I use an ongoing spreadsheet to keep track of and to report my demographics and stats for each telepsychiatry consult shift I do. I’ve done thousands of consults in over two dozen South Carolina emergency departments over the last half-dozen years. We have now gone over thirty thousand consults as a group.
It never ceases to amaze me, as I fire up my computer, log on to my systems and bring up the spreadsheet for the shift ahead, that one column is remarkably uniform and consistent, sometimes for days at a time. It is the column that asks for an abbreviated reason for the consultation request. It usually looks like this:
SI stands for suicidal ideation. And that is one of the most common chief psychiatric complaints we see in the emergency department.
Sometimes, I am so busy trying to see all of these people that I cannot afford the luxury of slowing down, looking for trends, trying to analyze why we might be so busy during that particular weekend and the like. There is just not time. However, it is hard not to see the obvious pattern created by the number of people who come into the EDs and state to a staff member that they want to kill themselves.
Why do we all want to die?
Sure, the world has its ups and downs and stresses, but there seems to be so many people who are bent on their own demise that it is mind-boggling.
Allow me to posit some reasons for this disturbing trend:
We do not feel that we belong.
I heard that folks who are required to check the”other” box on standard forms do not feel special when doing so. They actually can be made to feel apart from, cast out, cut off from the mainstream, since they don’t fit a standard group. It is socially and emotionally ostracizing. It means that we do not belong. That hurts.
We do not feel loved.
OK, I know that is “shrink talk” and too touchy-feely for some of you, but hear me out. I hear over and over from folks in the ED that they do not feel loved by their parents, their spouse, their children or anyone else. Once again, whether it is feeling like the “other” or not loved by anyone at all, it is a huge cause of self-loathing, isolation and hopelessness that will drive someone towards not wanting to exist at all.
Everything seems too hard these days. Nothing is guaranteed.
It used to be if you went to school, graduated, kept your nose clean and played by the rules, you would almost certainly succeed in life. You would be able to find a job, you would have a place to live, you might find love and even raise a family. Today, it seems that none of this is guaranteed and that for some it all seems just out of reach. Sometimes, people who appear at first blush to be lazy are just depressed, unmotivated, not well-trained, not educated, and simply down on their luck. They see little hope for success no matter how hard they try, so they don’t try. It is sometimes easier to just give up, find someone or something to blame, and give up, rather than working to make things better.
We feel hopeless.
Hope keeps us getting up in the morning. Hope keeps us going to school, working our way up the ladder, doing the jobs that no one else wants to do, taking on challenges that we are afraid of. If we lose hope, we have lost our will to challenge ourselves. We have lost our dreams for the future. We have lost our ability to see ourselves in the distance, happy and healthy and prosperous.
What exacerbates these core states and feelings? What makes it hard to fight back and move past them? What do I see most often in the emergency department when someone has come in after cutting, swallowing a bottle of Tylenol or drinking themselves into oblivion?
Relationship problems are always in the mix. A teenager breaks up with the love of her life and now thinks that life is over. (She cuts herself on the arms and legs where no one can easily see her attempts to deal with her pain). A middle-aged man is a raging alcoholic but has no insight into how this is devastating his family. His wife leaves him, taking their three small children with her. He comes in with a blood-alcohol level five times the legal limit. An elderly man has just lost his wife of sixty years to cancer. He is lost without her, and he does not want to go on. He is a retired police officer, owns several handguns and knows how to use them.
Financial problems and reversals can produce high levels of anxiety that seem insurmountable. Some folks are almost paralyzed by just not being able to buy gas for the car or groceries for the kids this week. Others may be better to do, but the shock of losing value in their retirement portfolios or not being able to make the mortgage payment on a huge house that they really cannot afford leads to guilt and shame and feelings of failure. Both can feel like the easiest way out is to simply not be here anymore.
Some patients are dealing with chronic mental or physical conditions that they are simply tired of. The ups and downs of bipolar disorder, the pain of congenital spinal malformations, the physical and emotional trauma of cancer and its treatment can all lead to feelings that it would just be better to end things on your own terms rather than wait for the diseases to take their course.
Perceived failures and disappointments (both disappointing yourself or others) often lead to the mistaken notion that if you kill yourself, the problem goes away for not just you but everyone involved with you. The thing that most of these folks have not thought about to any degree is the pure devastation that is left in the wake of suicide. The family members, spouses and friends who must live on after you are gone must ask all the hard questions, the what ifs the whys. The guilt and emotional suffering they feel is tremendous, and it never really, truly goes away.
Fear and anxiety drive many suicide attempts. Odd, since most people think that only those who are severely depressed kill themselves. Anxiety, severe and unrelenting, actually leads more folks to actually complete an attempt than depression. The underlying shame, guilt, or other emotions that drive the anxiety are often not discovered in time or are so well hidden by the patient that it is only after the successful suicide that these are uncovered and better understood, often from the note or other communication left by the deceased.
What is the common feeling that weaves its way through it all? Hopelessness. If you think that there is no way out, that there are no viable solutions left, that you have exhausted all reasonable possibilities for making your situation better, then that gun or bottle of pills or telephone pole look like rational and logical answers for your unanswerable questions. You give up. You quit looking for answers. You feel lighter, happier, more confident because you have made that decision just to let it all go. If there is no intervention, swift and appropriate, you will die.
What are all these stresses and problems complicated by, as if it could get any worse?
One of the most common accelerants for suicidal ideation and attempts is intoxication with alcohol and other drugs. Decreased inhibitions, poor judgment, impulsivity and poor decision-making all lead to potential problems when one is already contemplating self-harm. If you are already stressed, at the end of your rope, and contemplating ending it to escape the anxiety and pain you feel, reach out and get help. Drinking, smoking and popping pills rarely make things look better.
Poor social support is another major deficit that exacerbates suicidality. I see countless patients who truly do not have family, friends, church or anyone else they can call on in a time of need. They are really, truly alone. Isolation and disconnection from other people kill.
Lack of access to care also makes things worse just when the help is needed the most. The shrinking of available mental health resources in this country has lead to a dearth of programs that address acute illness, and this does not bode well for someone who needs help now, not three weeks from now or at the next available appointment time.
Concomitant mental and physical illnesses can spell disaster. Those dealing with longstanding cardiac disease, severe diabetes, metastatic cancer, and other devastating illnesses may be overwhelmed with the emotional counterpart of the illness and if not noticed or addressed, it may steadily worsen and become malignant itself.
What to do if you find that you are one of those people who is thinking that death looks like your only option?
Talk to your family, your girlfriend, your husband, your minister or priest.
See a psychiatrist or other qualified mental health professional right away. If you are turned away when you call, call somewhere else. Don’t accept anything less than an option for immediate assessment. This is your life in the balance, and it is important.
Suicide kills over forty-four thousand people in the United States every year. For each completed suicide there are twenty-five attempts. On average, there are over one hundred twenty suicides per day in the U.S.
There are many reasons that many of us really want to die.
The job for the rest of us is to convince those folks on the edge that there is help.
There is treatment.
There is hope.
Greg Smith is a psychiatrist who blogs at gregsmithmd.
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