Chronic suicidal thoughts . . . to be or not to be . . .

The presence of chronic suicidal thoughts is one of the more difficult issues to deal with in psychiatry.  It is one of the issues that separates psychiatry from all other branches of medicine.  When patients see my colleagues, they want to get better.  Sometimes, when patients see me . . . they just want to die.  This freaks people out.  Me too, sometimes.  But it is part of the business so, I guess, I have learned to deal with it.  Part of the difficulty with it is the sense of being out of control of it.  Surgeons like to cut and sew.  If something is broken, the way to fix it surgically is pretty clear (tho’ obviously requires great skill).  Maybe it will work, maybe it won’t . . . but what to do is usually clear.  And the doctor runs under the assumption that the patient will do everything in their power to cooperate with the healing process.  Patients who present with chronic suicidal thoughts are not so simple.  This is especially true if the patient does not have clear stressors that are producing this sense of despair.  Someone who has experienced significant loss, be it job or a relative, often has difficulty re-defining himself.  That sense of loss-of-self that comes with that situation gives us a clear direction to proceed.  Most of us have had such a loss, and most of us have entertained killing ourselves.  Thoughts like that are really quite normal . . . as long as you don’t follow through on them . . . And addressing the issues is relatively straight forward.  Redefine yourself while grieving the loss. (I didn’t say it was easy . . . just straight forward).

But what about the person who has relatively little life stress?  Or the stressors are not the sort that would seem to be at the root of such a strong desire to eliminate one’s self.  This intangible state is what is most difficult for the patient, for their family, and for the health care providers that are involved.  For some patients, the presence of chronic suicidal thoughts can be the manifestation of past abuse.  It can be an indication of significant personality disorder.  But for many, it seems to be an independent entity that occurs with limited cause.  

Very scary.

Very, very scary.

But, not without a possible solution.  

More than with any other patient group, a patient with suicidal thoughts must be connected with a therapist that they trust and respect.  They must be actively working with that therapist on life skills management that includes social networking without fostering dependence, developing a pattern of activity for oneself that supports physical and emotional health, and strengthening spiritual connectedness with other people and whatever you conceive as “God”.  And, most importantly, an emotional distance between who you are and what you think.  After all, we don’t have to follow through on EVERYTHING we think about doing.  Imagine the chaos if we did!!  Even though the thought to kill one’s self can seem as irresistible as the urge to take the next breath, it is necessary to purposefully distance yourself from that thought.  Acknowledge the thought . . . but distance yourself from it.  ”OK, I have the thought to hurt myself . . . I think I’ll go for a walk instead . . . ”  I encourage those patients who I see with these thoughts to develop a very clear list of things that they will do before hurting themselves.  I don’t tell them they cannot hurt themselves.  I decided a long time ago that it was foolish for me to think that my admonishment to not hurt yourself would carry more weight than someone who is close to the person.  But I do expect that they will follow through on our plan (key here is OUR plan) to keep them safe.  And one of the items on that list of to-do’s is that they MUST talk to me or their therapist.  Not TRY to reach me . . . but actually talk to me or their therapist.  The idea here is to create a system of diversions that waste time.  The more time that goes by, the more likely it is that the patient will move from the “have to hurt myself” stage to the chronic nagging stage of self-injurious thoughts that are much easier to ignore.

While this sounds a bit simplistic . . . it can work.  If the patient “works it”.  As with all of medicine, the active participation of the patient in the healing process makes a profound difference.

From a pharmacologic standpoint, what is done with chronic suicidal thoughts?  Obviously, the underlying depression or anxiety is treated.  But, in addition to that, Lithium can be used.  Of all the medicines that we have, Lithium is the only one that has been shown to decrease frequency and severity of suicidal thoughts.  Sometimes, the effect is very dramatic.  I have had patients who have had suicidal thoughts for years find resolution for these symptoms after just a few days on Lithium.  It is magic when it happens!  Both for me and for them.  

As difficult as suicidal thoughts are for the patient and for those around them, I can say that it is exceedingly rare for someone to not get better if they hang in there and work hard at it.  But it is the sort of psychiatric problem that requires openness with your mental health care provider, trust that things will get better, and resolve to do what it takes to make things better.  Most importantly, I try to instill the understanding in the patient that they are not alone.  That their life, however much they do not value it, is valuable to other people.  That the effects of suicide are much more than they can understand when they are overwhelmed by their thoughts.  The move It’s a Wonderful Life is a bit cliche and sweet . . . but every patient who has survived a period of suicidal thoughts or actions reaches a point where they say . . . “I’m so glad I’m alive”.

–Dan Hartman, MD