A Tribute to Robin - Suicide Awareness

It was not long ago that the media was focused on Heroin following the death of actor Philip Seymour Hoffman.  Although the fatalities resulting from accidental overdoses of this deadly opiate have surpassed deaths from MVA's and homocides in my city alone, the truth often times requires a jolt to our senses.  We were in disbelief.  Not  that this esteemed actor could have suffered from such an addiction but that he was unaware of the potency of the heroin he was using - that he would die that night.  It was ruled an accidental overdose.  Lesson learned?  Heroin is equally capable of causing death as it is euphoria.

Sadly, we are now focused on suicide.  We struggle again with our confusion over Robin William's death.  Although the circumstances are different, one death accidental, the other, intentional, we struggle with the circumstances surrounding his death - recent attempts to maintain sobriety, knowledge that he was suffering from a severe depression, the awareness that Robin KNEW he would die that night.  We just don't want to go there.  We don't want to permit our senses to imagine the severe pain he was in.

Now we are focusing on the topic of Suicide.  And it seems appropriate for me to follow yesterday's blog devoted to depression with this topic.  I had published this suicide article some years ago in a 4 part series dealing with depression.  The risks and warning signs are listed.  But as we all have concluded, no one can accurately predict the intentions of those that suffer.

The one thing I have learned throughout the years - if one intends to die, they most likely will be successful.  The most important risk factors I know are a previous history of attempts, use of alcohol or drugs that can lower inhibitions, the likelihood of rescue is reduced, and, a seldom discussed risk factor - a change in energy and mood.

Allow me to elaborate.  If the individual suddenly shows a change in their mood or energy level, e.g., wanting to shop or go outside vs. isolating and beginning to display a smile vs. crying,  then consider that suicidal intent may already be present.  The smile may indicated an internal resolution that the decision to end his/her life has finally been made.  The increased energy allows the sufferer to develop the plan and carry out the intent.  Lesson learned?  No one is immune.

Below is my original blog.

Over 34,000 people die of suicide a year - translating to one person dying every 15 minutes. Although women are more likely to try, men are more successful because of the more violent means they choose - firearms or hanging. 90% of adults and 60% of adolescents who commit suicide have a diagnosed mental illness, especially depression or substance abuse. And, sadly, 70% of older individuals visited their PCP within the month of their suicide.

The above statistics are important as it underscores this very important consideration - that suicide might be preventable.

Again, I always consider the Biopsychosocial characteristics of an individual when considering signs of suicide as well as risks of suicide. And why? Because there is no poster person that represents the face of suicide. Although statistics are an important consideration, it is the individual we are truly analyzing.

The following are WARNING SIGNS listed by a Suicide Prevention Program called Yellow Ribbon. Please visit them at www.yellowribbon.org:

WARNING SIGNS

Abrupt changes in personality
Giving away possessions
Previous suicide attempt
Use of drugs and/or alcohol
Change in eating pattern - significant weight change
Change in sleeping pattern - insomnia/oversleeping
Unwillingness or inability to communicate
Depression
Extreme or extended boredom
Accident prone (carelessness)
Unusual sadness, discouragement and loneliness.
Talk of wanting to die
Neglect of academic work and/or personal appearance
Family disruptions - divorce, trauma, losing loved one.
Running away from home or truancy from school.
Rebelliousness - reckless behavior.
Withdrawal from people/activities they love.
Confusion - Inability to concentrate
Chronic Pain, Panic or Anxiety
Perfectionism
Restlessness

Many of the above warning signs refer to the biological and psychological factors I discussed in previous posts. Yellow Ribbon also emphasizes the need to consider the RISK FACTORS. Many of those listed here refer to the sociological factors. Coupling the two gives a clearer suicidal risk. I agree entirely.

RISK FACTORS

Problems with school or the law
Breakup of a romance
Unexpected pregnancy
A stressful family life. (having parents
who are depressed or are substance
abusers, or a family history of suicide
Loss of security...fear of authority, peers,
group or gang members
Stress due to new situations; college
or relocating to a new community
Failing in school or failing to pass
an important test
A serious illness or injury to oneself
Seriously injuring another person or
causing another person's death
(example: automobile accident)
Major loss...of a loved one,
a home, divorce in the family,
a trauma, a relationship

Yellow Ribbon stresses the following:
Suicide victims are not trying to end their life - they are trying to end the pain!

How can we help?
First of all, don't be afraid to be direct. Talk openly and matter-of-factly about suicide.
You have to be willing to listen. Allow the person to express their feelings.
Do not be judgmental. Don't debate whether suicide is right or wrong, or feelings are good or bad. Don't lecture on the value of life.
Don't be afraid to get involved, to be available, to show interest and support
Don't act shocked. You want to maintain their trust in you,
Don't be sworn to secrecy.
Offer hope that alternatives are available but do not offer glib reassurance.
Ask if they have a plan. Take action. Remove any means, such as guns or stockpiled pills.
Get help from persons or agencies specializing in crisis intervention and suicide prevention.

If you are experiencing thoughts of suicide, or have even developed a plan or have the intent, please contact someone you know, visit the closest ER or call the number listed below.

If you are worried about someone and see some warning signs and/or identify risks, please consider getting involved.

The National Hopeline Network 1-800-SUICIDE provides access to trained telephone counselors, 24 hours a day, 7 days a week.

When I lost my son, Andy, at age 19, to an accidental drug overdose, I started a foundation modeled after Jason's Foundation which is dedicated to the silent epidemic of teen suicide. Please visit www.jasonfoundation.com if you are concerned about our younger generation.

Peace be with you, Robin.

In memory of Robin - May your legacy inspire others to seek help for depression.

As we all attempt to understand the tragic death of Robin Williams, a man whose unique talents could make us laugh like no other, we are also contemplating the question, "why?".  Why could this man, who was blessed with so many riches, be depressed as the reports are bearing out.  Some reports have gone so far as to speculate suicide.  We are in disbelief.  How could this be?

Did you not think he was human?  That he was immune to influences that affect us all - our family history, our ability to cope, our daily stressors?  His laughter lifted many of us out of the doldrums, me included.  And his sensitivity, his ability to play roles that demanded he tap into his emotional side, enabled him to portray award worthy roles such as Patch Adams and the professor in Dead Poet's Society.   But Depression knows no boundaries.

This blog is devoted to Robin Williams.  May his legacy inspire others to seek the treatment they need for depression.

What is depression? If you were to ask your friends or family, or be brave enough to conduct a survey of passing strangers on a street corner, I guarantee you would get a variety of different responses. That is because depression has become an umbrella term used by many individuals to describe a number of different moods ranging from "the blues" to a severe, debilitating state where nothing but suicide could end their pain. There is quite a gap between these two ends of the spectrum. So, let's begin by defining depression more clearly.

First of all, I am very grateful to have a person who is feeling "depressed" actually sitting in my office. Most of my patients who are depressed may be referred by their primary care provider (and may not follow through). Some are brought by a family member or friend, not necessarily willing to provide details to a complete stranger. Very few individuals come on their on volition. So, when I am given this opportunity, I better be able to diagnose my client correctly. 

As a psychiatrist, I rely on specific criteria to diagnosis an individual with a major depressive episode. The interview is critical in gathering the objective data. I rely on an acronym to obtain the necessary information - SIGECAPSS. This represents the following symptoms: (S) Sadness or depression; (I) lack of interest or anhedonia; (G) guilt, poor self-esteem, worthlessness; (E) loss of energy; (C) poor concentration; (A) changes in appetite, either increased or decreased; (P) psychomotor retardation or agitation - most likely observed by others ("All you do is sit around" or "You seem more edgy than usual"); (S) changes in sleep pattern, either increased or decreased; and, most importantly, (S) suicidal thoughts, plans, or intent. The DSM-IV manual (the psychiatrist's bible for establishing diagnoses) requires that at least five (or more) of the above symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) (S) depressed mood or (2) (I) loss of interest or pleasure. If the symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning such as family relationships then it becomes a major depressive disorder. I have also been required to rule out any medical condition that could contribute to depression (e.g. hypothyroidism), any concurrent use of alcohol or drugs that can influence or mimic some of the above symptoms, or bereavement symptoms that have not become more debilitating after a two month interval. I am not at all dismissing the depression that can be attributed to other general medical conditions, substance abuse, or pathological bereavement. These individuals are just diagnosed under  different terminologies. In addition, individuals with other mental illness, including bipolar disorder, schizoaffective disorder, or adjustment disorder with depressed mood can also experience the same symptoms. It is beyond the intention of this posting to address these other conditions but will be discussed at another time.

When I wrote above that I am "grateful" to be able to assess a person face to face, I truly meant this. Depression is treatable. Statistics claim that women are twice as likely to develop depression than are men. Based on the gender of my clients, I suspect that this statistic is true. However, men are also less likely to admit that they might be suffering from depression. Woman are more likely to attempt suicide but men are more successful.

PLEASE!!!!! Even if you are feeling "a little blue", or if a friend, a colleague, a family member gives you some feedback about a change in your behavior, promise me that you will at least talk to your primary care physician. If you do not have one, turn your insurance card over and call the number for behavior health services for a referral. If you do not have insurance, there are community mental health services in your county that can offer you services. MOST IMPORTANT - if you have thoughts of suicide, please go to the nearest Emergency Room for an evaluation. Please promise me that. I may not know you or the extent of your grief or your stressors. But I do know that everyone on this earth is precious. Life is precious. Please have faith and know that you are loved.