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Illuminating the reasons for suicide

A writer tries to educate the public and fight misconceptions about mental illness.

By BILL DURYEA, Times Staff Writer

© St. Petersburg Times, published July 21, 2000

Dr. Kay Redfield Jamison, a professor of psychiatry at Johns Hopkins University School of Medicine, is the author of Night Falls Fast: Understanding Suicide. The book, published last year, has won popular as well as critical acclaim, which is all the more notable given society's discomfort with the subject and disdain for the act itself.

And yet suicide is the third-leading cause of death among age 15-24 in the United States and the second-leading cause among college students. Approximately 30,500 Americans kill themselves every year. (Roughly 1,300 people each day make an attempt serious enough to require medical treatment.) By contrast there are roughly 20,000 homicides a year.

Jamison's work on the subject has shattered many misconceptions about suicide, one of which is that it is an inexplicable act. The road to suicide is well-marked, Jamison argues. And because suicidal behavior is so predictable, Jamison says, it is all the more regrettable that more medical professionals do not recognize suicide as a preventable public health crisis.

In the wake of Hillsborough State Attorney Harry Lee Coe III's suicide last week, media coverage in this newspaper and elsewhere focused on the events immediately preceding his death. We asked Jamison if it is reasonable to think an explanation for Coe's action could be found by examining the final days of his life.

JAMISON: I think it's reasonable to focus on that in part. Certainly (recent events) would be very important, and certainly he had a majorly traumatic thing happen to him, but I doubt that is the only thing that would be important or relevant. There are a lot of other things that would be relevant as well.

TIMES: What would those things be?
JAMISON: Since 90 to 95 percent of the suicides are associated with a history of mental illness, usually depression, that would have been something. He could have been one of the extremely unusual people who was not affected by depression who committed suicide.

TIMES: Would we necessarily know whether he was affected by depression?
JAMISON: No. No. The people who would know would be most definitely him and his doctors, if he talked to a doctor about it. Many people who are depressed never seek treatment.

TIMES: So mental illness plays a very significant role, in 90 to 95 percent of the cases . . .
JAMISON: In almost all suicides. And usually it's (in) combination (with) some tremendous psychological stress or financial stress or romantic reversal or whatever. But it's usually the case that obviously the people who have those terrible things happen to them do not commit suicide. Very few people commit suicide in response to catastrophe.

TIMES: If this information is known, and you certainly have been doing your part to get it out to the public, why does society seem so reluctant to treat depression and suicide as manifestations of a disease?
JAMISON: Not seemingly reluctant, it is reluctant. I think partly it is counterintuitive. Most people when (they) think of depression, don't think of illness. Most people who have depression don't conceptualize it that way. It's an illness that has biological roots, but its manifestations are in behavior, and in mood and in energy and in thought. So because those are the things that define us, our humanity basically, we don't tend to think of those things as illnesses. So I think that's part of the problem.

Even with illnesses such as bipolar (disorder) or manic-depression, which is highly associated with suicide, even though it's a very genetic illness, one of the most genetic illnesses in medicine, people still tend to think that it's a mental or psychological disorder. The very fact that we call these mental illnesses, for example, means that we focus on one small part of what these illnesses are. Depression is as much an illness about sleep disorders, about a lack of energy, about agitation, about perturbed mood as it is about thinking. I mean there are many, many aspects to depression other than just "being mental."

TIMES: And part of bipolar disorder is that some of the manic episodes can be rather intoxicating to the person who is experiencing them, that there seems to be benefits to the mania, greater acuity, for example.
JAMISON: For a while, in the very mild forms, in the early stages of mania. They are addictive and I think addictive at a biological as well psychological level. But I think society first of all just doesn't realize the terrible anguish that's involved. And until recently, because of the tremendous publicity associated with anti-depressants, they didn't realize it was treatable. The assumption was always: "Pull yourself together, get a grip, move on, quit feeling sorry for yourself." I think there is a change in the public perception on that now. But I think as a society, the medical community and the psychological community have not done everything they could do to educate the public. It's a public health issue as much as an individual clinical issue.

TIMES: How do you go about changing those perceptions?
JAMISON: I think you have public campaigns in the same way that, you know, cancer has had campaigns. There have been high blood pressure campaigns. I think the Surgeon General (Dr. David Satcher) has made an incredible contribution by being so lucid and articulate and adamant. As a physician he has just gone in and said, "Look, what is killing people, young people in this country, older people? What is devastating the health of this country?" And the answer, a lot (of the time), is psychiatric illnesses.

TIMES: When you first addressed your own manic-depression and suicide attempt in your book An Unquiet Mind, you said you were afraid of what might happen if you spoke out . . .
AMISON: (Laughing) Yeah . . .

TIMES: But that anything would be preferable to dishonesty and silence.
JAMISON: After a certain point, yes . . .

TIMES: What has the reaction been?
JAMISON: I think overwhelmingly people have been quite wonderful. I've had a lot of support from my colleagues in psychiatry and in medicine and psychology. There have been quite a few comments (about) the judgment involved in being public, and occasionally feeling patronized and put in sort of the patient column. It's not something that you do lightly. It's been difficult, but I'm glad I did it.

TIMES: Have you detected over that time any change in society's attitudes toward psychological disorders?
JAMISON: I wouldn't attribute it to me, but certainly in the last five years there's been an incredible change. It's just not nearly enough. I think that it's probably very unreasonable to expect that attitudes that have been around for probably 10,000 years are going to change as quickly as one would like. I think that's unreasonable to expect of human nature.

My concern is that people who are in incredible pain and thinking about suicide or just in incredible pain because they are depressed or psychotic don't know that they can find help. That seems, in a civilized society, to be pretty awful. It's bad enough to have these illnesses without feeling you have to be so dreadfully alone with them.

TIMES: I guess also there's the added complication that refusing to take medication is almost a hallmark of some of those illnesses.
JAMISON: That's certainly true. In general it's hard to keep people on medication for chronic illnesses, whether you're talking about lung disease, heart disease, epilepsy. But certainly with psychiatric illnesses it's difficult. But also it's very hard for people, from a stigma point of view, to say that they are taking medication. If you're a public official, or in politics, to bring it back home to what you've been talking about, it's very hard for a politician to say, "I've gotten psychiatric treatment."

To me the responsible thing to do is to get psychiatric care and get it taken care of. Our society says exactly the opposite. Every reinforcement in this society is to keep quiet and do nothing. I think that's terrible. It means that either you're going to have a lot of people lying or you're going to have a lot of people in unnecessary pain and possibly with impaired judgment.

These are very common illnesses. It's not like we're talking about some very strange, rare disease. You're talking about, in the case of depression, up to 20 percent of society will have at least one major episode and in the case of manic-depression 1 to 2 percent. So these are not uncommon illnesses at all.

TIMES: Where does media do harm and where does it do good when it covers suicides?
JAMISON: I think the media has been terrific in many respects over the past five, 10 years in covering mental illness. They have written, by and large, very accurate stories about depression, about schizophrenia and other types of mental illness, often with sidebars about where to go for help. I think those are both very practical and they also change attitudes in the process of the reporting of them.

When suicides are reported in a sensational manner with a great deal of graphic detail about how it was done and where and romanticizing it and basically saying, the child was this great child and all of sudden he or she just killed themselves, as opposed to saying they had mental illness in a matter of fact sort of way. Reporting it, rather than sensationalizing it.

TIMES: Does the Human Genome project and the science it is creating give you more reason to be apprehensive or hopeful?
JAMISON: Hopeful. Overwhelmingly. I'm very intimately involved with that project. I think all of us have concerns. You would be brain-dead not to be concerned about some aspects of privacy and discrimination because mental illness has been discriminated against so long and with increased genetic information you run that risk.

But overwhelmingly the positive side of being able to diagnose people more accurately and earlier, before the illness progresses, because these illnesses have a progressive toll on the brain. Particularly schizophrenia and manic depression. Each time you have a psychotic break it's a real toll, just like you can't keep having repeated heart attacks, you can't keep having these recurrent episodes of psychosis.

Being able to move in early and save people's lives from completely falling apart is terribly important. Much more important, to understand what's causing these illnesses means that you can develop treatments that are far more specific and presumably with far fewer side effects, so people will be more willing to take them.

Where to call for help

Crisis prevention and suicide hot lines are available throughout the Tampa Bay area. In an emergency, do not hesitate to call 911 from any location. Here are crisis numbers:

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