November of the Soul
Page 85
308 study of ten centers: Hendin, Suicide in America, 183.
308 half of the four thousand calls: Lester and Lester, Suicide, 162.
308 psychiatrist Jerome Motto: J. A. Motto, “Evaluation of a Suicide Prevention Center by Sampling the Population at Risk,” Suicide and Life-Threatening Behavior 2 (1) (1971): 18–22.
308 eighteen-month follow-up: R. E. Litman and C. I. Wold, “Beyond Crisis Intervention,” in Shneidman, Suicidology, 525–46.
310 “The committee finds”: Goldsmith et al., Reducing Suicide, 9.
310 University of Alabama study: H. L. Miller et al., “An Analysis of the Effects of Suicide Prevention Facilities on Suicide Rates in the United States,” American Journal of Public Health 74 (4) (1984): 340–43.
Chapter III Treatment
313 “People say”: Giffin and Felsenthal, Cry for Help, 41.
314 A twenty-year follow-up study: Brown et al., “Risk Factors for Suicide.”
314 Reasons for Living scale: M. M. Linehan et al., paper presented at the Fourteenth Annual Meeting of the American Association of Suicidology, Albuquerque, N.M., 1981.
314 Risk-Rescue Rating: A. D. Weisman and J. W. Worden, “Risk-Rescue Rating in Suicide Assessment,” Archives of General Psychiatry 26 (1972): 553–60.
314 like the weather: Simon, “Suicide Prevention Contract.”
315 SAD PERSONS scale: W. M. Patterson et al., “Evaluation of Suicidal Patients: The SAD PERSONS Scale,” Psychosomatics 24 (4) (1983): 343–49.
315 “Patient Monitoring of Suicidal Risk”: R. C. Drye et al., “No-Suicide Decisions: Patient Monitoring of Suicidal Risk,” American Journal of Psychiatry 130 (2) (1973): 171–74.
315 whether they actually work: A recent study of seventy-six people who completed suicide either as hospital inpatients or immediately after discharge found that more than three-quarters denied suicidal thoughts or intent as their last communication to mental health professionals. “Many clinicians use a patient’s denial of suicide to relieve their anxiety,” warned psychiatrist Jan Fawcett, a coauthor of the study. “But this denial is not to be relied upon.” K. A. Busch et al., “Clinical Correlates of Inpatient Suicide,” Journal of Clinical Psychiatry 64 (1) (2003): 14–19. See also E. Bender, “Suicide Expert Calls for More Aggressive Screening,” Psychiatric News 38 (11) (2003): 28.
315 survey at Harvard Medical School: M. C. Miller et al., “Talisman or Taboo? The Controversy of the Suicide Prevention Contract,” Harvard Review of Psychiatry 6 (1998): 78–87. For an overview of the subject, see M. C. Miller, “Suicide-Prevention Contracts: Advantages, Disadvantages, and an Alternative Approach,” in Jacobs, Harvard Medical School Guide, 463–81.
315 “the use of such clinical contracts”: M. Goin, “The ‘Suicide-Prevention Contract’: A Dangerous Myth,” Psychiatric News 38 (14) (2003), pn.psychiatryonline.org.
315 “The contract against self-harm”: Simon, “Suicide Prevention Contract.”
316 proved unsuccessful: Pokorny, “Prediction of Suicide.”
316 computer was shown to be more accurate: J. H. Greist et al., “A Computer Interview for Suicide-Risk Prediction,” American Journal of Psychiatry 130 (12) (1973): 1327–32.
316 brought to emergency rooms: A. Spirito et al., “Attempted Suicide in Adolescence: A Review and Critique of the Literature,” Clinical Psychology Review 9 (3) (1989): 335–63.
316 getting the person: It has been estimated that only 12 percent of those who attempt suicide receive medical attention. Indeed, it is said that over 90 percent of people who complete suicide have a diagnosable mental disorder. Yet two-thirds of all people with diagnosable mental disorders do not receive treatment. (Of those who do receive treatment, only half see mental health professionals. And only about half of those who receive treatment—be it from a mental health professional or a physician—are diagnosed and treated appropriately.) There are a number of reasons for this. Suicidal people face stigma on two fronts, the diminishing but still considerable stigma of mental illness, and the stigma of suicide. Many face financial obstacles: 16 percent of Americans have no medical insurance (for minorities, the figure is even higher), and even those who are insured are unlikely to receive adequate coverage; carriers commonly have greater restrictions for coverage of mental illness than for other health conditions. Many of those who end up taking medications stop prematurely. Some are discouraged by unpleasant side effects, which usually start before the therapeutic benefit is felt. Others give up because they begin to feel better and want to see if they can do without the medications. (Patients must often try several different drugs or combinations of drugs at different dosage levels before one works. After each new medication is introduced, several weeks or more must pass before patient and clinician can determine whether it is effective.) Compliance rates for patients on antidepressants run about 65–80 percent; for lithium, about 60 percent; for anticonvulsants, about 55 percent. (The FDA stresses the importance of close monitoring, especially during the first few months of treatment—patients are most likely to become suicidal within the first nine days of starting antidepressant medication—or whenever dosages are altered or medications changed.) See “Barriers to Effective Treatment and Intervention,” in Goldsmith et al., Reducing Suicide, 331–73.
317 “The immediate goal” and “I did several things”: Shneidman, Definition of Suicide, 229.
318 “Suicidal behaviors”: J. A. Motto, “Recognition, Evaluation, and Management of Persons at Risk for Suicide,” Personnel and Guidance Journal 26 (1978): 537–43.
318 “Suicide proneness”: D. H. Buie and J. T. Maltsberger, “The Psychology and Assessment of Suicide” (unpublished paper), 18.
318 “In our age the triumph”: D. Merkin, “Psychoanalysis: Is It Science or Is It Toast?” New York Times Book Review, September 5, 2004, 9.
319 “immobile” and “waxlike”: Whitaker, Mad in America, 154.
319 Prozac Nation: E. Wurtzel, Prozac Nation (Boston: Houghton Mifflin, 1995).
319 thirteen times more likely: R. J. Baldessarini et al., “Treating the Suicidal Patient with Bipolar Disorder: Reducing Suicide Risk with Lithium,” Annals of the New York Academy of Sciences 932 (2001): 24–38.
319 a German study: K. Thies-Flechtner et al., “Effect of Prophylactic Treatment on Suicide Risk in Patients with Major Affective Disorders. Data from a Randomized Prospective Trial,” Pharmacopsychiatry 29 (3) (1996): 103–7.
320 suicidal acts rose sixteenfold: Baldessarini et al., “Effects of Lithium.”
320 only 8–17 percent: Goldsmith et al., Reducing Suicide, 237.
320 6–14 percent: Ibid., 237.
321 Those concerns resurfaced: Much of my discussion of the SSRI controversy is taken from articles in the New York Times in 2004.
322 only 20 percent: Mahler, “Antidepressant Dilemma,” 61.
322 “It is probably the case”: A. Solomon. “A Bitter Pill,” New York Times, March 29, 2004.
322 439 depressed teenagers: J. March, “Fluoxetine, Cognitive-Behavioral Therapy, and Their Combination for Adolescents with Depression: Treatment for Adolescents with Depression Study (TADS) Randomized Controlled Trial,” Journal of the American Medical Association 292 (7) (2004): 807–20.
323 “Medicine alone is not sufficient”: Goldsmith et al., Reducing Suicide, 258.
323 modus operandi: Electroconvulsive therapy, for instance, is said by some clinicians to be the most effective treatment for severe suicidal depression, because when it works, it works so quickly. (As to why it works, doctors are still at a loss to explain.) Overused and abused in the days when it was known as shock treatment, ECT may now, in a kinder, gentler incarnation, be underutilized because of its lingering stigma. (ECT has not been subject to clinical studies, and there is no conclusive evidence that ECT has a long-term effect on suicide rate and suicidal behavior.)
324 “psychodynamic formulation”: Buie and Maltsberger, Practical Formulation of Suicide Risk. See also J. T. Maltsberger, “The Psychodyna
mic Understanding of Suicide,” in Jacobs, Harvard Medical School Guide, 72–82.
326 no better than radiologists: A. L. Berman, “Notes on Turning 18 (and 75): A Critical Look at Our Adolescence” (paper presented at the Eighteenth Annual Meeting of the American Association of Suicidology, Toronto, Canada, April 18–21, 1985).
326 A 1983 survey: Study by A. L. Berman, ibid.
326 “relatively superficial in nature”: Ellis et al., “Patient Suicide.”
326 “Residents are trained”: See Light, Becoming Psychiatrists; Light, “Psychiatrists and Suicide”; Light, “Professional Problems”; and Light, “Treating Suicide.”
327 “During the course”: Stone, “Suicide Precipitated by Psychotherapy.”
327 a series of papers: A. A. Stone and H. M. Shein, “Psychotherapy of the Hospitalized Suicidal Patient,” American Journal of Psychotherapy 22 (1) (1968): 15–25; H. M. Shein and A. A. Stone, “Psychotherapy Designed to Detect and Treat Suicidal Potential,” American Journal of Psychiatry 125 (9) (1969): 141–45; and Shein and Stone, “Monitoring and Treatment.” The story of Shein’s suicide is told in Beam, Gracefully Insane, 222–32. Sociologist Rose Coser’s nuanced examination of the rash of suicides about which Shein and Stone wrote can be found in Coser, Training in Ambiguity.
327 “Some patients almost ready”: J. T. Maltsberger, and D. H. Buie Jr., “Common Errors in the Management of Suicidal Patients” (unpublished paper, 1980), 14.
328 Impressed with the jocular: Stone, “Suicide Precipitated by Psychotherapy,” 5.
328 In one of the few papers: Maltsberger and Buie, “Countertransference Hate.”
328 William Wheat isolated: Hendin, Suicide in America, 169. In 2001, the authors of a study in which data were collected from twenty-six therapists who had had a patient complete suicide came to a similar conclusion. “The 26 suicide cases we studied suggest that therapists working with suicidal patients frequently fail to recognize the severity of the emotional crises they experience,” they wrote. “Our data indicate that only a small percentage of persons who are intent on killing themselves while in treatment give the therapist little or no indication of their crisis.” Hendin et al., “Recognizing and Responding.”
329 more than two hundred therapists: Litman, “When Patients Commit Suicide.”
330 describe a man: N. L. Farberow et al., “Suicide Among Schizophrenic Mental Hospital Patients,” in Farberow and Shneidman, Cry for Help, 90.
331 ascendancy of HMOs: In 1999, 72 percent of Americans with health insurance were covered by managed care, which promotes treatment of mental health in primary care, limits access to mental health specialists, and has severely reduced coverage of inpatient and outpatient care (between 1988 and 1998, managed care plans cut their spending on psychiatric treatment by 55 percent). Although the influence of managed care on suicide itself is largely unexamined, a 1999 study of 1,204 outpatients with depression in seven different HMOs, which found that only 48–60 percent received some sort of mental health care, concluded that patients with suicidal ideation were at particular risk for receiving inappropriate treatment. (K. B. Wells et al., “Quality of Care for Primary Care Patients with Depression in Managed Care,” Archives of Family Medicine 8 [6] [1999]: 529–36.) People who complete suicide have substantially more difficulty getting health care at all. A study of 22,957 deceased people of all ages found that, compared with people who died of illnesses or injuries, those who complete suicide are three times more likely to have difficulty accessing health care (and twice as likely to refuse needed care)—because of trouble paying bills, difficulty being admitted to a treatment facility, problems finding a doctor, and so on. (C. L. Miller and B. Druss, “Datapoints: Suicide and Access to Care,” Psychiatric Services 52 [12] [2001]: 1566.)
331 perhaps least prepared: There is evidence that physician training might impact the suicide rate. In the 1980s, on the Swedish island of Gotland, where most treatment is provided by GPs, suicide prevention experts trained island physicians about recognition and treatment of depressed and suicidal people. Despite physician fears that they’d trigger suicides if they asked their patients about suicide, the island’s suicide rate was lower by 60 percent (almost entirely due to a decrease in suicide by females; the male rate was essentially unchanged), a decrease exceeding that of Sweden as a whole over that same time. Although the rate eventually rose back to pretraining levels, coinciding with the departure of about half the island’s physicians, the results were nevertheless promising. (W. Rutz et al., “Long-Term Effects of an Educational Program for General Practitioners Given by the Swedish Committee for the Prevention and Treatment of Depression,” Acta Psychiatrica Scandinavica 85 [1992]: 83–88; Z. Rihmer et al., “Depression and Suicide on Gotland: An Intensive Study of All Suicides Before and After a Depression-Training Programme for General Practitioners,” Journal of Affective Disorders 35 (1995): 147–52.)
331 “leaves them in the role”: From a speech to the APA’s annual Institute on Psychiatric Services, October, 1997, as reported in Psychiatric News, www.psych.org/pnews/97–12–05/primary.
331 widespread lack of knowledge: J. W. J. Williams et al., “Primary Care Physicians’ Approach to Depressive Disorders: Effects of Physician Speciality and Practice Structure,” Archives of Family Medicine 8 (1) (1999): 58–67.
331 more than half of patients with depression: E. S. Higgins, “A Review of Unrecognized Mental Illness in Primary Care: Prevalence, Natural History, and Efforts to Change the Course,” Archives of Family Medicine 3 (10) (1994): 908–17.
331 72 percent had prescribed SSRIs: Voelker, “SSRI Use Common,” 1882.
331 Philadelphia medical schools: Light, Becoming Psychiatrists, 30.
332 91 percent of physicians: Giffin and Felsenthal, Cry for Help, 28.
332 believe the old canard: K. Michel, “Suicide Prevention and Primary Care,” in K. Hawton and K. van Heeringen, eds., International Handbook of Suicide and Attempted Suicide (Chichester, UK: John Wiley and Sons, 2000), 661–74.
332 primary care physicians: Williams et al., “Primary Care Physicians’ Approach.”
333 “hundreds of ways”: Reynolds and Farberow, Suicide.
333 a study of hospitalized patients: Jamison, Night Falls Fast, 152.
333 suicides at Metropolitan State Hospital: A. R. Beisser and J. E. Blanchette, “A Study of Suicides in a Mental Hospital,” Diseases of the Nervous System 22 (1961): 365–69.
333 a study attributing a decline: L. F. Woolley and A. H. Eichert, “Notes on the Problem of Suicide and Escape,” American Journal of Psychiatry 98 (1941): 110–18.
333 “rather hesitantly”: Styron’s account of his hospitalization can be found in Darkness Visible, 67–75.
334 “begin planning for discharge”: American Psychiatric Association, “Psychiatric Hospitalization,” www.psych.org/public_info/hospital.
334 “extremely difficult”: Okin, “Future of State Hospitals,” 579.
335 “Often caught in the dilemma”: Jamison, Night Falls Fast, 153.
336 A study by San Francisco psychiatrist: Motto and Bostrom, “Randomized Controlled Trial.”
337 “one of the ways that the Lord”: The story of the lawsuit is told in M. A. Weitz, Clergy Malpractice in America: Nally v. Grace Community Church of the Valley (Lawrence: University Press of Kansas, 2001).
338 “Suicide can best be understood”: Shneidman, Definition of Suicide, 226.
338 appeared on the television news show: Giffin and Felsenthal, Cry for Help, 162–63.
Chapter IV Social Studies
340 One August day: For historical material on the Golden Gate Bridge, see A. Brown, Golden Gate: Biography of a Bridge (Garden City, N.Y.: Doubleday, 1965).
341 “almost any place in Japan”: O. D. Russell, “Suicide in Japan,” American Mercury, July 1930, 342.
341 On January 7, 1933: The description of the suicides at Mihara-Yama is drawn from newspaper and magazine accounts of the time, and from Ellis and Allen, Trai
tor Within, 94–99.
342 A study of 116 people: Y. Takahashi, “Aokigahara-Jukai: Suicide and Amnesia in Mt. Fuji’s Black Forest” (paper presented at a joint meeting of the American Association of Suicidology and the International Association for Suicide Prevention, San Francisco, May 25–30, 1987). In today’s industrialized Japan, several Tokyo skyscrapers have taken their places as suicide landmarks. The Takashimadaira public housing complex, sixty-four apartment buildings on the edge of Tokyo, opened in April 1972. Within eight years, more than seventy people leaped from its rooftops—some journeying from as many as 120 miles away—earning it the nickname Mecca for Suicide.
342 “At one time there seemed”: W. Sweetser, Mental Hygiene: or, an Examination of the Intellect and Passions (New York: George P. Putnam, 1850), 292.
344 the names of 515 people: Seiden, “Where Are They Now?”
344 David Rosen interviewed: D. H. Rosen, “Suicide Survivors: Psychotherapeutic Implications of Egocide,” Suicide and Life-Threatening Behavior 6 (4) (1976): 209–15.
344 second study by Seiden: Seiden and Spence, “Tale of Two Bridges.”
345 moot political issue: In 1977, the bridge’s fortieth anniversary year, pro-barrier activists held a Memorial Day rally on the bridge to commemorate the more than six hundred bridge suicides. Ironically, one of the speakers was the Reverend Jim Jones, who arrived with three busloads of his People’s Temple followers. “It is entirely fitting that on Memorial Day we are here on account of the hundreds of people who are not casualties of war, but casualties of society,” he said. “For, in the final analysis, we have to bear collective responsibility for those individuals who could not find a place to go with their burdens, who came to that place of total helplessness, total despondency, where they took their own lives here on this beautiful bridge, this Golden Gate Bridge, a symbol of human ingenuity, technological genius but social failure.” Eighteen months later he would lead 912 of his followers into mass suicide in the jungles of Guyana. The text of Jones’s speech is reprinted in R. H. Seiden, “Reverend Jones on Suicide,” Suicide and Life-Threatening Behavior 9 (2) (1979): 116–19.