I lost a patient to suicide.
It was many years ago, but I still cringe with a sense of loss, failure and even shame every time I think about it. And I think about it often.
Mr. P was in his 60s, an executive who had been hospitalized for depression. He was better now, discharged from the hospital and returning to see me as an outpatient -- and denying the suicidal impulses that led to his admission. Denying it consistently until that one moment when he let his guard down, looked me straight in the eye and said, "You know, doc, I could really do it."
It was a chilling psychotherapy moment, which I will never forget, but it passed quickly. He backed down immediately, protesting, "Oh, but you know I wouldn't really. I couldn't -- and I would tell you if I really started thinking about it more." No matter how hard I dug, I could not get past this denial. But his warning stands out in retrospect as a cry for help that even he could not silence -- the tip, perhaps, of an iceberg of desperation and hopelessness that he worked so hard to hide from me.
Psychiatrists weigh many factors in assessing suicide risk: the presence of depression or other mental illness, recent losses, coping skills, the presence of supports in the person's life, substance abuse, impulsivity, reasons to live and many more. In the end, it is what patients are willing to tell you about their depression, hopelessness and desperation and what they are willing to share of their thoughts about suicide that is central to identifying the degree of risk.
One major obstacle to preventing suicide is shame. Shame is a central driver of the stigma that attaches to mental illness, and it is stigma that allows us, as a society, to provide so inadequately for the care of the mentally ill. (The Substance Abuse and Mental Health Services Administration reports that 20 percent of Americans live with a mental illness and that less than 40 percent of them received any treatment in 2010.)
Shame often prevents people from sharing their pain with those around them and from seeking the care that may be available. Sometimes it is shame that drives a person to suicide -- an arrest for embezzlement or another crime, a business failure or other personal catastrophe that is humiliating beyond tolerance. Ultimately, suicide is experienced as shameful because it is seen as a moral failure and, in most religions, a sin.
The reality is that, all too often, suicide is the endpoint of severe mental illness. Though we strive mightily to prevent it, for some it becomes a terminal illness, taking a toll annually that ranks it among the major disease killers. The conundrum is that, unlike other terminal illnesses, it doesn't have to happen. It seems inevitable when the person, intent on dying, refuses to share suicidal thoughts, yet it remains a volitional act, a choice the person has made. We are haunted by the possibility that he could have chosen otherwise.
The final irony is the degree to which shame, which pervades all aspects of suicide, infects the clinician who loses a patient this way. While an oncologist may struggle with a patient's death from terminal cancer, the struggle is framed by the inevitability of the patient's death. The psychiatrist, on the other hand, is left wondering, "If only I had listened more carefully or thought to ask the right question."
Should I have weighed Mr. P's warning to me more heavily, though he backtracked vigorously from it? Of course, in retrospect I wish I had. But it is so easy to confuse our retrospective knowledge of a bad outcome with what we could possibly have known beforehand. I have been working this question for years.
Hank Schwartz is psychiatrist in chief and vice president of behavioral health at the Institute of Living/Hartford Hospital.
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