suicide

     I've been thinking about suicide a lot lately.  No, not in that way.  I've had several patients lately who have either been severely depressed or outright suicidal.  That would be normal if I was still on my psych rotation.  But these were surgical patients.  It got me to pondering the dilemma of the suicidal impulse.  I first looked through the literature, at least as it will pertain to me going into family practice.  It turns out we do a pretty poor job of identifying and treating depression, never mind suicidal patients.  No surprises there.  If we were good at it, then I suspect the suicide rate wouldn't be double the homicide rate.  So I instead turned to the writings of those who had either pondered or followed through the act of ending one's own life.  This excerpt from the internet genius, but now deceased Aaron Swartz is pretty descriptive into what those tortured souls must feel.

Depressed mood: Surely there have been times when you’ve been sad. Perhaps a loved one has abandoned you or a plan has gone horribly awry. Your face falls. Perhaps you cry. You feel worthless. You wonder whether it’s worth going on. Everything you think about seems bleak — the things you’ve done, the things you hope to do, the people around you. You want to lie in bed and keep the lights off. Depressed mood is like that, only it doesn’t come for any reason and it doesn’t go for any either. Go outside and get some fresh air or cuddle with a loved one and you don’t feel any better, only more upset at being unable to feel the joy that everyone else seems to feel. Everything gets colored by the sadness. 

At best, you tell yourself that your thinking is irrational, that it is simply a mood disorder, that you should get on with your life. But sometimes that is worse. You feel as if streaks of pain are running through your head, you thrash your body, you search for some escape but find none. And this is one of the more moderate forms. As George Scialabba put it, “acute depression does not feel like falling ill, it feels like being tortured … the pain is not localized; it runs along every nerve, an unconsuming fire. … Even though one knows better, one cannot believe that it will ever end, or that anyone else has ever felt anything like it.” 

The economist Richard Layard, after advocating that the goal of public policy should be to maximize happiness, set out to learn what the greatest impediment to happiness was today. His conclusion: depression. Depression causes nearly half of all disability, it affects one in six, and explains more current unhappiness than poverty. And (important for public policy) Cognitive-Behavioral Therapy has a short-term success rate of 50%. Sadly, depression (like other mental illnesses, especially addiction) is not seen as “real” enough to deserve the investment and awareness of conditions like breast cancer (1 in 8) or AIDS (1 in 150). And there is, of course, the shame.