by this bald statement and querying it in my mind.
I now know this opinion to be incorrect, from my own experience, and from research.
People who make such statements are ill informed and have no understanding of the situation.
Closer to the truth was a comment made by our younger son, James. While he was at Wesley College at the University of Sydney, a beautiful, talented, and popular woman friend of fellow residents suicided. The residents were searching for a reason. ‘Why? She had everything.’
In our subsequent discussion, James reflected, ‘They lose hope, Mum’.
Although James was 18 at the time, I remember thinking, out of the mouths of babes.
It was an insight to me in 1990.
Now I, too, have experienced that absence of hope, as well as the crushing load of unsolvable problems – called ‘entrapment’; an appalling aspect of this organic illness, blandly called clinical depression.
William Styron (1925–2006), a Pulitzer Prize-winner, writes about absence of hope in his beautifully crafted book, Darkness Visible.
Of the unfortunate people who suicide, Styron says, ‘… to the tragic legion who are compelled to destroy themselves there should be no more reproof attached – than to the victims of terminal cancer’. My dash; when I had depression, with its accompanying deterioration in comprehension, I needed the dash to make sense of this statement.
I agree with Styron.
Styron himself was treading single-mindedly towards suicide until he heard a song his long-dead mother used to sing, the Brahms Alto Rhapsody. He suddenly realised that his own suicide would be more than he ‘could inflict … upon those, so close to me …’.
He ‘drew upon some last gleam of sanity’ and woke his wife; lengthy hospitalisation and recovery followed.
Let me list the nine classic signs of depression, of which I had eight – depressed or sad mood; exhaustion; loss of pleasure in things that normally give pleasure, including sex (with severe depression, both men and women are impotent); marked weight loss or gain; changes in sleep – too much or too little; feeling agitated – anxiously upset, or slowed down; feeling worthless or guilty; loss of concentration or difficulty in making even simple decisions; and frequent thoughts of suicide.
Absence of hope is almost always present.
3. Antidepressants
Patients with severe depression, such as I experienced, are prescribed antidepressants – and counselling as soon as the antidepressants have ‘kicked in’. Inexplicably some people with serious depression choose not to take antidepressants. Do they also refuse antibiotics for life-threatening pneumonia?
This early stage of taking medication can be deadly.
Those around the patient may think, ‘They’re on medication now; they’ll improve. I don’t have to watch them so closely’.
The patient may think, ‘I am taking my tablets – I must be getting better’.
In fact – until the tablets’ rapid effect on the brain’s chemicals begins to be felt by the patient, he or she continues to slide downhill. It can take from two to six weeks before the dread begins to lift. An æon to the depressed patient.
In his book The Yipping Tiger, Perminder Sachdev, Scientia Professor of Neuropsychiatry at the University of NSW, writes about this lag in feeling any benefit. The reuptake block in the brain occurs within minutes to hours, but the antidepressant effect typically takes weeks.
Be very watchful for signs of suicide in the first few weeks after starting antidepressants.
Even after the patient begins to feel better, they may still have suicidal thoughts ‘in startling clarity’, a psychiatrist informed me.
All patients with serious depression have glimpsed their own horror finale, but to them – with the distorted thinking that accompanies depression – it is not horror, but a sensible solution.
It often seems the only solution; the permanent solution to what others see as a temporary crisis.
When patients first come home from hospital is also a dangerous time.
They have a lift in energy and are well enough to come home, but they are still likely to be having suicidal thoughts, again, ‘in startling clarity’.
Now they have the energy to carry out those thoughts, to suicide.
I know of two people who did just that – two individual cases; they were unguarded for only five minutes or so.
4. An insider’s account of near-suicidal depression
Like virtually everyone with depression the symptoms of serious depression left me totally exhausted.
And so I slept.
But even sleep offered no escape from depression’s terror; dreaded nightmares strode through my nights.
When I woke, on the brink of the abyss, the black demon of depression was waiting – to taunt me, to smother me, to overwhelm me with indescribable terror.
A silent, internal, desperate struggle.
It was especially during the ten to fourteen days after I was prescribed antidepressants (as I continued to plummet before I felt any benefit from the tablets) that I was thinking,
‘If I were dead, I would not be feeling like this’.
‘If I were dead, I would escape my terrible fear and mental agony, as well as all my grim physical symptoms.’
‘I can’t argue with that!’ quipped a friend when I related these thoughts to him after I recovered.
I was so anxious for the pain, the burdens, the anguish to disappear that I prayed desperately and repeatedly for the world to end … quickly … now! It needed to be instantaneous. Like my ability to read, my faith regressed and became simplistic. I perceived this end-of-world scenario to be the only escape route open to me at that deep stage of my depression.
I thought – and there was a lot of wild thought skittering about,
‘If the world blows up, those I love will die with me’.
‘But if only I die, John (my husband) and our two sons will be left behind and they’ll be upset.’
Seemed like fair reasoning to me.
‘Upset’?? That’s putting it mildly!
Be aware, the reasoning of severely depressed patients is illogical – but to them, it is logical.
At my lowest ebb, I was thinking that my death would affect only John and our sons … and my sister. My parents were dead. But of course it would have ‘upset’ our sons’ wives – our wonderful instant daughters as I call them, as well as other relations and many friends.
After I had recovered, one dear friend asked in disbelief, ‘What about me?’.
‘You didn’t rate a thought,’ I answered with a laugh.
And my sister? Even though my mind was in seething turmoil, I was able to ‘talk straight’ to myself.
‘You cannot die yet. Your sister is still alive, and you told your mother on her deathbed that you would always be a friend to her’. So in one sense, this vow to my mother was an important force in keeping me alive.
Friedrich Nietzsche (1844–1900), a German philosopher, wrote about this power of a reason to live:
‘He who has a why to live for, can bear almost any how’ (my italics). Put another way, if we have a reason to live, we can live through almost anything.
In Man’s Search for Meaning, the Austrian neurologist and psychiatrist Victor Frankl (1905–1997), who survived concentration camp, writes that he used Nietzsche’s insight in a talk he was asked to give while in prison. In the imposed darkness of the ‘dormitory’ (an abysmal hut), Frankl asked his ragged, dispirited fellow-prisoners to think of who, and what unfinished task, would be waiting for them when they were released. ‘Live on,’ he was urging.
Who, and what, are waiting for you?
The German title of Frankl’s book translates as ‘Saying Yes to Life in Spite of Everything:…’
My psychiatrist friend said, ‘It is important to understand that it is the nature of depression for the world of the patient to gradually shrink, until it contains only one – the patient.
Then finally, the patient turns against that one. The next or simultaneous step is to exclude even that one; to suicide’.
I mentioned earlier, I was prescribed antidepressants. Without them, how long would I have been able to cling to life? If my condition had worsened, I would soon have been enduring the aching, solitary, world-of-one, and then… who knows?
The agony may well have become too great, and death too attractive.
Those who cannot endure the torment any longer, suicide – or die of depression, as some suggest suicide be called; the anguish and the effort of living are too much to bear.
Others, because their self-esteem is so low, think it would be better for everyone if they ‘weren’t around’.
5. Acting a double life
As carers and friends, we need to realise that depressed people are capable of carrying on a double life.
I did. While I was trying to ‘smile’ (think grimace) as John thought he was sharing a joke with me, I was imagining what it would be like to be dead; to have no pain.
John had no idea what I was thinking – and I had no intention of telling him! It would have frightened him, so I maintained my convincing, exhausting double act to protect him.
Lewis Wolpert (b. 1929) writes of this dual role in the Introduction to Malignant Sadness.
He reports that a mother was able to speak cheerfully with her son ‘at the same time that she was composing, in her mind, the suicide note she would leave for him’.
Because many depressed patients who are planning suicide are able to act so well, their deaths catch carers off-guard. Seriously depressed patients, in this category, do not want friends or family to know their plans. They might thwart those plans.
We need to be constantly vigilant. I can’t stress this strongly enough.
I know of seven cases where a loved one seemed well enough, but was suddenly dead. This includes the three who had suddenly ‘improved’. My friends – who are the close relatives or friends of the victims – were devastated, and recovery for them has been terribly difficult.
We may assure our friends that they should not feel guilty of dereliction – neglect – of duty, or lack of care for the patient, because the depressed can be such magnificent actors. I know! And many who plan suicide are very determined to ‘succeed’, if not on the first attempt then on the second, or third…
A determined patient will even find a way to suicide in hospital, so devoted carers must not berate themselves if the feared act occurs.
But suicide is so, so difficult for the bereaved to come to terms with.
‘If only …,’ they lament, wringing their hands. ‘If only…’
Suicide is even more ghastly when the family had no idea the victim was depressed.
6. What can friends and carers do to help the suicidal?
- Encourage the patient to be open; to speak about their illness, and about any suicidal tendencies. Ask, ‘Are you thinking of suicide?’
Do not be concerned that this will plant the idea of suicide in the patient’s mind.
It won’t. Like all seriously depressed patients they will have thought of suicide long before you.
Encourage the patient to talk while you listen.
Refrain from judging, offering advice, or interrupting – except to ask an occasional question to gain greater insight, or to clarify what the sufferer is saying.
Find out if they have worked out exact details of their suicide. How? When? Where?
If they have thought through details, act. Do not mull over the situation, or assume the crisis ‘will pass’, or that ‘it is not serious, really’. Death is permanent!
Keep pills, ropes, knives, car keys, … away from the patient if they are suicidal. Many single-car fatal accidents – straight into the tree, for instance – are planned suicides.
Do not allow patients who have a right to own a gun (farmers, soldiers, police, competition shooters) access to their guns. As I write, a distressing story about a desperate grazier who shot his 400 starving cattle, and then himself, dominates my mind. Every way he turned, he was defeated. ‘Entrapment’ – one of the hallmarks of depression.
Assist patients to acknowledge their illness; to speak about it, and about their thoughts, especially their thoughts.
Because most people with depression feel they are worthless, they are apt to keep to themselves, to try to hide their illness, and to hide their thoughts. This is dangerous if the patient is seriously suicidal. When a prominent South Australian businessman and doctor suicided, his son said, ‘Dad, both in business and personally, was very good at hiding his emotions’. The Advertiser 11.8.2005
As I said, all seriously depressed people consider taking their life. To them it seems a ‘logical’ solution to removing the pain and misery; and indeed, suicide is effective, and long-lasting! – but terribly sad.
- If the patient does speak about their thoughts, listen intently.
An important aspect of communicating with the patient, is listening. True listening is a great gift for the depressed.
- ‘Wait’ beside the patient. This is a vital role friends can play.
In The Wounded Healer, the famous writer and pastor-priest Henri Nouwen (1932–1996) writes, ‘Thousands of people suicide because there is no one waiting for them tomorrow’; either there is no one waiting for them, or they believe ‘no one is waiting for them tomorrow’.
I was fortunate; I knew my husband and friends were ‘waiting’ for me.
Let the afflicted know, ‘We are here for you, attempting to understand your suffering’.
Those around the patient must be ‘relentlessly optimistic’, the psychiatrist said.
Patients need to be told frequently that they will recover – it will pass, it will pass – and that friends will support them.
- Speak up – say you care; even if you don’t usually verbalise your feelings.
Actions speak louder than words, we are told, but the depressed need words as well as actions.
Speak lovingly to depressed dear ones (and well ones, too). Don’t wait until funerals! The dead cannot benefit from tender words.
When Robert, our older son, sent me an SMS during his then five-year-old son’s sleepover with us, saying ‘He’s a lovely chap’, I read it to Ryan. Ryan laughed with joy and said, ‘I like it when he says that’.
- If the patient is seriously suicidal, stay with them – all the time, if it is not dangerous for you.
Talk soothingly to them and ring the doctor or psychiatrist. If that is unsuccessful, ring 000 (in Australia) and ask for ‘ambulance’ or ‘police’. My psychiatrist friend mentioned that he has always had wonderful help from the police in taking people to hospital.
With a seriously suicidal patient, there can be an awkward waiting phase; waiting for help to come.
If the situation is urgent, take the patient to Emergency at a hospital, either by yourself (if you think it is safe), or with the help of others.
- Disregard requests for secrecy from the patient – for example, ‘Don’t tell anyone if I tell you my plans for suicide’.
By telling you their plans, this category of patient is actually asking you for help. In any case, everyone is going to know if you ‘don’t tell’ and they die.
7. Stereotypes – people who are at high risk
Because it is helpful to know which people might be considering suicide, I list them below.
- people who have made previous suicide attempts – especially the over 65s. Many will succeed on future attempts;
- the elderly in pain;
- middle aged men who have financial loss, or loss of status (such as job loss);
- previously successful businesswomen who sacrifice their business for some pressing reason; losing the sense of success and accomplishment the business gave
- men on the land who feel ashamed they can no longer provide for their family, as they would like – because of drought, flood, fire, rural debt, or low market prices; men, it is you your family and friends value;
- depressed youth (or patients of any age) + substance abuse – alcohol and/or drugs (including tobacco);
- depressed patients who have had a family member or friend suicide; even the suicide of a favourite pop star can prompt depressed youth to suicide;
- depressed patients who have many, seemingly insurmountable, problems + perceived lack of support.
8. Indications of extreme danger
And what are the extreme danger signals the suicidal person gives?
We need to take note of these.
Just as there is no typical depression patient – the symptoms (signs of illness) vary from patient to patient, so there is no typical, potential victim of suicide.
However some signs are common to both.
I will group these danger signals for suicide into three sections.
A. Mental State – changes in normal thinking (called ‘mental functioning’)
- as I mentioned above, unexplained happiness, or a sense of calm, in the patient who has been anxious, without hope, desperate or seriously depressed. They are happier because they have worked out a suicide plan – the dread will come to an end. One group of the suicidally depressed keeps this secret. The other group ‘asks’ for help.
- moodiness can be a normal symptom of depression but we need to be alert if there is a change in the moodiness e.g. if the patient is becoming increasingly withdrawn;
- extreme depression + denial of thoughts about suicide (called ‘suicidal ideation’); they may or may not have worked out a plan;
- extreme depression + extreme detachment; the patient is in their own world – disconnected;
- evasiveness about suicide when the subject is raised.
B. Attitude – the way we think or feel
- a cold and calculated attitude to suicide when the patient is speaking about suicide;
- desire for reunion with dead ‘significant others’ – people they have loved; people who were important to them.
C. Behaviour – how we act
The patient on a suicide mission is driven, and can accomplish whatever they think needs to be done. Do not underestimate the depressed person slumped, seemingly lifeless, in a chair; they can kill themselves just as well as the pacing ‘caged lion’ type of patient.
9. We need to be alarmed by these behaviours
- giving away or destroying loved possessions – as many people do towards the end of their lives;
- giving away pets, or arranging for their care; the Russian proverb, Your dog wishes you a long life, encourages us to live;
- writing a will, or farewell note; saying goodbye when it is not appropriate;
- using songs, drawings, writing or telling stories to describe death;
- spending extravagantly;
- taking out life insurance;
- withdrawing from others;
- taking unnecessary risks; being reckless;
- inflicting self injury;
- increasing the use of alcohol or drugs, including tobacco;
- raging, or being violent or angry;
- out-of-character neglect of personal appearance;
- making actual statements about death e.g. ‘I can’t stand it any longer’; ‘There’s no way out’; ‘You’ll miss me when I’m gone’; ‘You’ll be better off without me’ or, as I said several times, ‘Death would be a good option’;
Even if the patient speaks jokingly about death – as I did, with a little laugh – take them very seriously. Watch them, listen to them; they may only speak once.
More than 75% of people who suicide say or do things to let others know their plans.
If the seriously depressed patient speaks about suicide, let them talk. Listen; actively listen.
Telling them, ‘You’ll feel better later’ or ‘Count your blessings’, is no help whatsoever. It is, in fact, unhelpful. It simply convinces the patient that you have no understanding of their terror and desolation – and therefore you cannot be relied on to provide a lifeline. And, if they live, they may not confide in you again. A waste of their time, and energy; depressed people are exhausted.
As many people who suicide give only a few of the above ‘signals’, it is dangerous to wait until the patient has ‘ticked’ all the above dot points. Be vigilant; act; you may save a life.
10. The most dangerous times for suicide
To recap, the most dangerous times for suicide are:
- after diagnosis, at the beginning of serious depression, when depression is still careering downhill – because the benefit of the antidepressant tablets can take two to six weeks to be felt;
- as the depression lifts – when the patient has the energy to carry out suicide;
- when the patient comes out of hospital – again, there is a lift in energy at this time, and
- at difficult or sad times e.g. around court appearances, at Christmas or religious celebrations, anniversaries…
11. What helps us not to suicide
Finally, what helps us not to suicide?
- marriage, or significant attachments to people, causes, goals, philosophies or things that are very important to us;
- beliefs or group belief; although the corrupt cult leader, Jim Jones, by his sinister manipulation, actually caused the suicides of his followers at Jonestown, Guyana, in 1979;
- belonging to a social group such as an ethnic minority;
- living in a capital city.
Suicide is devastating for everyone.
It is my desire that this information will help prevent suicides
and their deep, continuing, accompanying grief.
Life is for living!
If you, or someone you know, is in urgent need of assistance, please do not hesitate to ring one of the following help lines.
Lifeline Australia 13 11 14
beyondblue 1300 22 4636
SANE Helpline 1800 18 7263
For young people between 5 and 25 ring Kids Helpline 1800 55 1800. They also have Web counselling and Email counselling.
On 11th October 2015, I was interviewed by the host of “Australia All Over”, an ABC radio programme.
This is the interview.
Adapted extract from Depression Unmasked – escape routes from despair (unpublished)
© 2016 Bethel Hunter. All Rights Reserved.