OMG!!!That'sWhatTheySaid -- Failed Method/Successful Attempt

OMG!  it has been four months since I last gave an OMG! Award.  It's not that I don't keep finding excellent candidates.  It's just that I have been covering other major topics.  Plus, life just...

I am amazed and disappointed to give this month's award to HealthCentral.com for their July 22nd news release, Failed Suicide Method May Predict Likelihood of Successful Attempt.

First, let me introduce HealthCentral.com.  From their website:

Health Central's mission is to empower millions of people to improve and take control of their health and well-being.

• Our 35+ sites provide clinical resources and real-life support to those with life-changing conditions.

• Our wellness resources and tools help people to live healthier, more fulfilled lives.
  

• We are honored to serve over 12 million visitors each month.

Health Central addresses lots of different health issues, including mental health.  Often their information is excellent.  This time they missed the boat with this OMG Award-winning title to one of their featured articles.  They don't get points for originality.  They have repeated a much too popular -- what shall I call it?

Let me put it this way:

A twenty-seven year old woman is diagnosed with breast cancer.  Young women with breast cancer generally have a poor prognosis.  So she receives the most aggressive treatment available, including procedures that damage her body in ways that can be mended and other ways that cannot.  She undergoes intense pharmacological treatment using harsh chemicals that leave her sick, debilitated and at risk for other health complications.  Willing to try anything, she joins a support group, does mindfulness and visualization and changes her diet.

These measures eventually do work.  Her cancer goes into remission.  Her health is monitored carefully for a long time.  Just when she and her family begin to breathe again, she relapses.  Again, she opts for aggressive treatment, tries new drugs prescribed in off-label use, and again is left too weak to care for her children or leave the house.

This time, everybody's best efforts do not work.  She dies.

Does her doctor call that a success?  Does the preacher say she fought a long hard battle and finally succeeded?

Let me put it another way.

A middle-aged man has heart disease.  He gets regular medical attention, takes all his meds, monitors everything he is supposed to monitor, changes his lifestyle, even his job to reduce stress.

Nevertheless, he has a heart attack, in fact, several heart attacks.  Each time he is rushed to the hospital, where emergency personnel work their butts off to save him.  He is transferred to ICU, then to a regular bed, then to rehab.  His family posts frequent status reports on facebook, and his church prays for him every week.

Does anybody say he failed?  That he wasn't serious about these heart attacks of his?  When he returns to church or the golf course, do they turn their faces, afraid they might say the wrong thing and provoke another attack?  One that might be successful?

Mental illness is physical illness.  It has a mortality rate, just like cancer and heart disease.  We struggle desperately for years and undergo every treatment we can find and tolerate, trying to survive our illnesses.  Death by mental illness is not a success.  It is a tragedy.  Survival is not a failure.  When somebody has to be rushed to the hospital and manages to fight his or her way back to life, it is a hard won victory celebrated in heaven.  It ought to be celebrated on earth.  This person deserves a party.  With balloons.  And a cake.

Now let me pause to discuss the content of the article with this outrageous title, because the article does give important information.

The article reports research into the prognosis of suicidal individuals according to the method of self-harm they originally use.  The numbers are astounding.

Those whose initial act of self-harm takes the form of hanging, suffocation or strangulation have the poorest prognosis.  Of those who survive, 85% of them die at their own hand within a year.  They do not get it out of their system.  They die.  Within the year.  85% of them.

Those who jump, or use a firearm or drowning are at a moderately lower risk of subsequent death (69-78%, as reported in the original research.)  Those who use poisoning, overdose or cutting have the lowest risk of completed suicide with in year (25-36%.)

These figures hold true when controlling for diagnosis and for sociological factors.

That said, the single greatest risk factor for death by suicide is a previously survived episode.  Nobody gets it out of their system.

These findings have implications for aftercare.  Just as the most aggressive treatment is warranted for younger women with breast cancer and out of shape persons with heart disease, those whose original method of self-harm is hanging, strangulation or suffocation need the most intensive follow-up, monitoring and treatment.

Again that said, one potentially harmful consequence of this report is that those who use less lethal means, such as cutting or poison, may be dismissed as not serious, as engaging in attention-seeking behavior.

Yes, cutting and overdose are attention-seeking behaviors.  They are the serious attempts of seriously ill people to get serious attention for their serious condition.

Cutting and overdose have serious health consequences.  They are the methods used most often by Latina and African-American girls, who have less access to health care and mental health care anyway.  The consequences of not receiving the attention that these girls plead for are first, brain and liver damage, and then further deterioration of their lives, including dropping out of school, substance abuse, being continued victims of violence at their own hand or that of family and acquaintances, continued poor health choices and early death on account of all of the above.

If you turn your face from anybody who commits a potentially fatal act of self-harm by any means, you become the Scribe who turned his face from the man who was mugged, beaten and left for dead on the road to Jericho, because you count your agenda more important than that person's life.

As I said, this would be an unintended consequence of this article, and one that the author seek to avoid: However, "although use of more lethal methods of self-harm is an important index of suicide risk, it should not obscure the fact that self-harm in general is a key indicator of an increased risk of suicide," Hawton wrote.

Back to the OMG! Award.  I am on a Mission from God.  It is my mission, in whatever years I have remaining of my own life, permanently to eradicate the use of the word successful in the same sentence as the word suicide, and to eliminate the scandalous naming of survival as failure.

So I plead for your help.  I plead, when you hear a grieving friend or family member say that their loved one who died of mental illness was successful in the attempt, I plead that you tell that person, kindly and gently, Suicide is not a choice; it happens when pain exceeds resources for coping with pain.  I am so sorry for your loss, and so sorry that your loved one has lost the battle.

I plead that you, whenever you hear health care professionals refer to a failed attempt, that you feel and that you express your shock and horror at the words.  I plead that you confront them, and urge then to examine the hostility toward their patients and clients that lie beneath their words.

I don't usually inform people that they are winners of the OMG!!That'sWhatTheySaid Award.  Following what I have urged you to do, I will inform Health Central of their award.  Right now. 

Nationalism and Patriotism -- For the Love of My Country

There is nothing funny about nationalism. Nationalism does not laugh at itself.

Patriotism, on the other hand, is like family. The Muppets are patriotic. Even those who don't speak English.

Language in the Clinician's Office

This week I return to my favorite theme -- the power of language.  Those of us who have a mental illness deal with the power of language every day.  Notice I didn't call us the mentally ill.  Language forms who we are in this world.  It underpins the terms of our treatment.  It structures how we pay for our treatment.  Diagnosis is where language meets money.  And money is power, power over our lives.

Reframing is a process of becoming conscious of the power of language.  This is a standard tool in Cognitive Behavioral Therapy.  The term is used in a variant of CBT called Neuro-Linguistic Reprogramming (NLP).

OMGThat'sWhatTheySaid! -- They

"We are more alike than we are different."  That was the first thing they wrote on the whiteboard at my Peer to Peer class.  And that was the first thing I wrote in my new notebook.  I had a sense that a revolution was coming.  But I didn't know yet what it was.

The next week we introduced ourselves by how we are different, our differential diagnoses.  We were Mary Obsessive Compulsive Disorder, Frank Bipolar, Sarah Borderline Personality Disorder, Peter Bipolar Antisocial Schizoaffective Disorder ("But I'm not so sure the schizoaffective part is right"), James Schizophrenia, Anna Major Depressive Disorder, Henry Bipolar Alcoholic, Willa Major Depressive Disorder ("But I wonder about Bipolar II").  Of course, I have changed the names.

The power of naming -- the third week we sorted out our seating arrangements.  That wasn't part of the class.  It just happened, when we entered the room and chose our seats.  The OCDs sat with the OCDs.  The Mood Disorders sat with the Mood Disorders. Interestingly enough, those with Schizophrenia did not sit together.  They dispersed themselves among us Mood Disorders.

OMGThat'sWhatTheySaid! -- Stigma

On November 26th, the New York Times published an article about the presidential policy not to write letters of condolence to the families of service men and women who commit suicide in a war zone.  These letters of condolence have gone out since Abraham Lincoln started writing them during the Civil War.  Given the upswing of suicides in the Armed Services lately and the attendant publicity, this policy of silence, which began in the Clinton era, is coming under scrutiny and challenge.

In response to this article, psychiatrist Dr. Paul Steinberg wrote an Op-Ed commentary titled "Obama's Condolence Problem," winning him this month's OMG Award for -- oh, it's hard to choose.  There are so many prize-worthy lines.  But let's call it for: Indeed, there is nothing wrong with stigmatizing suicide while doing everything possible to de-stigmatize the help soldiers need in dealing with post-traumatic stress and suicidal thoughts. I will deconstruct this sentence after putting it in context.

Dr. Steinberg is concerned that any recognition of suicide, even the reporting of it, glorifies it and makes the taking of one’s life a more viable option. If suicide appears to be a more reasonable way of handling life’s stresses than seeking help, then suicide rates increase.

Dr. Steinberg is clearly in the voluntarist camp, believing that people make a conscious, reasoned choice to kill themselves.  Suicide, in his view, is an option, a way of handling life's stresses.  He is in, if not good, then plentiful company, who believe that even while the thought processes of those who commit suicide are impaired, their will is not. They remain responsible for their choice.

Regular Prozac Monologues readers know that I am not in the same company.  Dr. David L. Conroy gave me the words.  From Out of the Nightmare: Recovery from Depression and Suicidal Pain, "Suicide is not chosen; it happens when pain exceeds resources for coping with pain."

Conroy describes the many ways that people who are suicidal attempt to reduce their pain and save their own lives.  Those who are suicidal sometimes use the language of choice and reason.  Conroy, who speaks from personal experience, says it is terrifying to have such little control over our own emotional state that it can shove us headlong over the abyss.  This lack of control is part of, and adds to suicidal pain.  To claim that we have considered the options and are making a reasoned decision is a grasping for the image of control; it is an effort to relieve pain.

Steinberg asserts that choosing suicide over treatment is deserving of shame.  Now that first-rate treatments for depression and post-traumatic stress have evolved and are readily available, and people with emotional problems do not have to suffer quietly, are we taking away the shame of suicide?  When he decribes depression treatments as first-rate, he parts company with the National Institute of Mental Health and many doing research in the field, who acknowledge the true state of treatment.  At least a third of those who seek treatment are not able to find a medication that is effective and tolerable.  Meanwhile, certain side effects of these first-rate treatments themselves increase the risk of suicide, doubling it in the case of insomnia, a frequent side effect of SSRI's and SNRI's.  Akathesia (called "inner restlessness" on prescribing information sheets) is one of the most under-reported side effects, due to euphemisms, and among the five top risk factors for suicide among hospitalized patients.  [Side note: when you read "inner restlessness" on your prescribing sheet, did you realize that "inner restlessness" could significantly raise your risk of suicide?]

Steinberg believes that letters of condolence to family members could be an inadvertent incentive to suicide.  In light of the condolence-letter controversy, the administration is appropriately reviewing the policy that has been in place for at least 17 years — and may indeed want to consider leaving it as it is. But as a country, let’s focus our energies on doing everything we can to diminish inadvertent incentives that might increase self-inflicted deaths.  And elsewhere: We need to find the right balance between concern for the spouses, children and parents left behind, and any efforts to prevent subsequent suicides in the military.

I feel downright silly answering this argument.  But here it is:

First, the shaming of suicide is indeed one of the resources that we possess against it.  But it is an even more significant reason why people do not acknowledge and seek help for thoughts of doing it.  Shame interferes with willingness to report symptoms.  And failure to report symptoms is a significant factor in failure to recover.  To think that we can shame suicide and prevent it at the same time is fanciful. There is no balance to be found here.

Second, it is well known that surviving family members are themselves at greater risk of suicide.  Shame increases their pain, including their suicidal pain.  It is a barrier that prevents them from seeking support and prevents friends from offering it.  A letter from the President could go some distance in reducing the shame of family members and providing comfort in the midst of their pain.  If prevention of suicide is the goal, here is the most direct intervention the President could make.

Now back to the beginning.  Indeed, there is nothing wrong with stigmatizing suicide while doing everything possible to de-stigmatize the help soldiers need in dealing with post-traumatic stress and suicidal thoughts.  Putting to one side the impossibility of de-stigmatizing the second while stigmatizing the first, let's take a closer look at what Dr. Steinberg wants to de-stigmatize -- the help soldiers need.  What help would that be?  Psychiatry, leading the mental health professionals.

Steinberg wants to stigmatize suicide and de-stigmatize himself.  That's natural enough.  Nobody likes to be the object of stigma.  People who experience suicidal pain can identify with him in his desire. But I took a fanciful direction upon reading this op-ed piece.  I imagined Dr. Steinberg as a chaplain taking a course in Clinical Pastoral Education.  Are my clergy readers following me here?  Think back to your CPE experience.  Imagine the conversation in group after Dr. Steinberg says Indeed, there is nothing wrong with stigmatizing suicide while doing everything possible to de-stigmatize the help soldiers need in dealing with post-traumatic stress and suicidal thoughts.  Somebody from my CPE group would surely have asked, "How does it feel to be the object of stigma?"  And if he returned the question with a quizzical look, "How do you feel to know that people would rather commit suicide than come to you for help?  What does that mean to you personally?"

To my psychiatrist readers (do I have any?), do you have any training like CPE, where you are asked to examine your personal feelings and consider how they affect your judgments and your treatment of patients?  Does it include your judgments about suicide?  How do you feel about yourself when one of your patients commits suicide?   How do you feel about that patient, and the next patient with suicidal ideation?  Can you acknowledge those feelings?  Is shame part of your own experience?  Where have you put your shame?  Your feelings are just that, feelings.  Can you use them to inform your understanding of your patients?

I posted a facebook status last week with a link to Dr. Steinberg's article, asking, "Do patients with any other disease face such disrespect from their doctors?"  I am going out on a limb here.  But I wonder if many psychiatrists have not yet dealt with their feelings about their patients' dying.  When oncologists did, the treatment of cancer patients changed.  Now, who even remembers that cancer once was shamed?

OMGThat'sWhatTheySaid! -- Language

The following post contains material that could be considered uppity, outlaw, provocative, offensive and paranoid. 

This month's OMGThat'sWhatTheySaid Award considers the nature of the vocabulary that we all use for mental illness, in particular, the language that norms the relationship between those who receive a diagnosis and those who make it.

Once upon a time, I wrote a senior thesis for Reed College on this topic.  I was a religion major, and it was 1975, when the Episcopal Church was considering the ordination of women.  My topic was what priests are called.  My thesis was that the language we use establishes the normative relationship between priest and parishioner.  I am discouraged thirty-four years later, that new, freshly graduated priests in Iowa still permit and even encourage little old ladies to call these twenty-somethings "Father."  Oh well.

In the mental health field, this kind of paternalism is out of favor, perhaps the influence of so many women in the field.  But the language has not escaped from reinforcing the power relationship, one up and one down.

Suicide Prevention for All of Us

I end this month's focus on suicide with what we can do. Remember, "Suicide is not chosen; it happens when pain exceeds resources for coping with pain." (David L. Conroy, Out of the Nightmare: Recovery from Depression and Suicidal Pain)

So the way out of the nightmare is laid before us: reduce pain and increase resources.   Somewhere below is something you can do for yourself, for those you love and for those whom you have been commanded to love, if you believe in that sort of thing.   These lists are from Conroy, pp. 300-302.  My remarks are in brackets.

OMG!!! That's What They Said!

First, how did I ever start reading so much about depression, medication and the brain, the topics of Prozac Monologues?  Well, it was after I took two antidepressants that made me crazy and one that made me sad.  Then I was back in a psychiatrist's office, and she said, You have to weigh the costs and benefits.  And I took her seriously. 

But the information she gave me and that I found on the prescription information sheet wasn't very much information at all, not the kind that would have helped me when I was taking the antidepressants that made me crazy.  I knew this because I had read them, and they didn't help me.  I will write more about this some other time. 

The Language Of Doctors And Scientists