But perhaps more damagingly, in the twenty-first century, this also likely means men in crisis aren’t getting care. We tend not to see depression in dudes. In reporting out this book I had a hard time finding men willing to talk to me about their struggles with depression—men of colour, most of all. Gary Newman, a case worker in Toronto who spent his life working with troubled young Black men, had to pause and think when I asked if he knew of anyone who might want to talk to me: in all his years doing community work, he hadn’t encountered anyone who’d been diagnosed with depression. “That’s odd and speaks volumes,” he said.9
The fact that men are more likely than women to kill themselves only muddies matters further. Society has created a damaging gendered dichotomy that exists outside humans’ actual proclivity for dead-end despair.
MICHAEL
In the most marginalized and in the most successful we miss depression when it’s staring us in the face.
When you hear someone say, “He had it all,” the archetype you picture probably looks a lot like Lisa’s older brother Michael. He was a superstar attorney with a beautiful wife, three beautiful kids, beautiful dogs in a beautiful house in Atlanta. Addicted only to his phone. “He was an athlete, he skied, he ran, he was a great son. A phenomenal brother….Every role he did he was extraordinary. That’s why this was such an unbelievable shock,” Lisa said. “He was fearless.”10
No one really believed he could have crippling depression. Not Michael himself or the doctors and therapists he saw. Not his wife, who couldn’t reconcile this with the man she knew. Michael bounced between therapists and doctors and medications, “a whole array of different mood stabilizers,” none of which seemed to work. “He got good care. He had good insurance, he had the money.” He checked himself in to residential treatment programs—the Houston-based Menninger Clinic; a ranch in the Midwest; a facility near Los Angeles. “He didn’t relate to the people,” Lisa said. In these places, too, Michael’s high-achieving success worked against him. Being surrounded by people wracked by addiction and isolation along with their depression made him feel he didn’t belong, didn’t need that kind of care. “I think sometimes they feel like they don’t necessarily identify with these other people, because they don’t have the same problem.”
When Michael returned early from a stint at the Menninger Clinic “he came home feeling good, like he was helping other people there. A little bit of a manic thing, he thinks he’s helping other people and he doesn’t really need to be there. He thought he was fine. And I think they, even, somehow, thought it was okay for him to leave,” Lisa said. “He would be charming, you know? And he had the gift of gab, and was very convincing. So I think he would fool people….He was the man that always got dressed, you know? He would put on his suit and tie when he went to the office.
“Everyone perceived him as the problem-solver. You have a problem? Go to Michael. You need tickets to a football game and can’t find them? Michael will know someone….Sometimes the people that are the most successful, they can’t—when they’re used to being the winner and they’re used to fixing things, and now something is broken and they can’t fix it, yet they’re doing everything they’re supposed to—they take their meds, they show up for appointments and they’re still not getting better, you know? That’s frustrating.”
Lisa calls it Michael’s “non-lethal attempt,” the time he overdosed on pills and was rushed to the psychiatric emerg. Nobody kept him, not even overnight. She wishes Michael and his nonplussed family had at least been given a brochure telling them about the risks of suicide and depression. “When my dog gets his teeth cleaned I get a better handout. He was in a high-risk category, and nobody bothered to say that….That first time when he went, when he took the pills, how did they not take that opportunity? He came in with the family, why were they not given information?”
This went on for a while. Michael’s degree of despondence ebbed and flowed. Then a bad cycling accident, followed by closing his law practice, made life much worse. “That was my brother’s identity….It was something he’d created.” The final days of Michael’s life were especially bad. He called his doctor, who upped his antidepressant dose, but he insisted he didn’t have to go to hospital.
On the last morning of Michael’s life his wife woke up to find him gone. He reappeared shortly after, said he’d been out walking. He looked at her funny—glassy-eyed, Lisa related, “like he wasn’t really seeing” her. Michael’s wife went back into their bedroom to get the dog’s leash and he was gone by the time she returned; no sign of him as she headed out the door with the dog for a walk. The tenth-storey ledge from which he jumped was lined by a railing tall enough to require concerted effort to climb over. “It’s not like it’s just an edge where you don’t have a second to think.”
Lisa got the call from her nephew’s wife. “I just stopped in my tracks. I really don’t remember the rest of the conversation….All I know is I just started screaming and screaming and screaming.” She hadn’t spoken to him that weekend. She’d been trying to give him space after he accused her of feeling sorry for him. “I said, ‘No, I don’t! I feel bad….I don’t pity you. You’re a winner. You’re going to be fine.’ I was trying not to smother him.”
Lisa knows what depression looks like: she went through it. She watched her dad go through it, hours sunk motionless into a living room chair. “I never really saw Michael like that. Because of who he was, as a person, nobody—I never—it was the biggest shock in my life….You think the people who would kill themselves would be the lonely people, who don’t have any money, don’t have anything to live for. My brother had everything.”
19
Through the Cracks
Brian David Geisheimer died on the train tracks near the bank of the Fraser River’s twisting route through the Lower Mainland on its way from the Rockies to the Pacific. It would have been well after dark as he picked his way through the December night across the highway, a two-lane stretch passing houses on big lots and a low-slung motel nearby, through a thin stand of trees to reach the tracks themselves. But he’d been missing from the psych ward since late morning.
We know he died at 9:03 p.m.—a precision made possible by freight scheduling, which shows exactly what time the train reached him. “Multiple blunt force injury” is what they call it when a locomotive smashes into you at high speed.
Sebastien Pavit Abdi’s time of death is less exact: there’s a two-hour window during which the nineteen-year-old hanged himself, asphyxiating to death in his family home.
That same late April day, several hours earlier, Sarah Louise Charles threw herself to her death from her apartment ten storeys up.
All three died within a four-month period in 2014 and 2015. All killed themselves within hours of leaving, against medical advice, the same psychiatric ward at Abbotsford Regional Hospital near Vancouver, British Columbia, where they were supposed to have been receiving care and kept safe from their own overwhelming desire for death.
An inquest into their deaths found the hospital needed better protocols for assessing risk and for following through on those assessments, especially when the risk is high. It called on the health authority to improve its Code Yellow protocol, the code used for when a patient absconds, to quicken communication, tailor urgency to risk level, coordinate better with security guards, get police to ping the person’s cell phone right away. To ensure, on discharge, that “the patient is not being rereleased into an environment that contains all of the same stressors that brought on acute care.”1 This seems at once intuitive and tricky, and it involves a therapeutically effective transition from inpatient to outpatient care that should be a matter of course but in reality rarely happens. The inquest also recommended mandatory “training and retraining” of mental health professionals in suicide risk assessment. According to a response sent to the coroner in the fall of 2018, Fraser Health has acted on several of these recommendations, including piloting standardized suicide screening, developi
ng policies for sharing information with families and requesting funding to improve its patient release and transition process.2
Even if your patients don’t walk out the door and kill themselves it isn’t uncommon to lose them in the transition between inpatient and outpatient care. About a third of people discharged from psychiatric hospitals in Ontario see neither family doctor nor psychiatrist within a month of discharge. That could easily have been me, leaving hospital after a suicide attempt without so much as a follow-up appointment. By contrast, the vast majority of people discharged with a congestive heart failure diagnosis see their family doctor, a cardiologist or another specialist within a month, Paul Kurdyak tells me in his downtown office overlooking the Spadina streetcar line. It’s no surprise, then, that one in ten people hospitalized for depression will be back in hospital for the same reason within a month. “It’s a terrible patient outcome,” he says, and it’s like he’s seeing in his mind’s eye all these people lost to care. “But also, we’re spending thousands of dollars on hospitalization [and] having one in four to one in three people drop off a cliff….This is a ridiculous, wasteful scenario. But it’s pretty common.” 3
In her work at the National Institute of Mental Health (NIMH) brain bank, Melanie Bose’s postmortem detective work digging into brain donors’ psychological pathologies gives her a rear-view glimpse at all the missed medical connections—records of hospital discharges with no indication of a follow-up appointment; therapeutic fits and starts with no lasting treatment. She has seen those cracks up close, in her work at a psychiatric hospital almost two decades earlier. It’s not enough to schedule a follow-up appointment when someone is discharged (which not every hospital does anyway). “It depends on how motivated the person is to seek treatment, how much they like the provider, how close they are to their house, [whether] you’re too depressed to have the energy.” You need more of a nudge. “Just sending a brief message in the mail, you know, after a certain amount of time, they’ve shown that practice actually leads to lowered risk.”4
Yes. A mailout, so that along with flyers for pizza and realtors and gym memberships is a little note saying, “Hey, how are you doing? We hope you’re okay. If not, if you have questions or want to chat, give us a shout or drop by. Here’s the phone number, the address, the hours. Here’s how to reach us by transit.”
I’ve gotten snail mail asking for donations to hospitals that had discharged me weeks earlier. The literal least they could do is include a little “Hey, are you thinking of killing yourself?” note.
It’s easy to imagine that people who die preventable deaths were far removed from the protective embrace of society, outside the reach of any safety net—beyond help. That’s a comforting lie: before people kill themselves, before they deteriorate, self-isolate, become incapacitated ciphers, they have family and friends and colleagues. Most, even when their illness begins to hijack and torment their brains, do interact with the institutions whose purpose is to get them well. Brian Ahmedani—director of Behavioral Health Services research at the Henry Ford Health System in Detroit, who was smart and kind and generous with his time—tugged threads backward to look at the histories of people who’d killed themselves and found that 83 percent of the 5,894 people in eight states he tracked over a ten-year period had contact with the health care system in the year before they killed themselves; half in their final twenty-eight days. One-fifth had a mental health–related visit in the four weeks before they killed themselves but most had no indication of a mental health problem in any health visit over that period of time. Everyone in the study had health insurance. All were “patients in well-resourced health systems.” All took their own lives.5
What strikes Ahmedani isn’t the close and frequent contact that people sucked into despair have had with the health system—“often people reach out for help right before a suicide attempt”—what strikes him is the way the system missed them. And of the myriad ways to lose people to treatable conditions, perhaps the most basic is when they’re right in front of you. People are going untreated not because they aren’t seeking medical care but because clinicians aren’t really seeing the patient. And that’s huge.6
“That, to me, is the most surprising thing,” he tells me by phone. “They’re reaching out—almost everyone’s making some sort of visit—but either people aren’t presenting symptoms right before they die, and it’s just very impulsive, or we’re just completely missing it. And I suspect it’s a little bit of both.”
This is where the Zero Suicide strategy comes in. Pioneered in the early 2000s at the Henry Ford Health System where Ahmedani is doing his groundbreaking research, it focuses on catching people at risk of suicide who are already in a health system. The version that’s now being adopted around the world has seven components: to lead like you mean it; to train your workforce to spot and mitigate suicide risk; to screen, at every opportunity, for that risk, and to build those screenings into your workflow; to engage people at risk with safety plans where they outline what they’ll do if shit gets real; to treat suicidality with care that’s been shown to work; to transition people in a way that ensures they don’t fall through the cracks between inpatient and outpatient, between one clinician and another; and to track your progress and improve upon it.7
Sounds obvious. It isn’t.
“It really became, in my view, quite transformational for the department in how we thought about care,” said Cathrine Frank, chair of Psychiatry and Behavioral Health at Henry Ford. “When we set the goal there was pushback from our staff….‘How could you set a goal that is impossible?’ People worried about lawsuits; they worried about not being able to deal with it. And when you really came to look at it, well, if zero isn’t the goal what would the goal be? It’s my relative, your friend, your teacher. It became transformational as we talked about it.”8
Brian Ahmedani also underscores the need to screen for depression and suicide in all kinds of health encounters, because most people who kill themselves won’t have gotten mental health care but will have gotten some other kind of care in the year before they die. If you don’t look out for them in other health realms, he told me, they’re lost.
This assumes the patient you’re screening for suicide is willing to talk to you about their desire to die. Before my first attempt and in the weeks following, I certainly wouldn’t have told anyone. I didn’t trust clinicians. I didn’t trust myself. I didn’t believe my wish for oblivion was treatable, so why put myself through well-meaning interventions when honesty could very well get me locked in a hospital? I’ve gotten better at acknowledging and talking about my desire for death and attempts to fulfill it, but I’ve never been more intent on denying my suicidality than while deepest in its grip and most intent on following through.
Maybe the tired-eyed psychiatrist who assessed me that first Saturday morning in the psych emerg, who didn’t know I’d been brought in against my will, who discharged me with a prescription for sleeping pills I overdosed on the next day, maybe she wasn’t seeing the suicidal person in front of her. Or maybe I was dissembling too well—so intent on breaking free I convinced even myself that I was fine.
“The hardest ones to treat are the ones who’ve just made a decision and they aren’t going to give you a clue about their plan,” Jane Pearson, the head of Adult Preventive Intervention and chair of the Suicide Research Consortium at NIMH, tells me over the phone—she’s among those at the forefront of tackling and somehow slowing or reversing the freaky spike in American suicides. “Fortunately, that’s not the majority of people.”9
When she says screening should be everywhere, she means it. Even when the person you’re broaching it with is a child. “People are really scared when kids talk about this. And then they’re like, ‘Does this kid really know what they’re saying?’…So the challenge here is trying to identify that risk and understand it more.”
* * *
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FAMILY PHYSICIANS ARE supposed to be your first point of c
ontact for depression just like anything else. That’s why it’s called primary care.
So it’s imperative GPs know how to diagnose and treat mental illness, how to assess when their patients need specialized care, and how to connect them to that care. But when it comes to severe mental illness, they may not have the knowledge and familiarity they need, says Mark Olfson, a psychiatrist at Columbia University, when I bug him with questions. “When you survey primary care doctors and you ask them which specialty they have the hardest time referring patients to, or have the hardest time identifying resources for, mental health comes to the top of the list,” he says. “They’re not set up to provide the level of intensity and the specialization of treatment that a lot of these more complex problems demand.”10
Then there’s the money question. Family doctors often lack the financial incentives to take the time to deal with complex, challenging, miserable patients.
Most health systems in both Canada and the US are based on a fee-for-service model, which means your family doc has an incentive to see as many patients as possible. The more patients in, or the more discrete tasks performed, the more money they make. They’re also flooded with patients sporting an array of maladies, from sniffles to sepsis. It’s tough to take time to probe someone’s psyche, let alone attempt psychotherapy.
That’s not a good enough excuse, Brian Ahmedani tells me. If someone comes in for a cold and screens positive for suicide, “what’s the most important condition there? Should we really be all that worried about a cold if four days later a person’s not going to be alive anymore?”
Hello I Want to Die Please Fix Me Page 19