About a year ago, I was working in the Emergency Department, taking care of a lovely 22 year old woman, a recent college graduate, that we’ll call Mary (not her real name) who came in with her family saying she was suicidal. Mary denied wanting to kill herself, but her family was insistent that she was extremely depressed, and had plans. When I asked Mary if that was true, she didn’t speak, she just shook her head, “no” and mumbled something I took to be, “s’embarrassing.”
I looked at the family and asked, looking at each of them, if they had actually heard Mary say she was suicidal, or heard a specific plan. In turn, they each shook their heads, “no”. “What makes you think she’s suicidal?” I asked them. They each gave me similar answers, amounting to “she’s giving all her stuff away,” and “talking about when she’s gone.” None of it was certain, none of it was a direct threat, but all of it, together, given Mary’s downtrodden appearance and history of depression told a pretty alarming story.
The problem is, none of it was definitive. And, without definitive, nobody was going to write an order to put Mary into inpatient mental-health treatment against her will. And Mary wasn’t going willingly, that was clear enough. And I didn’t have time for any of this. I had four more patients to see, and more coming by the minute. So I stood there, and wondered what the heck I could do in 3 minutes or less to solve this problem without sending Mary out to die. I was pretty certain, too, that Mary would try to kill herself if I let her out of that emergency department. Her sadness was so all-pervasive that just being in the room with her made me want to cry.
Finally, I sighed, and sat down on Mary’s bed. I asked everyone else to leave. “Mary,” I said, “I get that you’re embarrassed that you feel this way, embarrassed that your family has brought you here, embarrassed that you can’t get better or fight this on your own. But, I want to tell you some things you might not have realized. First, this kind of severe depression is a disease, like cancer, or the flu, or pneumonia. And, like cancer, it can be lethal. Yes, that’s right. It is a disease that can kill you. Now, it’s a weird kind of disease, because it’s your own hand that it will use to try to kill you. Really, though, if you think about it, that’s no different than cancer. Cancer uses your own cells to kill you, after all. For that matter, so does HIV.”
Mary started to tear up, “What do you mean?” She asked.
“I mean that this feeling you’re having, this feeling of just wanting this pain to end is not under your control. People talk about suicide being ‘selfish’, but that’s because they don’t understand what you are feeling right now. You’re in so much pain,” at this point tears were streaming down Mary’s face, “you just can’t take it anymore. Just like a cancer patient who cannot take enough narcotics to make the pain stop and wants to die. It’s that level of pain—and, unlike cancer, very few people can look at the pain and feel any sort of empathy for you, or understanding.”
“But what do I do??? How else can I make it stop!?” Mary sobbed.
I put my fingers on her hand, “Mary, it can get better. I’m here to tell you there is a light at the end of this tunnel. Over ninety percent of people who actually attempt suicide are later grateful that they failed. I’m not telling you it will be easy, or quick. I can only say that if you give us a chance, give yourself a chance, with inpatient treatment—where you won’t be able to harm yourself so easily—you can get better, you will get better.”
I’m glad to say that Mary did agree to inpatient treatment, and did admit that she was suicidal—although without any particularly formed plan. I’d like to be able to say that she went on to live happily ever after, but there are two problems with that. First, I have no idea what happened to Mary after she left my emergency department. Emergency Medicine doctors and nurses rarely know what happens to our patients after they leave us—particularly if they go to a mental-health ward.
Second, well, depression is often a chronic relapsing-remitting disease. That means even after Mary is stabilized, there is a good chance she’ll have another episode of severe depression, and maybe even another episode of feeling suicidal. Often depressed patients go through cycles of being depressed and suicidal throughout their lifetimes. Sometimes they’ll be doing well, and a divorce, or post-partum depression, or a job-loss will trigger their depression. Sometimes things will be going great and, for no reason at all, they will become deeply depressed.
Mary’s family did everything they were supposed to. They recognized the signs that Mary was depressed and planning to do something about it, and they brought her in. They seemed empathetic and caring, yet Mary was still embarrassed about the whole episode. The problem was with her perspective about depression, and it is a perspective our society as a whole shares.
Our society sees depression as a weakness and suicide as selfish. The truth is that depression is severe, unrelenting, pain. It is pain of the worst sort, the kind of pain you can’t explain or point to. There is no blood, no cut, nor pulsating mass. It’s just there, at the core of the depressed person, and it hurts every bit as much as cancer, or a broken leg, or a kidney stone. There is no quick medication for it—and it is excruciating.
That’s what makes severe depression lethal. The pain grows so great that it must be stopped, any way it can be. Depression also interferes with good judgment, empathy for others, and the ability to see the future as being any better. So, of course, severely people try to help themselves by ending it all with suicide. What else are they going to do?
That is why I don’t think that we should call successful suicide “suicide” anymore. I think we should call it “Death from depression” and recognize the true disease process that is causing death. Attempted suicide should be called “lethal depression”. Suicide implies merely self-agency, that it is the victim of suicide who is to blame—as if it is the victim of cancer who is to blame for their own cells running wild.
Until we wrap our heads around the fact that depression is not somehow self-willed by the patient, and that they are not weak or selfish for wanting to end it, it is going to be hard, too hard, for the Mary’s of this world to seek the help they need. And too many of them will die needlessly. Feeling alone, and embarrassed.
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