Thoughts about suicide post-stroke: A most difficult intervention

The interview had lasted fifteen minutes so far, and we’d made minimal progress. I was a medical student doing a rotation at a physical medicine and rehabilitation clinic back in my home state, Wisconsin. It was the end of the day; to save time, the senior resident, Paul, had joined me in the exam room so that we could hear Leora’s medical history together.

A year earlier, Leora, in her mid-fifties, had suffered a stroke. After a few weeks in the acute-rehabilitation hospital, she’d been discharged, and she and her husband, Ellis, had been lost to follow-up. Now they were back, hoping to resume Leora’s care.

Sitting in her wheelchair, Leora looked tough but weathered. The food stains on her T-shirt and sweatpants were telltale signs of the stroke’s effects — one-sided paralysis and difficulty swallowing — or possibly of caregiver fatigue. Or both.

“Have you been feeling down since returning home?” I asked her, working my way through the list of questions I’d been taught to use during these interviews.

Leora looked at Ellis, who had been doing the talking so far. A wiry, alert man in blue jeans and a sweatshirt, he looked capable and energetic.

“That’s one I can’t answer for you, honey,” he said, with a hint of weary exasperation.

“Yeath,” Leora said reluctantly, her speech slurred by the paralysis.

This answer dictated my next question: “Have you thought about harming yourself?”

Again, she gave Ellis a look. He kept silent.

“Yeath,” she muttered.

This startled me. Ellis seemed surprised, too. He looked at Leora with dawning curiosity.

I asked the next question, not wanting to hear the answer.

“Do you have a plan for how you would harm yourself?”

“Yeath.”

“Do you intend to harm yourself?” I asked, alarmed.

Seemingly resigned that Ellis would not, could not answer for her, Leora said, “Yeath.”

Clearly, Ellis shared our alarm. He told us how, being unaware of Leora’s state of mind, he had been leaving her home alone during the day. There were firearms in the house, and despite Leora’s disabilities, she could have used them.

Now Paul took over, explaining gently how often strokes can lead to depression. We examined Leora, then excused ourselves to discuss the case with the attending physician and the nurse.

This was always the drill, but it felt different now. I’d seen suicide attempts on the medicine wards; this was my first such experience with an outpatient.

We decided that Leora should be admitted to the hospital: with or without her consent.

The attending physician, Dr. Patel, came with us, introduced herself and said, “Leora, we are worried about you. As you know, you’re no longer able to do the things you could a few months ago. You’re no longer using full sentences, you’re not able to walk as well, and you are unable to dress and groom yourself as you did before. We’d like to admit you to the hospital and begin some intensive therapies. But, more importantly, we want to help with the depression and make sure that you do not harm yourself.”

Leora made it clear that she disagreed: emphatically.

“NOOOOO,” she moaned laboriously.

“I understand that this is not what you expected when you came in, but we’re concerned about your state of mind,” Dr. Patel continued, gently but inexorably. “You’ve mentioned intending to harm yourself, and you have a clear plan. We’re worried about this.”

“No. No. No,” Leora repeated.

Dr. Patel turned to Ellis. Tears stood in his eyes.

“I had no clue,” he said quietly. “I feel horrible. I just had no clue.”

Agreeing that Leora needed to be hospitalized, he warned that it wouldn’t be easy. “I can try to convince her, but she’s stubborn: I know she won’t change her mind. And if you’re asking me to sign forms to commit her, I can’t. She’d never forgive me.”

“Okay, we understand,” Dr. Patel replied sympathetically. She turned to Leora. “We will need to seek legal means to have you hospitalized against your will, Leora. I know you don’t like this, but … ”

“Nooooo. No. No. No. No. No!” Leora interrupted. Using her one functional leg, she propelled her wheelchair through the door and into the hallway, then stopped. Without Ellis’s help, she wouldn’t be able to make it out of the clinic.

She sat there silently, facing away from us.

Ellis wiped his eyes.

“I had no clue she felt like that,” he said. “I just thought she was tired and in pain … How didn’t I know?”

“It can be very difficult for someone in your position to see the symptoms of post-stroke depression,” Dr. Patel reassured him.

As Ellis tried to persuade Leora to agree to hospitalization, we called the EMS staff to pick her up, speaking in hushed tones although the clinic had been closed for an hour or more.

The EMS personnel arrived, then left with Leora.

I took a deep breath, thinking, Well, that’s that …

Then Sue, the nurse, suddenly broke down in tears. Sobbing inconsolably, she slipped into an exam room. Dr. Patel followed, gave her a hug and spoke kindly, then left her in privacy.

“Her daughter committed suicide a few weeks ago,” she whispered to me.

I was speechless. Only now did I sense how many powerful emotions this episode had sparked.

Ellis felt shocked by the news that his longtime wife, whom he’d helped to nurse back to health, wanted to end her life.

Sue had remembered her daughter’s suicide, wondering what clues she’d missed and whether anyone could have done something to save her.

I had tried to hold onto my medical student role, learning as much as I could about functional regression, aphasia, post-stroke depression and suicidal intent in stroke patients. But I’d also felt anxious, overwhelmed and relieved that it wasn’t up to me to handle this all by myself.

Later, at the acute-rehabilitation facility, I cared for Leora as an inpatient. Though initially wary, she gradually began to speak more openly, and I’d like to think that she forgave us eventually.

As jarring and upsetting as it felt to have Leora committed against her will, when I saw how devastated Sue had been by her daughter’s suicide, and how grateful Ellis felt for our intervention, I knew that we’d done the right thing. And as awkward and anxiety-provoking as it was to force myself to ask those questions and hear the answers, I’m convinced that I need to stay willing to do that.

I hope that, going forward, I’ll find it easier to have those difficult conversations: if ever, and whenever, they’re needed.

Kyle Bernard is a medical student. This article was originally published in Pulse — voices from the heart of medicine, and is reprinted with permission.

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  • QQQ

    Excellent article! Thank you for posting!

  • JR DNR

    I like* how you took this situation and made it all about how it impacted you, the patient’s husband, and a nurse… and not about her at all.

    * = sarcasm

    And this is why many people who are struggling lie about it and no one sees the signs. Admit it and you lose the ability to be treated on your own terms. Don’t admit it and it can’t be addressed. Admit it and you lose the ability to be treated on your own terms. Don’t admit it and it can’t be addressed…

    • MentalPatient

      If the woman lives in California, the SWAT team will be showing up to invade her home and seize those firearms, rather than let her husband lock them up in a safe or put them at a relative’s house.

    • iphone12

      Exactly JR DNR. Why wasn’t the next question after this woman admitted she was down to find out what problems she was experiencing and how her therapy could be optimized. It seems that would have done wonders for her depression and made her stop having suicidal thoughts and plans.

      Instead every understandable human emotion in reaction to illness turns into medical pathalogizing which of course, will lead to people hiding their intent.

      And of course I am sure she got put on antidepressants which will do wonders for her cognitive issues since no one will carefully monitor her for side effects. And yes, I am being sarcastic.

      • guest

        I agree. When I worked on the stroke unit I was amazed at how quickly a psych consult was called to assess the patient for depression, a patient who just woke up to realize they had gone from independent one day to completely dependent the next. Patients weren’t even given the opportunity to feel badly about the loss before here comes the psych consult. Not at all how I would want to be treated. There is definitely a place for psychiatric care, but someone who has just experienced a catastrophic loss should be able to grieve without people immediately jumping in to pathologize it.

  • MentalPatient

    Those folks will probably be missed, DSR, but lots of people who WANT help lie about it too, after the first involuntary intervention, because the mental health system is a steam roller that will crush people rather than help. It’s what I call “fake help,” where you lose control of your treatment but the help is so substandard in quality and quantity that it does nothing but make the patient worse.

    But the people referring people to the “fake help” can pat themselves on the back and feel good about themselves when in some cases, they just sent that patient to Hades. Most people who work in mental health that I’ve talked to seem to be aware of this situation of useless help and the occasional abusive workers, and are pretty sad about it, but they can’t do anything. idk the answer is. There is so little love in this world.

    • SarahJ89

      I would never, ever confide in anyone if I were suicidally depressed. I spent 20 years being misdiagnosed and mistreated by the mental health “system” that mistook simply hypothyroidism for “treatment refractory depression.” Things do tend to be treatment refractory if you provide the wrong treatment and refuse to listen to the patient.

      The only thing they have to offer someone who is suicidal is temporary warehousing and drugs. After that the person is labeled and loses all credibility with the medical profession. From then on you’re nothing but a head case.

      Most of the people I know who have actually made improvements in their mental health issues have done so outside of the system. Self-help, peer support, learning symptom management ala Mary Ellen Copeland and oh yes, finally getting actual medical issues properly diagnosed and treated work wonders.

      • MentalPatient

        It comes back to there is too little love in this world, and our society refuses to provide any real help to those who are in extreme distress. The very kind, competent mental health professionals are completely undermined by the burnouts who cause harm and because of CYA the entire hospital environment is negative.

        I tell people to look for a crisis bed in a local group home instead, but I don’t think those exist most places and a person probably has to deny they are suicidal in order to get in.

        When a doctor is confronted with a suicidal patient, they really have no other options than to put someone in a useless possibly counterproductive hospital. I didn’t mean to soundly criticize the person who wrote this blog post. But that person should know that even though they did what was more or less required in our society, they probably didn’t help that person.

        I remember what mental health care was like 25 years ago, and even though there were some burnout hateful staff then, and abuses regarding restraints, at the same time, there was actually concrete help provided. There were educational groups that actually taught useful skills. Now there isn’t even money or time for patients to make a mosaic trivet in occupational therapy. LOL and sad at the same time! Sort of a symbol for the whole thing.

        • SarahJ89

          Hey Mental Pt.,
          The bottom line really is love. You can dress it in professional clothes all you want. But it’s the only truly transformative antidote out there to emotional distress. The professionals who have helped me really did it with love. The ones who did not and the many who did so much damage used their professional skills to bludgeon their patients into compliance. “Control is the other side of helping.”

    • SarahJ89

      OMG, this is so good I wish I could like it a zillion times.

      The brightest and the best are not usually found on the evening or night shift. I’ve seen staff deliberately bait annoying patients so they can call security and have the patient hauled off bodily to isolation or a locked ward.

      We *know* rapists often tie their victims down and we *know* 60% of mental health patients have an abuse history (I can’t recall the citation on this at the moment). Yet we continue to tie patients in four-point restraints when there are other options (graduated show of force, body bags, never leaving anyone in restraints unattended). One woman I know died in restraints after four days in this condition. In our state staff is only required to check on the patient every two hours. I wouldn’t treat a dog that way.

      During my fruitless sojourn in the halls of mental health I was “treated” in a hospital that employed a very sweet nurse. The woman was like a scared rabbit, clearly on heavy medication herself. We all felt sorry for her. However, she was incompetent. For some reason the hospital’s “solution” was to make her the med nurse!

      We patients would note when she was on duty and each take one mentally befuddled patient to watch over during meds. We’d stand next to the person we’d selected and *before* they took the pills we’d ask them “Does this look like your usual medication?” Each of us would find at least one mistake per round of meds that needed correction–the wrong med or wrong dose. The hapless nurse would thank us and go get the correct med. She actually seemed to appreciate the help. None of us wanted to see her lose her job–we had the intuitive sense she probably had an abusive home life.

      Such is the crazy world of mental health. I am so glad a local nurse practitioner finally noticed and treated my hypothyroidism so I was able to escape that system, rebuild my life and recover from all that iatrogenic damage.

  • JR DNR

    I find this is the most helpful page on suicide in existance:

    http://www.metanoia.org/suicide/

    When pain exceeds pain-coping resources, suicidal feelings are the result. Suicide is neither wrong nor right; it is not a defect of character; it is morally neutral. It is simply an imbalance of pain versus coping resources.

    You can survive suicidal feelings if you do either of two things: (1) find a way to reduce your pain, or (2) find a way to increase your coping resources. Both are possible.

    • SarahJ89

      I agree.

  • Suzi Q 38

    As difficult as suicide sounds, she is allowed to feel like doing that to herself if living this way is painful for her. We don’t know what it feels like to be unable to move. We also don’t know how difficult it is for her to be dependent on so many people and alone at home for hours by herself.
    I am glad that the conversation got started and she got some much needed help.
    Sometimes, I think we are kinder to animals.

    • SarahJ89

      The other option might be to (du-uh) provide some serious rehab and support in her home to actually, you know, deal with the underlying issues.

      I was amazed no one actually bothered to ask specifically what her plan might be. It seems like a rather crucial thing to know in order to assess her situation accurately.

      • Suzi Q 38

        You make a good point.
        Has she had a round (6-8 weeks) of intensive rehabilitation (physical, occupational, and speech) at a highly regarded rehabilitation hospital or center that specializes in head injury and/or strokes?
        I found one for my father in law when he lived with us for 7 or so years after his strokes. He lived there for 6 weeks.
        After he was finished with the first 6 weeks, I sent him to
        a veteran’s teaching hospital (Loma Linda VA) and he thrived there. He came home being able to put food in the microwave, make transfers, put on clothing, food himself, and walk with a claw cane.

        I also found him a nurse who would come and stay with him MWF, 6 hours a day. She would also assist him in getting up, dressing, going to the bathroom, and showering. Tues and Thurs He would go to the adult day care center at the rehabilitation hospital.

        Anyway, that hospital worked wonders. He was never cured of his condition, but he could do a lot more for himself, and go out more. On Mondays and Wednesdays I found a stroke club group of people who all had had strokes. They went bowling every week, went shopping at Target during the holidays, went on harbor cruises, and even went to plays. Volunteers would come and show them movies or powerpoint presentations of their recent trips all around the world.

        Getting back to the patient:
        Understandably she is depressed and upset.
        I don’t know how much rehab she has had.

        The insurance company will try to “farm” patients like this off to a physical therapist (visiting) at a local nursing home.
        This is NOT the same as what I have described above.

        I had to hint that I was going to have to get a lawyer to write them a letter about denying my FIL the proper care.
        They finally acquiesced, and approved a 6 week stay for post stroke treatment at one of the best rehabilitation hospitals in our western states.

        Do not take “no” for an answer. Be direct and persuasive. State what you want and ask the insurance company too make it happen for you. If not, get a lawyer to write a letter on your family member’s behalf.

        • SarahJ89

          No good rehab in our area. The one place uses older patients as cash cows. It’s a wonder they aren’t mooing by the time their Medicare money has been milked out of them.

          We’re moving out of this area. Too dangerous to be old or ill here.

          • Suzi Q 38

            I understand.
            It is good that you are thinking about your future health care.
            Mine has had ups and downs, but I liked being able to follow a neurologist who was a fantastic clinician. I even bring my daughter, who is an NP in to see her as well. I made this a learning experience for her.

  • MentalPatient

    Another issue in Wisconsin, I was told by a doctor, the psychiatrist cannot put a person on a 72 hour hold. I was told the police must be called to do that. Maybe I misunderstood, maybe that changed, but the law was distressing to the doctor who told me that. I did a quick google, and it does look on the TAC website as if WI law only provides for a police officer to put somebody on a hold. I guess that part of the story was left out for this blog post. People should know that they really aren’t helping most of the time when they get someone into the hospital for mental health problems. She probably got kicked out of the hospital after 3 days of nothing. Fake help.

    • DeceasedMD

      i think that is a little known fact in most states. the police are becoming the new psychiatrists.

      • SarahJ89

        And they may well do a better job. I know in my town I owe my life to the local cop who mopped up after a psychiatrist nearly killed me.

  • JR DNR

    Thank you for your comments. I wouldn’t interpret a question on ‘self harm’ to mean ‘suicidal thoughts’ myself. Some people self-injure as a coping skill, but they rarely do anything that isn’t superficial. To me that’s what ‘self harm’ would mean.. and I’m not a post-stroke patient limited to a few vowel sounds. Did she clearly understand they were asking about “intent to kill oneself” and not “accidentally harming oneself due to disability”? To me the description makes her sound like she’s completely confused and doesn’t understand what is happening around her.

    This just seems like it was handled in completely the wrong way.

  • SarahJ89

    Or… they don’t want to be locked up and drugged.

  • guest

    Eek! I’m going to hope that that the patient actually articulated a clear plan rather than just saying yes to a question before she was hauled off to the psych ward. I worked on a stroke unit for years, and it’s not uncommon for patients who have had a stroke to say “yes” and “no” to questions even when they don’t really understand what is being asked.

  • http://www.myheartsisters.org/ Carolyn Thomas

    How could anybody spending time with this woman possibly be shocked by her perfectly understandable suicidal thoughts when even the attending described her as “no longer able to do the things she could a few
    months ago, no longer using full sentences, not able to
    walk as well, unable to dress and groom herself as she did
    before.”

    I would have thought they’d be equally shocked that somehow this patient “had been lost to follow-up”. That’s the real tragedy in this case.

    We see the same lack of awareness among health care professionals about the known dangers of post-event depression in heart disease. See “When Are Cardiologist Going To Start Talking About Depression?” http://myheartsisters.org/2013/01/03/cardiologists-talking-about-depression/

    A 2007 study reported in the European Journal of Cardiovascular Nursing on depression in women with coronary artery disease found that 74%
    of women diagnosed with post-cardiac event depression still had
    impaired physical and social functioning one year after their heart
    attack. That impairment also meant that overall recovery, independence and quality of life was also impacted.

    Pro-active early mental health monitoring and counselling for a patient like the one described in this post (essentially abandoned by the health care system) has to be a smarter idea than just waiting for signs of suicidal ideation to emerge.

  • Suzi Q 38

    I am not sure that aggressive care was offered to her.
    Even if aggressive care was offered and then refused by her at first, it does not mean that she will always say “No.”
    Strokes have a way of healing or not healing. The outcome of these patients are rarely predictable.

    What I do know from experience is this:
    Sometimes the family is so devastated from this debilitating condition that they give up on their family member and go back to whatever they had been doing prior to the series of major strokes.
    They are non-verbally telling the family member /patient that they “have little hope.” When this happens, depression definitely makes an appearance.

    Life does not always go as planned.
    If the family, along with their doctors, figured out a plan for the stroke patient, the patient might benefit from these aggressive plans, rather than sink more into depression and suicidal thoughts because nothing is being done, and no one is talking about physical therapy, at least.

    Not everyone lives well, and then dies on command.
    Stroke patients can have the stroke(s), then not be able to walk or talk for months if not years.

    I told my FIL that the woke up for a reason: He was not dead.
    This means we will get him help to the best of our ability.

    He ended up living 12 years as a stroke survivor. Slowly, after rehab, he got better and better.