Anxiety, for example, can be either a symptom of depression or another illness altogether. The two frequently coexist. One distinguishing factor I learned while navigating my own neuroses is the nature of the worry: people with anxiety disorder tend to freak out about the future—what they want to do, what they’re going to do, the infinite ways they could conceivably screw it up. If you’re depressed, there isn’t much of a future to worry about. People with depression-flavoured anxiety suffer crippling worry about the past, not despite our inability to change it but because of that. We ruminate endlessly about shit we did this morning or yesterday or last week or last year and how unforgivable it was and how everyone judged and continues to judge us and maybe we should ask them about it or no that would make it worse and what are all the possible ways they could have been upset about it and who are all the people they probably told? Angsty, ruminating moose.
The checklist is also incredibly reductive. The DSM’s authors boil down diagnosis of mental illness to something resembling an online quiz: Which Disney Princess Mental Disorder Are You? Online questionnaires like these do exist, with varying imprimaturs of medical legitimacy. You click through, answering questions about your levels of stress, anxiety, enervation, restlessness, appetite, mood. You’re asked about your desire to die and when you click “hells, yes,” a dialogue box pops up with a crisis line to call. I’ve clicked through a couple of those quizzes, both largely based on the kinds of questionnaires used to diagnose people in a clinical setting, both giving me that two-dimensional flounder feeling as I wondered what small changes to my answers I could make to get a different verdict.
Benoit Mulsant wants to see more of those quizzes. I’d sought him out at CAMH where he’s Clinician Scientist, and among other things he’s working on a way to diagnose and, hopefully, treat people in remote areas without access to psychiatric care. This matters: so much of mental health care is concentrated in big cities that it can be impossible for many people to access even a basic assessment that would allow you to figure out what care you need and whom you need it from. Crisis becomes the default. He likens his initiative to a “concierge” for mental health care: train someone to put patients through a standardized, symptom-based screening protocol designed to determine the severity of their illness, the kind of care they need, and then refer them to whomever’s best and most accessibly positioned to provide that care. You don’t actually diagnose and you don’t need to be a physician or a nurse. You can administer the screening over the phone or online, so lack of physical access to a specialist doesn’t preclude you from at least figuring out whoever’s most likely to be able to help you, and then contacting that person directly to set something up.2
This “concierge” isn’t widely available yet. For now, most formal diagnoses are still based on in-person interviews criticized by turns as too formulaic or too subjective. In his (fascinating) 2015 tome dedicated to a history of our conceptualization of mental illness, Madness in Civilization, Andrew Scull dismisses modern psychiatry’s diagnostic methodology as “a ‘tick the boxes’ approach to diagnosis” that “eliminate[s] so far as is possible individual clinical judgment” and promotes “rapid, routine and replicable labelling.”3 But at the same time, I find, the DSM diagnoses rely overwhelmingly on a patient’s ability to self-report and a physician’s ability to recognize and identify nebulous characteristics that aren’t nearly as easily categorized as the DSM would suggest. It doesn’t help that people suffering from psychiatric illnesses often lack insight into their diseases as a result of the disease itself. As a doctor you need to assess a patient’s mental state and read the bullshit between the lines. I don’t doubt most clinicians have become adept at ferreting out the sick from the sad, malingerers from those trying to hide a more serious malaise. But a measure so subject to interpretation leaves a lotta room for error: When a doctor asks you if you’ve been feeling down, if you’ve lost interest in your daily activities, your definition of feeling down might differ from theirs. When a doctor asks if you’ve thought about killing yourself at all in the past two weeks, and you hesitate before saying no, how the doctor deals with that can change your diagnosis and course of treatment or lack thereof.
Given that this checklist definition was designed explicitly to avoid that awkward moment when two clinicians, ostensible experts in the same medical field, come to two different conclusions, it’s ironic that it continues to happen.
I learned this firsthand when I found out after the fact that I’d been diagnosed with two different illnesses by two psychiatrists at the same institution within days of each other, and came close to being discharged immediately without any plan of care and without even being told what my diagnosis was.
The first psychiatrist who evaluated me—the one who earned my family’s eternal dislike when she suggested we were all alcoholics—diagnosed me with borderline personality disorder. It’s a diagnosis associated with impulsivity, emotional instability and interpersonal problems that include anything from a lack of empathy to emotional manipulation or separation anxiety. It’s also characterized by almost dissociative self-harm, where you might surface afterward to wonder, “What just happened?” It’s the kind of diagnosis that’s easy enough to make, but has a much tougher time holding up to rigorous scrutiny. Knowing what I know now, I can understand why she’d slot someone who makes a serious suicide attempt and then insists everything’s totally okay into that category.
And I get why that diagnosis was wrong. Problems I developed in relating to people, I learned all too well, came from the social withdrawal that’s a common symptom of depression and turned me into an ornery unwilling hermit. My mercurial, erratic-seeming disposition came from the dizzying swing whenever my Super-Functional-Happy-Not-Depressed! coping-mechanism facade short-circuited to let my genuine unpalatable misery show through.
I didn’t have a personality disorder; I was just desperately trying to swallow a disease that kept clawing its way to the surface.
I’m exceptionally lucky I got that second opinion, even though it meant those awful extra two weeks locked up, and lucky that the second opinion, the diagnosis of major depressive disorder, prevailed. Other people I’ve spoken with have been handed a multitude of divergent diagnoses and endured years or months of ineffectual treatment with unpleasant side effects before they and their doctors hit on something that worked. One acquaintance was told she had depression, then post-traumatic stress disorder plus anxiety. Decades later, after she’d constructed an identity for herself and spoke regularly on public forums about what it’s like to battle mental illness, she was diagnosed with a personality disorder and the new, scary-sounding label sent her spiralling. The two of us pored over a binder of symptoms in an otherwise empty Japanese restaurant, by turns rationalizing, dismissing, making light of the label.
Chronic illness changes the way you see yourself—it outlasts jobs, homes, relationships. Even the flimsiest reification has power.
* * *
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ELLIOT GOLDNER, FORMER director of Simon Fraser University’s Centre for Applied Research in Mental Health & Addiction, started his career helping individuals struggling with mental illnesses and addiction in Vancouver’s notorious Downtown Eastside. I was lucky enough to speak with him before his death in 2016. He told me over the phone that depression is perhaps better characterized as a bunch of different illnesses with sometimes similar symptoms: some people do get sick as a result of trauma—such external shocks as abuse, war, loss and sundered relationships, financial or professional disaster. Others don’t have that tangible experiential trigger.4
That kind, my kind, the depression without an experiential trigger, is the kind we understand the least and that tends to be most resistant to treatment. It could be immunological; it could be parasitic; it could be genetic or epigenetic, or some weird combination of all or none of the above. Some prominent physicians have suggested depression results from unbalanced gastrointestinal microflora or a severe al
lergic reaction, or the common parasite Toxoplasma gondii—better known as the crazy cat lady parasite. (Sadly there’s no evidence so far in favour of mood-stabilizing fecal transplants or antidepressant parasite exorcisms.)
Such subjectivity around diagnoses offers little comfort to anyone skeptical of the field’s medical pedigree. And the critiques don’t come from antipsychiatry activists alone: each update to the DSM unfolds like a backstabbing melodrama for geeky doctors, as titans of psychiatry denounce each other’s approach to the foundation of diagnoses for the brainsick. Allen Frances, who co-authored the third edition back in the ’80s, slammed the later versions as sloppy, secretive and potentially pathologizing normal behaviour such as grief.5 Even the most prominent members of the psychiatric establishment have expressed skepticism bordering on blasphemy. “There’s no reality” in the DSM’s diagnoses, then NIMH director Thomas Insel said shortly before the DSM-5 came out in 2013. “These are just constructs….We might have to stop using terms like depression or schizophrenia, because they are getting in our way, confusing things.”6
The DSM has loomed large in the public and medical imagination, as a kind of bible and infallible conferrer of identity. But it’s more useful, Thomas Insel advised me, to treat it as a dictionary rather than an encyclopedia.7 This makes sense, but perhaps it’s best to treat it as no more authoritative than its name suggests—a manual of diagnoses, a role it often plays now. It’s possible, as much as psychiatry’s categorizing authorities might hate to admit it, that our diagnostic designations are arbitrary enough to be unnecessary. Does it really matter if our best definitions of depression and other mood disorders are so nebulous as to lack meaning, as long as we can identify the people who need treatment and get them treatment that will alleviate suffering, make life worth living, without causing harm?
Maybe not. But, as I found out, we’re pretty bad at treatment, too. Especially when it comes to the most fatal psychiatric phenomenon we’re up against.
9
Suicide Blues
I never know what to say when people ask whether I’ve been thinking of killing myself “lately.” Have you blinked lately? Longings for death are fleeting mosquitos that swarm—“Why am I alive?” “I want to die.” “I should be dead”—dozens of times a day. They’re compulsive obsessions, methods brainstormed at least once or twice daily, detailed plans hatched at least once a week. They’re grisly nightly visions of accidents or homicides.
Suicidal ideations materialize like sexual fantasies: vivid, unbidden, distracting. Like a desiccating thirst pulling thoughts away from all else. The same anticipated relief. The same agony when that release proves out of reach. Blue balls, but for death.
I pictured in detail my bodily decomposition. What would go first? Would I stay fresh longer if I left the air conditioning on high? How long before the smell seeped into the apartment hallway, or through ventilation shafts into other apartments? My poor neighbours. I should send them flowers. I had an overwhelming desire to turn in my body and donate it wholesale. “I have so many organs!” I’d declare to anyone who’d listen, mutter to myself several times a day. This is just weird enough to sound like a sick joke to another human being but for me it never was: I was gobsmacked by my own wasteful monopoly on body parts. Dozens of people die every day awaiting organs, and here I was hogging so many of them—perfectly good pancreas, lungs, liver, kidneys that could save the lives of people who could then go on to win Nobel Prizes or solve refugee crises. That aspiration ran so deep, I felt cheated to discover you can only donate organs if you die while stabilized, on a ventilator—not if you’re dead on arrival at a hospital. (If that fact doesn’t sound devastating to you, you clearly don’t dream up suicides designed so that no one will find you for at least thirty hours.)
Everything presents a path to death. I was disappointed to find nothing weight-bearing in my apartment to which I could fasten a ligature, but that didn’t stop me from looping a stiffly knotted noose lengthwise around my door and trying to strangle myself with it. I peered over every ledge I got near and feverishly researched the toxicity and overdose potential of every drug I was prescribed.
When surgeons prescribed me Percocet in the wake of successive knee surgeries in 2017—meniscal arthroscopy followed four months later by a full-on ACL repair—all I could think of was the possibility of overdose. I said nothing when my first surgeon inadvertently wrote the same prescription twice: once before the procedure, and once afterward. The sixty 325-milligram pills I got each time felt like a precious gift, a personal hand grenade. I cursed my own weakness when I caved and took them one by one for actual post-surgery pain—wasting this precious resource on myself for no good reason.
But being swallowed by suicidality doesn’t make all my actions actively self-destructive. I’m a hyper-defensive cyclist and do everything I can not to become roadkill, notwithstanding fantasies of being hit, dragged, pulled beneath a truck’s undercarriage and crushed. I can’t think of subways and streetcars without imagining throwing myself in front of one but my metro horror has me flattened against the wall in subway stations, as far from the tracks as I can get.
Every time I told my psychiatrist I’d come close to self-obliteration he’d ask, “What stopped you?” At first this sounded like a taunt: Why don’t you kill yourself, already? If this were such a compelling obsession, why did I keep pussy-footing around it? His intent was not to goad me to suicide but to make me verbalize reasons for not dying. Even once I’d recognized this, I still felt again and again like I was coming up short: I didn’t feel I had a good enough reason for not having killed myself. I chickened out; I was tired; I didn’t want to die in a messy apartment and didn’t have the energy to clean it; I was scared of fucking up; I was scared of being found too soon. Other times, this line of questioning proved more illuminating: there were still questions I wanted to ask, things I wanted to do. Even half-assed senses of obligation—to work, to family, to someone I’d made plans to see—sometimes tipped the balance in favour of stasis over suicide. It’s something I still ask myself accusatorily—What is wrong with you? Why haven’t you killed yourself already?—but trying to elucidate good reasons for not being dead, writing them down for future reference, can be lifesaving.
Suicidality and curiosity are anathema to each other: You can’t want to know things if you want to die. As long as I had questions I had reason to live, and when I was overwhelmed by a desire for death I could not begin to do the curious work that made life worth living. Unable then to conceive of an existence without suicidality, death is the best imaginable outcome.
On good days I could convince myself that I was no less worthy of life than any other organism. But even if I can convince myself that, objectively speaking, I have about as much justification in being alive as a blackfly, my brain flits to a much less easily dismissible fixation: What if I just don’t want to be alive? What if I just don’t like it? What if I’m just tired? And no matter how much psychotherapy you practise, that’s tough to logic your way out of.
Pre-suicide priorities are nonsensical. I was most inclined to kill myself at times when I was confident no one would notice I was gone for a few days at least. Perhaps it’s a testament to my sense of urgent desperation that, paradoxically, my most serious attempts were at inopportune moments—when I was supposed to be at work or had upcoming appointments. Even then, I convinced myself I had to at least make an effort to clean the apartment. More than once, this weird standard helped me put off an attempt because I lacked the energy to empty the garbage or clean the bathroom. A couple of times I made a point of buying non-perishable snacks and hard liquor for whomever I thought would have the shitty task of cleaning out my apartment after my death.
What does one wear to one’s self-orchestrated death? Jeans, probably. And a T-shirt, but a clean one with no holes. A bra? If weeks- or months-old nail polish is chipping, do you peel it off or repaint it or does it not matter? Does comfort outweigh presentability, or is that dum
b given that you’re going to be beyond caring soon and this is the last impression loved ones will have of you? Showering and tooth-brushing is non-negotiable, obviously. Floss and deodorant, less so. But should you make sure your hair dries well before you plan to go horizontal, lest you die with flattened curls hugging your scalp? What about moisturizing lotion for soon-to-be-dead dry skin?
You’d think, amid all this obsession, all these fevered compulsive plans, I’d leave room for a little consideration for the people I love, the people I harm through my self-destructive actions. Families, familial obligations, can be protective factors: for weeks one spring the only thing stopping me from killing myself was the fear it would ruin my brother’s pending wedding. So why isn’t this a deterrent all of the time? The answer’s unflattering. I do think of my family and of the friends who count as family. I wish them joy and know I bring them profound concern. I hate myself for causing pain to the people I care about most, people who have the shitty luck of being close to me. But the guilt that engenders isn’t enough to dispel suicidal ideation.
Sometimes because, as hideous as this sounds to say, being loved is a necessary prerequisite for wanting to live but it is not sufficient on its own. And sometimes guilt at what I do to my family foments my desire to die: I feel like a septic limb that must be cut off lest it kill the whole organism. A painful excision, but a necessary one.
You won’t believe me but procrastination’s the best suicide-prevention measure out there. If all else fails, if drugs and psychotherapy and thought-record deconstructions all fall short and hope remains unreachable, the knowledge that you can still kill yourself tomorrow or next week or next month remains, perversely, the surest way to ensure you don’t kill yourself right this second. In that same vein, the notion you’ve squandered all your chances, reduced everything to shit and will never have another shot at fixing your fuckups or escaping the shame they elicit, makes suicide seem a much more immediate imperative.
Hello I Want to Die Please Fix Me Page 7