November of the Soul

by George Howe Colt

  The tricyclic antidepressants, on the other hand, while enormously helpful in relieving depression, are also potentially lethal; many people have ended up killing themselves with the very medication prescribed to keep them from killing themselves. Knowing that a mere six or seven pills might mean the difference between an effective dose and a fatal one, clinicians faced a catch-22—they couldn’t prescribe antidepressants without the risk of the patient using them to kill himself, but it was difficult to treat clinical depression without prescribing antidepressants. Patients near the beginning of treatment may experience what has been called rollback, in which the antidepressant gives them sufficient energy to act on their suicidal feelings—as well as supplying them with the means to do it—before their depression lifts completely.

  The introduction of the SSRIs seemed to resolve these issues. Although they are about as effective as the tricyclics, the SSRIs are less expensive, have fewer side effects (lowered libido being the most prominent), and are easier to administer. They are also far less toxic; used in intentional overdoses, they are rarely fatal. Indeed, many researchers suggest that the only problem with SSRIs is that not enough people take them and those who do don’t take enough. Studies of completed suicides reveal that only 8–17 percent were being treated with antidepressants or other prescription psychiatric medications, and only 6–14 percent of depressed suicide victims had dosage levels sufficient to be of any help. (Some of these low dosages, of course, can be attributed to patient noncompliance: one in four victims of suicide fail to adhere to their medication schedule in the month before death.)

  Given that they reduce depressive symptoms and decrease aggressive, impulsive behavior, it would seem to follow that the SSRIs might have a measurable effect on suicide. Indeed, the massive increase in the number of prescriptions written for SSRIs in the United States and several other countries over the 1990s correlated with a decline in suicide rates in those countries. At the same time, most controlled studies have failed to find that SSRI treatment has made statistically significant differences in suicidal behavior on an individual level. (It is difficult to gauge accurately the effect of medications on self-destructive behavior, because suicidal people are systematically excluded from clinical trials by drug companies hoping to demonstrate the superiority of their products and because it would be unethical to withhold treatment from them during a controlled prospective study.) Indeed, evidence of their efficacy in treating depression has also proved elusive; in half of all adult studies, SSRIs have proved no better than placebos.

  Nevertheless, the SSRIs were so popular that when reports began surfacing in the early 1990s suggesting that Prozac itself seemed to make some people suicidal, they were dismissed by pharmaceutical companies and federal regulators as vigorously as if someone had tried to discredit motherhood and apple pie. Those concerns resurfaced in 2003, however, when an FDA drug safety analyst reviewed the results of fifteen clinical trials evaluating the effect of various antidepressants on pediatric depression. Few of the trials showed that drugs relieved depression any better than placebos. (Indeed, of all the SSRIs, only Prozac has been shown to be effective in treating depressed pediatric patients.) Far more troubling, however, he found that children and teenagers given antidepressants were almost twice as likely as those given placebos to become suicidal. The risk was small—of one hundred pediatric patients given antidepressants, two or three might be expected to think about or attempt suicide who would otherwise not have—yet statistically significant. (None of the children in the trials completed suicide.) Perhaps most troubling of all, the results of many of these trials had been kept secret for years by the drug companies that had sponsored them.

  The news was so shocking that, seemingly in denial, the FDA initially disputed their own analyst’s findings and hired a team of researchers from Columbia University to reassess the data. The Columbia researchers, however, agreed with the FDA analyst. In October 2004, following hearings in which dozens of devastated parents blamed their children’s suicides on the drugs, the FDA required the makers of ten antidepressants (including Prozac, Zoloft, and Paxil) to include “black box” warnings on the labels attesting that they “increase the risk of suicidal thinking and behavior” in children and adolescents. (No one is yet certain whether SSRIs trigger suicidal behavior or whether, like the tricyclic antidepressants, they may supply patients with sufficient energy to act on their suicidal feelings before their depression lifts completely.)

  Given that both lives and money were at stake—$12 billion of antidepressants were sold worldwide in 2002—it was a difficult and contentious decision. Some therapists suggested that the efficacy of SSRIs and the ease of prescribing them had allowed physicians to become cavalier about dispensing them and expressed hope that the warnings would discourage indiscriminate and inappropriate use. Others worried that the warnings would scare therapists off from prescribing potentially lifesaving drugs for children in need. As it is, said psychiatrist John Mann of the New York State Psychiatric Institute, only 20 percent of the four thousand adolescents who kill themselves each year have ever taken antidepressants, and NIMH estimates that 15 percent of teenagers with untreated depression will eventually kill themselves. “It is probably the case that antidepressants both cause and prevent deaths,” wrote Andrew Solomon, author of The Noonday Demon, a study of depression, in the New York Times. “But it is also clearly the case that they prevent more deaths than they cause. The danger is that in seeking to prevent antidepressant-related suicide, we will increase depression-related suicide.”

  The ascendancy of the SSRIs has tipped the scales in the long, bitter turf war between biologically oriented and psychodynamically oriented therapists. These days, few clinicians would suggest that psychotherapy alone, without medication to address the underlying illness, is enough to prevent profoundly suicidal individuals from killing themselves. Yet many would maintain that medication alone is enough to deal with depressed and possibly suicidal individuals. Indeed, in most so-called therapy, the only contact the doctor may have with a patient following an initial assessment and prescription are brief follow-up visits to discuss side effects and to ascertain whether the dosage needs adjustment—a procedure quicker and, in many cases, no more personal, than an automobile’s three-thousand-mile oil change. Discussions of treatment issues in the literature revolve around medication, monitoring, and compliance; psychotherapy, if mentioned at all, is usually described only as an aid in encouraging adherence to the pharmaceutical schedule.

  The recent controversy over SSRIs and suicidal behavior suggests, however, that while psychopharmacology has changed the way we treat suicidal people, it may not, by itself, be enough. Despite their extraordinary success, medications have proved to be something of a red herring in the treatment of suicidal patients. They may relieve the symptoms of psychiatric illness, but they do little to alleviate the stresses—family problems, loss, trauma—that may have triggered or exacerbated the illness. And, says psychiatrist John Maltsberger, “While they are no doubt important in preventing a great many suicides, they do not necessarily alter the underlying vulnerability to suicide.” Indeed, the excitement over antidepressants has obscured the fact that depressed and suicidal patients are best served by a combination of medication and psychotherapy. When a recent NIMH study of 439 depressed teenagers concluded that Prozac was far more effective than talk therapy in treating depression, it was hailed as a triumph of medication over psychotherapy; all but ignored was the finding that the most effective treatment of all was Prozac and talk therapy. Numerous other studies have demonstrated better outcomes in depressed, bipolar, or schizophrenic patients who receive both medication and psychotherapy rather than drugs alone. Yet most insurance companies cover the costs of brief medication visits but not of more than a few sessions of psychotherapy, which is often dismissed as expensive, complicated, time-consuming, and even irrelevant. “Medicine alone is not sufficient for treatment of suicidality,” concluded a comprehensive repor
t on suicide by the Academy of Sciences in 2001. “. . . Psychotherapy provides a necessary therapeutic relationship that reduces the risk of suicide.”

  What kind of psychotherapy? Because the field is itself fragmented by turf battles, there is little agreement on how to treat any mental illness. A person suffering from depression may be treated with yoga, Reiki, massage, hypnosis, sleep-deprivation therapy, homeopathy, magnets, Saint-John’s-wort, Qigong, acupuncture, or any of the more than 250 types of psychotherapy practiced today. (Of them, only psychoanalysis is agreed to be inappropriate for suicidal patients: “Most are too anxious, too depressed, or just not well enough put together to stand it,” says Herbert Hendin, himself a psychoanalyst.) Although suicidal patients come with different diagnoses with different needs, they are likely to get whatever the therapist practices. “One would hope that clinicians had a number of strings to their therapeutic bow and would change depending on the nature of the problem,” says psychiatrist Leon Eisenberg. “Unfortunately, this field is characterized by people who do the same type of treatment for every customer that comes along.” A therapy that may work with suicidal patients will be ignored by most clinicians if it is not their modus operandi.

  Although evaluations of long-term therapeutic interventions on suicidality are rare—too difficult, too expensive, too risky, too ethically iffy—a few approaches appear to be helpful in reducing suicide risk. Beck’s cognitive behavior therapy, a short-term treatment that helps depressed patients to reinterpret their negative, distorted thoughts in a more realistic, positive light, seems to reduce the feelings of hopelessness that lie at the core of many suicides. Studies have shown it may reduce suicidal ideation and attempts more effectively than nondirective psychotherapy. Dialectical behavioral therapy, developed by University of Washington psychologist Marsha Linehan specifically for use with chronically suicidal people, helps the patient to develop alternatives to self-destructive behavior, and to find ways to handle the intense surges of emotion that characterize borderline and bipolar patients. In weekly psychotherapy sessions, a problematic behavior or event from the past week is discussed in detail; in weekly group therapy sessions, coping skills and mindfulness techniques adapted from Buddhist meditation are taught. Between sessions, therapist-client telephone contact is encouraged. “The emphasis is on teaching patients how to manage emotional trauma rather than on reducing them or taking them out of crises,” Linehan has written.

  Group therapy with suicide attempters has been valuable in reducing stigma and isolation. “The person realizes she’s not alone—that everyone else in the room has had suicidal thoughts, so there’s no need to maintain secrecy,” Chrisula Asimos, a San Francisco psychologist who worked with groups of suicidal people for many years, told me. The group, in fact, tends to reduce the focus on suicide. “The issue of suicide loses its impact,” says Asimos. “We talk openly about suicide, but we focus on other options. In a group, people can see how other people who have been there longer have moved away from suicidal behavior and explored healthier alternatives.” Bonding among group members (who are encouraged to be in individual therapy as well) extends beyond meetings; they organize group dinners and birthday parties, and like members of Alcoholics Anonymous who call each other when they have the urge to take a drink, they share home telephone numbers to be available to each other in times of crisis. When one group member who was acutely suicidal worried about jumping from her apartment window, the entire group helped her move from her lonely twentieth-floor rooms to a cheerful residence club on the ground floor.

  But while group therapy seems to make suicidal patients more comfortable, the thought of working with a roomful of high-risk patients can be daunting. “Group therapy for suicidal patients hasn’t caught on because therapists are afraid of it, and I can well understand why,” says Norman Farberow, who pioneered therapy groups for suicidal people at the Los Angeles Suicide Prevention Center. “Most suicidal people are insatiable in their need for care and support, and when you get a half dozen depressed and severely suicidal people together, it’s very draining.” There has been no conclusive research on the efficacy of groups for the suicidal, but of hundreds of high-risk patients who were in Farberow’s groups, none completed suicide while in the group, although two former members took their lives after they had left the group against staff advice. When I met Chrisula Asimos, she had been running groups for sixteen years; during that time, no member had completed suicide. At one meeting, however, an older member suffered a fatal heart attack while in the bathroom. It was a traumatic experience for the group, but, said Asimos, “I’m convinced he came there to die—that we were his family.”

  In some therapeutic approaches the therapist himself seems to serve as a substitute family. In their work with suicidal patients over several decades, Boston psychiatrists John Maltsberger and Dan Buie have evolved what they call the “psychodynamic formulation” of suicide. “This approach looks at suicide in terms of developmental failures that make it impossible to maintain a sense of self-worth,” says Maltsberger. “Many people who grow up suicide-vulnerable have failed to get the love they ought to have had from their mothers. Others have received good mothering but for little-understood reasons cannot make use of it.” In normal development, he explains, capacity for autonomy increases with age, enabling one to endure degrees of loneliness, depression, and anxiety. Suicide-vulnerable people fail to develop sustaining inner resources; they must depend on external supports. When those supports fail, suicide is a danger.

  Though Maltsberger’s theoretical approach to suicide is heavily influenced by Freud, in practice the psychodynamic formulation is quite practical. “It boils down to finding out what a person has to live for,” says Maltsberger. “Most people live for all sorts of things—friends, a special person, work—and if they lose something on one front, they pick it up on another. But suicidal people are quite deficient in any capacity to keep themselves afloat on the basis of inner resources. Once somebody threatens suicide, you start looking at what resources the person has.”

  Maltsberger and Buie specify three areas people live for: other people, work, and their body. “Obviously, when someone who is dependent and depressive loses a girlfriend or a husband, it can precipitate a suicidal crisis,” says Maltsberger. “Then there are people who never have relationships, who lock themselves in the library and devote themselves to scholarship. But when they retire or can’t work anymore, they may kill themselves. A surgeon may live only to operate; if he loses the use of his hands, he may do away with himself. And there are people who are very dependent and depressive, but as long as they can jog and look in the mirror and say ‘Gee, I’m in great shape,’ they can go on.

  “So if someone has relied all his life on some capacity to work at Sanskrit, and he goes blind, the task becomes to find what this person can substitute as a lifesaving activity.” Just as Shneidman worked to “widen the blinders” of the pregnant young woman on a short-term basis, Maltsberger, in the psychodynamic formulation, tries to help the patient expand his long-term reasons for living. “It isn’t always possible. Many people are quite indifferent to the love of others, for instance. Others may be indifferent to success at work. Suicidal people are very specialized in what they will accept as a reason for living.” At first, says Maltsberger, the therapist himself may have to constitute that reason “until the patient can regain his balance and stand up again.”

  The psychodynamic formulation offers therapists a practical way to help decide when someone is suicidal, what to do for treatment—which, in many cases, may involve medication—and whether hospitalization is indicated. It also requires a therapist to know a patient’s history thoroughly and to spot events in a patient’s daily calendar that might heighten suicide risk. “Treating suicidal people means being available—intensively—from time to time when they’re between supporting figures or research projects,” says Maltsberger. “I might call them on the telephone every day. You have to be waiting there like a ne
t, hoping that as time goes on the person can widen his repertoire and make room for other sustaining influences.”

  Even the psychodynamic formulation, however, offers only temporary relief. Can vulnerability to suicide be altered? Maltsberger sighs, like the Wizard of Oz after giving out heart, brains, and courage only to find that Dorothy still needs to find her way back to Kansas. “That’s most ambitious,” he says slowly. “That means helping the patient restructure his mind, which is very, very difficult and, in some cases, impossible.” He pauses. “Often psychiatrists don’t want to try.”

  In part because they are the only mental health professionals allowed to prescribe medication, psychiatrists have long been regarded as the last word for suicidal patients. “We all use psychiatrists as backups for these cases,” a Boston social worker told me. “The psychiatrist is the bottom line.” One would therefore expect psychiatrists to know a good deal about suicide. They don’t. In fact, they score no better then radiologists on tests determining their knowledge of suicide risk factors; other mental health professionals score only slightly higher than college students and the clergy. A 1983 survey of more than three hundred training institutions found, on average, no more than a half day’s formal education devoted to suicidology by any of the mental health disciplines. Fifteen years later, a survey of 166 psychiatry residency programs found that while most now offered training in the treatment of suicidal patients, such training was often “relatively superficial in nature” and was usually delivered in the context of supervised clinical work. Only one-quarter offered workshops devoted specifically to suicide. (Forty percent of graduate programs in clinical psychology offer formal training in treating suicidal patients.) What suicide training there is is increasingly devoted to pharmacology; discussions of family dynamics, interviewing techniques, and unconscious forces have given way to discussions of dosages and blood levels. Indeed, many clinicians feel that no specific training for suicide is needed. “Experience is the best teacher,” insists one psychiatrist. (Residents are likely to acquire experience; a majority of patients on training wards are there because of a suicide attempt or severe ideation.)