Monday, March 10, 2014

Suicide by depressed people isn't always irrational

I reproduce below my column from last weekend's Kingston Whig-Standard.
We are pretty big these days at setting up mental health programs. Educational institutions, city administrations and non-governmental groups are tripping over one another offering helplines, counseling and awareness activities targeting mental health. These services are mostly aimed, it seems to me, at stopping people from ending their lives prematurely.
Statistics Canada reports that about 60% of people committing suicide in the country suffer from clinical depression. Doesn’t that show that there is a great need for all those mental health initiatives? Well, here’s another fact: anti-depressants ‘fail to result in sustained positive effects for the majority of people who receive them.’ For the majority of patients with clinical depression there exist no satisfactory therapies.
How does it feel to suffer from depression? What does it mean for a depressed person to have depression? Depression doesn’t affect me personally, but very close loved ones have been struggling with it for many years. There was even a suicide attempt that at the time I managed to prevent from succeeding. It’s heartbreaking trying to help a loved one in that state of mind. It’s not about ‘picking yourself up’, ‘getting on with it’ and what-not other phrases I have heard over the years from people unable to understand the devastating impact depression has on people for whom therapies fail. I have seen people try every possible combination of medication on the market, endless psychotherapy and everything else under the sun. Nothing worked. Invariably, hit by an anxiety attack, or unable to sleep for extended periods of time, their psychiatrist was nowhere to be seen and an appointment certainly wasn’t available when it was needed. Perhaps not coincidentally this is true across countries. I have seen similar patterns of service delivery failures in Canada, Germany and Australia.
To give you an idea of what it feels like to suffer from depression, here is a personal account by Deborah E Gray. She describes on her website the impact depression had on her. Check out the many comments left there by other people with depression. Here is a short edited excerpt from her much longer list: “You don’t feel hopeful or happy about anything in your life. You’re crying a lot for no apparent reason, either at nothing, or something that normally would be insignificant. You feel like you’re moving (and thinking) in slow motion. Getting up in the morning requires a lot of effort. Carrying on a normal conversation is a struggle. You can’t seem to express yourself. You’re having trouble making simple decisions. Your friends and family really irritate you. You’re not sure if you still love your spouse/significant other. Smiling feels stiff and awkward. It’s like your smiling muscles are frozen. It seems like there’s a glass wall between you and the rest of the world. You’re forgetful, and it’s very difficult to concentrate on anything. You’re anxious and worried a lot. Everything seems hopeless. You feel like you can’t do anything right. You have recurring thoughts of death and/or suicidal impulses. Suicide seems like a welcome relief. Even on sunny days, it seems cloudy and gray. You feel as though you’re drowning or suffocating. Your senses seem dulled; food tastes bland and uninteresting, music doesn’t seem to affect you, you don’t bother smelling flowers anymore.”
If this is what your life looks like, is it really unreasonable for some people to call it a day and try to end their lives?
Our interventionism should be predicated on preserving lives that are considered worth living by those who have to live them. I have given some thought over the years to our justifications for interfering with decisions by competent depressed people to commit suicide. Many of them simply don’t seem to withstand critical scrutiny. For instance, it is argued by some that we should interfere with suicide attempts by depressed people, because they don’t really mean to commit suicide, it’s their depressed state of mind that is driving them there. The assumption here is that there is some other personal identity hidden in the depressed mind. I doubt that’s true. There is only us at any given point in time, and for the majority of patients for whom anti-depressants do not work that is all there is. Their perception of their reality isn’t clouded by their depression. It is actually quite offensive to tell someone with depression that their reality is different to what it clearly is for them. We can try to justify intervening in such circumstances by slapping the label ‘mental illness’ on them, but really this just begs the relevant questions. It’s not the case that every depressed person who contemplates committing suicide is actually incompetent to make that choice. It’s also not clear why any of this should matter a great deal if the depressed patients’ experienced quality of life is such that they will still not consider their life worth living after our successful rescue attempt. What’s the point of existing if, on balance, you don’t think it’s worth it?
When do people decide to commit suicide? Surely for many this occurs when they consider their lives not worth living any longer and when they don’t see a realistic chance that their lives will improve in such a way that they will be worth living again. If that’s correct, at least for some people with depression suicide is a rational response to their suffering.
Lest I am misunderstood here: My plea is not for an end to our currently fashionable focus on mental health. If anything, we should probably consider ending the stream of those nauseating ‘know a depressed person’ initiatives and pour those resources into front-line services that would permit suicidal depressed people to access high-quality emergency services when they need them. After all, we need only so manyself-help guides for friends of depressed people. Equally though, we should also cease to see every suicide by a depressed person as a disastrous failure of our health care delivery system, or, indeed, as our own disastrous failure. It is only a failure in of clinical research to deliver drugs capable of helping many depressed people in a manner they consider sufficiently acceptable that they do not commit suicide. Perhaps that’s where our money should go.
Udo Schuklenk holds the Ontario Research Chair in Bioethics and Public Policy at Queen’s University, he tweets @schuklenk.

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