Night Falls Fast

by Kay Redfield Jamison

  During the first hours of hospitalization she appeared as a neatly dressed attractive young woman who was immediately comfortable with staff and patients. There was no objective evidence of depression. Over the weekend she overdosed with alcohol and sedatives. On Monday when she reappeared at the hospital, medications were immediately discontinued. The patient made many attempts to have her medications restored to her and refused to recognize that her inappropriate use of medication could be sufficient grounds for the discontinuance. By Monday afternoon she had become openly seductive with the resident therapist and demanded sexual relations. Her appearance and behavior had become more disorganized and bizarre. Attempts to discuss the rapid fluctuation in the patient’s appearance and mental status were explained as evidence of her “illness,” for which she had no understanding. When the therapist pointed out that the patient’s ability to manage her own life and deal with her intense feelings seemed better prior to hospitalization, the patient became enraged and stated that she would go to another hospital where the doctors understood her better and would be less distant. She stormed out of his office and left the building

  After several minutes the therapist left his office. He returned ten minutes later and found the patient standing in a pool of blood. She had smashed the windows in his office and cut herself with the glass. Several months later she explained: “You were supposed to be in your office for me, even if I said I was leaving. I knew you would be there. When you weren’t, I suddenly saw my father’s face appear on the glass coming at me. A great tear appeared in his face. The world was being torn apart. I began to smash out the images.”

  The brief psychotic episode was followed by a second one on the same day when a meeting was held with the patient’s husband. In spite of the patient’s demonstrated capacity for regression, the conditions for treatment and hospitalization in terms of the patient’s responsibility for her own behavior were restarted. The patient began telling her husband of the doctor’s callous indifference to her. When this failed to alter the stated conditions for continuing treatment in the hospital, the patient fell to the floor, began chewing on the chair leg and making bizarre moans and cries. He pulled her off and angrily stated that her behavior clearly demonstrated her need for intense treatment and her inability to be responsible for herself. The therapist maintained his position, and the patient assumed a trancelike appearance. She and her husband left the office to seek hospitalization elsewhere.

  One hour later the therapist received a phone call from the patient. Her voice was clear and direct, as upon admission. She said, “Doctor, I agree.” Her agreement was to continue treatment as initially stated. She was immediately discharged and seen as an outpatient for the next one and one-half years. Several brief psychotic episodes occurred during subsequent therapy sessions. Each related to real or suspected object loss. The identification of the loss in each case was followed by the lifting of the psychosis within the treatment hour. Had this patient been seen during one of her regressed states without the benefits of previous history she could easily have been diagnosed as schizophrenic.

  The major clue of her actual diagnosis was the open and dramatic discussion of symptoms coupled with the mobilization of numerous people in the environment on her behalf.

  All the psychiatric conditions we have been discussing—the mood disorders, schizophrenia, and the anxiety and personality disorders—are not only painful and terrible illnesses to have, they also have profound, usually alienating and destabilizing, effects on the ability of the affected person to have meaningful relationships, to engage in satisfying and economically viable work, and to believe in the point of living. All these disorders are also made infinitely worse by using alcohol or drugs.

  Schizophrenia and the mood, anxiety, and personality disorders are at the heart of many suicides, but by no means all. Alcohol and drug abuse, either in their own right or, more commonly, in combination with depression and other mental illnesses, take a terrible toll as well. Substance abuse, like manic-depression and schizophrenia, usually begins early in life, often in adolescence or the early twenties, and, once it has set in, has a stubbornly progressive course. Despite massive and often irreversible personal, financial, social, legal, and professional problems, people with a drinking or drug abuse problem typically continue compulsively to use the substances that are destroying them.

  It is not always easy to sort out dependence on drugs or alcohol from the depressive illnesses that can precede, accompany, or follow the onset of substance abuse. Both kinds of problems involve disturbances in mood, thinking, behavior, sleep, and appetite. Alcoholism can cause most of the symptoms of depression, and very serious depression can follow prolonged periods of drinking. The reasons for this are both obvious and subtle. Psychiatric illnesses such as depression, mania, and schizophrenia are painful and frightening. Drugs and alcohol can, in the short term, bring relief from the despair and blot out, for a while, a sense of hopelessness and ragged nerves. Drinking increases not only during depression but most pathologically so when people are manic or experiencing agitated mixed states. These perturbing conditions invite the use of alcohol or other drugs, such as sedatives and hypnotics, to tamp down the restlessness, afford the possibility of sleep, and cloak, however briefly, the unpleasant sensations that are such a large part of these psychological and physical conditions.

  Self-medication to lessen disturbing thoughts and grisly moods tends to be quite specific in practice. Cocaine, for example, is used by many who are depressed not only as an antidepressant—albeit an exceedingly costly and ultimately damaging one—but also, in those with manic proclivities, to induce mild manias or prolong existing ones. Opium has served a lulling, numbing function for centuries, and alcohol, although pharmacologically a depressant and a killer of all but fractured sleep, is used by millions to erase the moment, give the slip to depression, and induce senselessness.

  The relationship between alcohol, drugs, and mental illness is a looping-back-upon-itself, reverberating one. Drugs, at first use, work well and often enough to have been employed for thousands of years throughout the world as a core means for grappling with anxiety, distress, depression, and psychosis. Fermented grains, rolled coca leaves, and the juice of poppies have been the commonest choices to chase the blues, resurrect the deadened senses, obliterate pell-mell thoughts, or stifle intrusive voices. But the use of such drugs has always been risky. To the extent that they work, they do so by altering the fine tuning of the brain and muffling its consciousness. As such, they are blunt agents that, with prolonged use, alter or damage the brain’s delicate chemistry. In doing so, they work huge damage in the relationships, jobs, health, and pride of those who are dependent on or addicted to them.

  Alcohol and drugs, used to contend with the pain of mental illness, more often worsen it. Independently or together they can precipitate acute episodes of psychosis, worsen the overall course of the underlying illness, and not only undermine the individual’s willingness to seek out and receive good clinical care but also sabotage the effectiveness of prescribed treatments. Substance abuse loads the cylinder with more bullets. By acting to disinhibit behavior, drugs and alcohol increase risk taking, violence, and impulsivity. For those who are suicidal or potentially so, this may be lethal. So too may the savage mood swings that often accompany substance abuse or withdrawal from drugs. With judgement warped, personal relationships made chaotic or destroyed, and an escalating desire for the substances that, over time, work decreasingly well, it is perhaps not surprising that when drug and alcohol abuse combine with psychopathology they form an intensely volatile environment for suicide.

  Research tends to support the idea that in those who have both, mental illness usually precedes the addictive disorders. Edgar Allan Poe, no stranger to turbulent moods chased back by wine and cider, observed, “I am constitutionally sensitive—nervous in a very unusual degree. I became insane, with long periods of horrible sanity. During these fits of absolute unconsciousness
I drank, God knows how much or how long. As a matter of course, my enemies referred the insanity to the drink rather than the drink to the insanity.” His description is a telling one.

  Unfortunately, mental illness and alcoholism or drug abuse often go together. Two of every three people with manic-depression, and one of every four with depression, have substantial alcohol or drug abuse problems; the rates for those with schizophrenia are nearly as high. More dangerously, those who are both mentally ill and have such a problem are at far greater risk of attempting or committing suicide. The combination of alcohol and depression is implicated in the majority of all suicides. Drugs and mood disorders tend to bring out the worst in one another: alone they are dreadful, together they kill.

  Poet John Berryman, in and out of hospitals for both his alcoholism and his manic-depression, saw his drinking and mental illness pull down the pilings of his life and erode the foundations of his marriage, friendships, and writing. Two years before he jumped to his death from a bridge—ending his own life, as his father and aunt had done before him—he wrote of the futility of his mental state. Returning to his home after yet another wild bender and ill-considered sexual entanglement, Berryman found himself confronted by his wife, an official from the university at which he taught, and police officers who were about to take him, in restraints, to a psychiatric hospital:

  He knew he was standing in his entry-hall. Wife facing him, cold eyes, her arm outstretched with a short glass—a little smaller than he liked—in her hand. Two cops to his left. His main Dean and wife somewhere right.… The girl had gone. He was looking into his wife’s eyes and he was hearing her say: “This is the last drink you will ever take.” Even as somewhere up in his feathery mind he said “Screw that,” somewhere he also had an unnerving and apocalyptic feeling that this might be true.

  CHAPTER 5

  What Matters It, If Rope or Garter

  —METHODS AND PLACES—

  Since we can die but once, what matters it,

  If rope or garter, poison, pistol, sword,

  Slow-wasting sickness, or the sudden burst

  Of valve arterial in the noble parts,

  Curtail the miseries of human life?

  Though varied is the cause, the effect’s the same:

  All to one common dissolution tends.

  —THOMAS CHATTERTON

  THE PARTICULARS of suicide hook our imagination in a dark way. Intrigued by even the banal ways of self-inflicted death and riveted by the bizarre, we try to reason backward from the choice of method and place to the anguish and weariness leading up to them. We assign meaning to the logistics of the act—a hanging in the woods, a slashed throat in the bathroom—in the hope of entering an inaccessible state of mind. Yet only a few methods—gunshot, jumping, poisons, gas, hanging, drowning—account for nearly all suicides.

  Seneca, in the first century, spoke of the ways: “In whatever direction you may turn your eyes,” he wrote, “there lies the means to end your woes. See you that precipice? Down that is the way to liberty. See you that sea, that river, that well? There sits liberty—at the bottom. See you that tree, stunted, blighted, and barren? Yet from its branches hangs liberty. See you that throat of yours, your gullet, your heart? … Do you ask what is the highway to liberty? Any vein in your body!”

  Yet, as Yale surgeon and author Sherwin Nuland points out, when it actually came time to kill himself Seneca found it more difficult than he had imagined or had advised others: “He plunged a dagger into the arteries of his arm,” writes Nuland, and “when the blood did not come fast enough to suit him, he cut the veins of his legs and knees. That not sufficing, poison was swallowed, also in vain.” Death came finally with steam suffocation in a bath.

  The sheer horror of the act of suicide tends to elicit anxiety and fear in those who have little personal familiarity with the bleak hopelessness underlying it. For those with familiarity, however, a grim wit can sum up the options. Dorothy Parker’s “Résumé” is one of the more mordant and famous contributions to the subject:

  Razors pain you;

  Rivers are damp;

  Acids stain you;

  And drugs cause cramp.

  Guns aren’t lawful;

  Nooses give;

  Gas smells awful;

  You might as well live.

  Parker lived what she wrote. Her first suicide attempt was with a razor to her veins, the second with an overdose of veronal, the third with barbiturates. Her depressions, not helped by her prodigious drinking, were frequent and awful, but she was able to use her deadly wit to deflect the pain, at least with her friends. Biographer Marion Meade captures Parker’s arch black humor poignantly:

  When Dorothy was sufficiently recovered to receive visitors, she prepared her performance. Even though she looked wan and still felt weak from crying, she greeted her Round Table friends with a cheerful grin and her customary barrage of four-letter words. Pale-blue ribbons were gaily tied around her bandaged wrists, and she waved her arms for emphasis as if she were proudly sporting a pair of diamond bracelets from Cartier’s. Had she been candid about her despair, they might have been forced to acknowledge the depth of her suffering and probably would have responded in a manner more suitable to the occasion. Playing it for laughs, she gave them an easy out.

  Edna St. Vincent Millay was born within a year of Parker, though lifestyles away; she too spent time in mental hospitals and wrote her share of gallows verse on suicide. Her “I Know a Hundred Ways to Die” was, rather strangely, published in a collection of poems for young people.

  I know a hundred ways to die.

  I’ve often thought I’d try one:

  Lie down beneath a motor truck

  Some day when standing by one.

  Or throw myself from off a bridge—

  Except such things must be

  So hard upon the scavengers

  And men that clean the sea.

  I know some poison I could drink.

  I’ve often thought I’d taste it.

  But mother bought it for the sink,

  And drinking it would waste it.

  Millay and Parker dashed off in rhyme the familiar ways of suicide, but emergency room doctors, police officers, undertakers, psychiatrists, and medical examiners keep a morbid trove of far more dreadful means of dying. In his 1840 book The Anatomy of Suicide, physician Forbes Winslow described a man who stabbed himself to death with his spectacles, another who threw himself to the bears in the Jardin du Roi in Paris, and yet another who suspended himself from the clapper of a village church bell. One Frenchman, who had been betrayed by his mistress, called his servant and informed him that he was going to kill himself. He asked him to make a candle of his fat, once he had died, and “carry it lighted to his mistress.” In his final letter to her he wrote, “As he had long burnt for her, she might now see that his flames were real; for the candle by which she would read the note was composed of part of his miserable body.” He then committed suicide.

  Later in the century, the superintendent of the New York State Lunatic Asylum described patients who had committed suicide by drinking boiling water, pushing broom handles down their throats, thrusting darning needles into their abdomens, or gulping down leather and iron.

  To kill themselves, the suicidal have jumped into volcanoes; starved themselves to death; thrust rumps of turkeys down their throats; swallowed dynamite, hot coals, underwear, or bed clothing; strangled themselves with their own hair; used electric drills to bore holes into their brains; walked off into the snow with no provisions and little clothing; placed their necks in vices; arranged for their own decapitation; and injected into themselves every substance known to man, including air, peanut butter, poison, mercury, and mayonnaise. They have flown bombers into mountains, applied black widow spiders to their skin, drowned in vats of beer or vinegar, and suffocated themselves in their refrigerators or hope chests. One of Karl Menninger’s patients tried repeatedly to kill himself by drinking raw hydrochloric acid; he su
rvived those attempts and died only after swallowing lighted firecrackers.

  Henry Romilly Fedden, writing about suicide earlier in this century, described a Polish woman who swallowed “four spoons, three knives, nineteen coins, twenty nails, seven window-bolts, a brass cross, one hundred and one pins, a stone, three pieces of glass and two beads from her rosary.” Another woman, a Parisian, applied a hundred leeches to her body.

  More recently, there have been several reports of suicidal men deliberately trying to infect themselves with the AIDS virus, and a disconcerting number of people who provoke police officers into killing them, a practice known to the police as “suicide by cop.” This baffling endgame, as it has been described by the New York Times, is now responsible for nearly 10 percent of fatal police shootings in the United States.

  Like the police, undertakers and medical examiners are often first or early witness to nightmarish death scenes. These scenes are terrible to consider when drugs or drowning are involved but mentally unshakable if a particularly bizarre or violent method has been used. In his book The Undertaking, poet and undertaker Thomas Lynch makes this explicit in a harrowing account of one suicide he tended:

  The cuckolded householder had sat up drinking after his wife had gone to bed announcing her intention to put spongy rollers in her hair. This had become an intimate code which meant to him she did not want to have sex with him but wanted to look good for the boss tomorrow. He’d finished the bottle of Dunphy’s Irish and raided her stash of Valium, then gone to the drawer where the Black & Decker electric carving knife was kept between Easters and Thanksgivings and Christmases. He’d plugged it into the wall socket on his side of the bed, locked his jaw against any utterance and, lying down beside her, applied the humming knife to his throat, severing his two ascending carotid arteries and jugular veins and making it half through his esophagus before he released his hold on the knife’s trigger. It had not been his coming to bed, nor the buzz of the knife, nor any sound he’d made, if, indeed, he’d made any that woke her. Rather, it was the warmth of his blood, that gushed from his severed blood vessels halfway up the master bedroom wall and soaked her and her spongy rollers and saturated the bed linen and mattress and box springs and puddled in the carpet beneath the bed that woke her wondering was it just a dream.