Ponderings on Suicide

Can suicidality exist in the absence of mental disease? I believe it can, though these circumstances may be rare. In considering physician-assisted suicide in states that permit it, mental health disorders must be ruled out as the impetus for ending one's life. In looking at California's 5150 section of the Welfare and Institutions Code, the part that permits involuntary psychiatric holds, a subject must be a danger to himself as a result of a psychiatric illness.

In what situations might someone want to end their life and yet not have a mental health disorder? Certainly, we think of patients with terminal illnesses with unremitting suffering. But we may also think of Socrates, found guilty of corrupting the minds of youth and impiety, sentenced to drink hemlock. We think of the Japanese Samurai code of bushido, or honor, which incorporates ritual suicide (seppuku).

Suicide is a touchy subject around here. Palo Alto has had a rash of high school suicides, leading to extensive debates, news articles, and academic research. It is awful, sad, and shocking to consider that a high school student may jump in front of a train because of stress. I hope the changes local schools are making and the awareness generated by a spotlight put on this problem will mitigate it.

But suicide is not a homogeneous problem. It's hard to empathize with someone who is suicidal because those who intervene have rarely been in those shoes. Experts conjecture on the factors that lead to suicidality, but those experts probably haven't been suicidal themselves. Our best source of knowing why people feel this way are probably from those who made unsuccessful attempts, but should we generalize what we glean from those individuals? It's almost like a group of rich people trying to figure out how to solve poverty; few of the well-meaning people working on the problem have actually felt the problem themselves.

When I rotated through psychiatry as a medical student, I didn't fully understand suicide assessment. At that time, it was almost a black-and-white thing; I had a list of questions and from those questions, I made an assessment of whether someone met criteria for a "5150." But reality isn't so clear-cut. I make a comparison to conversations with patients struggling with lifestyle changes. I probe a diabetic patient about why she isn't taking her insulin; I ask about her lifestyle, her finances, her priorities, her understanding of the disease, her ability to obtain her medication, the obstacles she has with taking it, her likes and dislikes, her hopes and fears. It's a long, painful conversation, but at the end, I begin to glimpse her holistically. Maybe this is the approach we ought to have with those who are suicidal. It is so easy to take a patient who ingested a bottle of pills, 5150 them and refer them to psychiatry. But if we truly seek to understand their behavior, we need to do a little more legwork than that.