"I Want To Die"

If you are a psychotherapist, counselor, psychoanalyst, and especially if you are a psychiatrist, you have heard variations of this refrain many times, which has soullessly come to be called "suicidal ideation". “I don’t want to live anymore… I want to kill myself… I wish it were all over…," etc. What to do with these laments?

Before I address the question, a personal note. I am 74 years old and I’ve been depressed many times. I have never had ETC or pharmacological intervention. I worked on the “depressions” the old-fashioned way. Reflection. Talk. Analysis. Struggle. My bias is that I don’t trust colleagues who claim they have never been depressed. Really? Never depressed? I don’t prescribe ECT either. I’ve witnessed only one ECT administered and that was during my training. OK, I got that off my chest.

Back to suicide talk. In Tom Szasz’s last book, Suicide Prohibition: The Shame of Medicine, (see my book review in Ethical Human Psychology and Psychiatry, Vol. 14, #1, 2012, pg. 74) he makes a powerful case that by locking up patients who speak about self harm we not only infringe on their civil liberties, but also drive that speech underground.

Think of it, if someone tells me they are suicidal I am duty bound to call the cops! An exaggeration, but not much of one. Hospitals and doctors are frequently sued by surviving families. “You should have been more attentive, careful, protective. Had you not been derelict my son/daughter/wife, etc., would still be alive.” So hospitals and clinics and counselors always have on their checklist a rating for self-harm. That checklist surely is for legal purposes. Or perhaps it is there for reassurance for the institution.

You would not be surprised, I suspect, that some in conventional psychiatry would promote, then, their various somatic treatments as suicide preventative. Allow me if you will to focus only on ECT. This blog is not going to be a diatribe against ECT. If you are hankering for an “I-hate-ECT" thesis, read Linda Andre’s Doctors of Deception: What They Don’t Want You To Know About Shock Treatment (2009, Rutgers University Press). She claims that ECT “impaired my intellect” (pg. 131) and did irreparable harm to retrieving her early life memories. She rakes the ECT profession over the coals.

If you are in a particularly angry mood you’ll like Andre’s book. She bashes Peter Breggin as well calling him a “costly disaster “(pg. 118). Evidently the Marilyn Rice case way back in 1977, the first case to adjudicate a malpractice suit against an ECT Doc for memory loss, did not go well for the plaintiff. Breggin was Rice’s expert witness. I’ve never discussed the case with Peter. I assume it is no easy task to prove that ECT treatment in one particular case is the cause of the memory loss. Do your own research. I’ll comment later.

Oh, but you may feel kindly about ECT. Then by all means read Edward Shorter’s and David Healy’s Shock Therapy, A History of Electro Convulsive Treatment in Mental Illness (2007, also Rutgers University Press) which they dedicate to a “small band of European emigres [who]… saw the merits in ECT… [they are] heroes in [the] 20^th century of psychiatry…” (dedication page)

Shorter is a prominent medical historian and Healy was a presenter at the 2015 ISEPP Conference. Healy is the beloved psychopharmacologist of our organization because of his litigative efforts that helped lead to the black box warning for SSRIs. In his book Let Them Eat Prozac (2004, New York University Press) he takes on the fraudulence in the psychopharmaceutical industry that hid the danger of SSRI therapy. In his book he also shares some of the best work I know of in testing the impact of these drugs on “normals.” On the other hand he is anti-beloved by many in our organization because of his high regard for ECT. Nobody’s perfect. 

In Shock Therapy, Shorter and Healy toss a lot of statistics at us (see page 97) supporting their thesis that ECT prevents suicide. Maybe. “[There is]…no doubt that ECT was effective in the prevention of suicide. This was confirmed in 2005 in a large multi-center study led by Charles Kellner at University of Medicine and Dentistry of New Jersey.” The second of 16 authors this study was Max Fink, the father of American ECT. The authors hold out this study as particularly worthy to their cause. The conclusion of this very ambitious study is that it was “irresponsible" not to prescribe ECT sooner clinically, not as a “last resort” after the failure of chemical treatments. I had to read this study. After all, I don’t want to be “irresponsible.” But first, some statistics.

If you go to the American Foundation for Suicide Prevention website you are quickly smacked with the statistic: “An American dies every 12.3 minutes by suicide.” That is 42,773 in 2016. Wow, a lot of suicide. And, oh, BTW, 90% of them had diagnosable disorders. Thank God for the DSM to clarify difficult issues!

Hold on. Let’s put aside the hysteria. Just how many people did die in 2016? According to the National Center for Health Statistics that would be 2,626,418. That is, one American died every 12 seconds in 2016. I did the math. What did they die of? The usual suspects:

-Heart Disease: 614,348

-Cancer: 591,699

-Stroke: 133,103

-Alzheimer’s 93,541

-Diabetes: 76,488

-Flu and Pneumonia: 55, 227

-Nephritis: 48,116

-Suicide: 42,777

In other words, only 1.5% of those who died in 2016 were those who chose to die sooner rather than later. When talking about death in America, suicide is not common. Yes, of course it is often tragic, like a kid suffering bullying who can’t stand it any more. Tragic does not mean common.

Back to Kellner and Fink’s large multi-center (there were 5 hospital centers throughout the country) work. They “studied “ 444 depressed ECT patients, 131 of whom reported suicidalness according to the Hamilton Depression Scale. Results: after one ECT treatment, 15% dropped their Hamiltonian suicidalness to 0; after 3 ECT treatments 38% dropped their Hamiltonian suicidalness; 61% after 6, and 76.3% after 9 ECT sessions. And 87.3% dropped their Hamiltonian suicidalness after completing the treatment course. Wow, pretty impressive. No? Well I’m not convinced either. Remember the statistic – suicide is really not that common. Thinking about ending an unhappy life is very common. So let’s go to the fine print.

There were 2 patients in the study who died of suicide, 2 white men aged 76 and 80. One had expressed “no suicidal intent” before or after the treatment and the other scored a “1” before and a ‘0’ after the treatment. Thus this study only corroborates that ECT has a dramatic impact on stopping thinking about suicide. It tells us nothing about the actual action.

And this is why I don’t prescribe ECT. It interferes with thinking and remembering. For me it is more a philosophical stance than a medical-statistical position. I value thinking and remembering. Thinking about suicide is so common, so important, but actual suicide is so rare, it is my impression that suicidal thinking and dialogue in therapy is much more about life than it is about death. What I mean is that many unhappy people just don’t have the language to examine their unhappiness. The best they can do is, “I want to die, end it.” The therapeutic relationship helps give voice and create expressive language. Scrutinizing why someone is suicidal is important, ok. But really, we know why people want to die: despair, rage, hopelessness, pain, profound shame, abject loss. That needs to be validated of course. But as important, perhaps more important is what keeps us alive. So for me it is more important to ask, “What stops you? Why haven’t you done it?” And then I begin to hear about their life. That’s where the therapeutic action is.

I’ve had one completed suicide in my practice, that is, one who killed himself while in therapy. He never once talked of ending his life. Not once. I wish he had. If he had, he might still be alive today.