One of the most provocative studies of suicide ever done was published in the September edition of the journal Social Psychiatry and Psychiatric Epidemiology. It appeared shortly after Robin Williams’ suicide, and shortly before the World Health Organization’s World Suicide Prevention Day. Both of those events received widespread media attention, but this study was not reported by any media that I’ve seen, except relatively obscurely by me in my role as news editor for the online science and psychiatry community Mad In America.
The study looked at a broad population and identified some closely related, easily modifiable factors in people’s lives that were linked to being 6 times, 28 times, and even 44 times more likely to commit suicide.
It’s important to pause on those numbers. In the world of suicide prevention statistics, they are truly staggering. What other risk factor is associated with people being 44 times more likely to kill themselves? There aren’t any. Not even close. That’s why this year the US Preventive Services Task Force once again recommended against conducting suicide screening tests – they just aren’t reliable. That’s why the most sage advice that the American Foundation for Suicide Prevention’s web page about “Warning Signs” can provide us with is to check if our loved ones are “looking for a way to kill themselves” or “calling people to say goodbye.”
And that’s also why it’s all the more curious that this new study has gone largely unreported. Most discoveries of potential suicide risk factors — no matter how seemingly tenuous — ignite widespread discussion. For example, in June, NBC, Reuters, the Associated Press, NPR, USA Today, Bloomberg, the Washington Post and many other news media headlined a study that loosely linked US FDA warnings on antidepressants to a relative 30% increase or 0.0002% absolute increase in occurrences in drug poisonings, a tentative proxy for suicide attempts. Hundreds of outlets reported in September on a study that found increases in the rate of suicides to be associated with decreases in exposure to sunshine – differences in rates that were so low that no outlets I saw even bothered to quote the actual numbers. Another study covered recently in the American Psychiatric Association’s flagship Psychiatric News, and widely replayed in other media, sounded the alarm that not getting enough sleep was associated with a 1.2 times higher likelihood of suicide.
None of those studies proved that FDA warnings, clouds, or restless nights cause suicides, but the mere notion that they might was widely considered to be worthy of discussing. Yet in this more recent study, the researchers found increases in the rates of suicides climbing exponentially, by factors of 6, 28, 44…
So what were those dramatic increases linked to? University of Copenhagen researchers led a nationwide study in Denmark comparing individuals who died from suicide to matched controls between the years 1996 and 2009. They then graded the type of psychiatric treatment people had experienced within one year of their suicide on a scale which included no treatment, psychiatrically medicated, contact with an outpatient psychiatric clinic, entrance to a psychiatric emergency room, and admission, voluntarily or involuntarily, into a psychiatric hospital.
From 2,429 suicides and 50,323 controls, the researchers found that taking psychiatric medications during the previous year made a person 5.8 times more likely to have killed themselves. If a person had made contact with a psychiatric outpatient clinic, they were 8.2 times more likely to have killed themselves. Visiting a psychiatric emergency room was linked to a 27.9 times greater likelihood of committing suicide. And if someone had actually been admitted to a psychiatric hospital, they were 44.3 times more likely to have commited suicide within the year.
“Psychiatric admission in the preceding year was highly associated with risk of dying from suicide,” concluded the researchers. “Furthermore, even individuals who have been in contact with psychiatric treatment but who have not been admitted are at highly increased risk of suicide.” Essentially, the researchers found that increasing levels of psychiatric care are associated with “a severely increased risk of dying.” They concluded, “The public health significance of this finding may be considerable.”
What is the significance? The Danish researchers argued that we were seeing the results of something like a cancer treatment study. Sicker people were appropriately getting into more intensive treatments, but unfortunately the sicker they were the more likely it was that they would still die, despite even the best of medicines. They also suggested that we may have therefore discovered the most accurate predictor of suicide we’ve ever found: The more someone seeks or is forced into psychiatric care, the closer they probably are on the trajectory towards suicide.
The only problem with this line of reasoning is that there’s no evidence to support it. Suicide is not a progressive illness like cancer; that is, there’s no evidence that people with suicidal feelings travel on a trajectory of ever-intensifying, ever-more-constant suicidal feelings while getting into ever more intensive psychiatric care until they die at steadily increasing rates along the way. If suicidality was in fact progressive in that way, we’d be much better at identifying where people are along that path and intervening at the right time to prevent suicides. Instead, completed suicides tend to be impulsive, related to a myriad of cascading, confounding, unpredictable factors, not much more common overall in people diagnosed with mental disorders than in the general population, and most often surprising to even those closest to the victims.
So then what’s the real reason that this Danish study is showing a step-by-step trajectory of more people killing themselves as the intensity of their psychiatric care increases?
An accompanying editorial in the same journal by two Australian psychiatrists pointed down a different avenue of analysis.
The editorial authors noted that the study’s own findings showed that the odds of psychiatrists either identifying or successfully helping suicidal people seemed to steadily worsen as their time of exposure to those patients increased. That suggested a dose-effect relationship. It was like a graph showing suicides going up in relation to the amount of exposure to sunshine going down, except 26 or 44 times more vivid. “Associations that are strong, demonstrate a dose-effect relationship, and have a plausible mechanism are more likely to indicate a causal relationship than associations that lack these characteristics,” the editorial authors argued.
And what could that causal relationship be? “There is now little doubt that suicide is associated with both stigma and trauma in the general community,” the editorial stated. “It is therefore entirely plausible that the stigma and trauma inherent in (particularly involuntary) psychiatric treatment might, in already vulnerable individuals, contribute to some suicides… Perhaps some aspects of even outpatient psychiatric contact are suicidogenic. These strong stepwise associations urge that we pay closer attention to this troubling possibility.”
That “troubling possibility,” the editorial authors concluded pointedly, is that “psychiatric care might, at least in part, cause suicide.”
And that troubling possibility is likely at the root of the lack of media reporting and public discussion surrounding this study. The possibility it raises is extremely inflammatory. The study raises doubts about all of our well-intentioned campaigns to increase funding to the psychiatric care system and to bring psychiatry’s messages about mental illness and suicide more proactively into our schools and workplaces. It undermines many of the rationales behind the involuntary outpatient committal laws that are emerging around the country. And it casts a dark, sinister pall over the incessant refrain that people feeling suicidal should “seek help.”
Yet it’s important to recognize that this Danish study has not emerged in isolation. For example, several studies, including one of 100 countries in 2004 and of 191 countries in 2013, have shown links between increasing funding to modern, western-style psychiatric mental health systems and increasing – not decreasing – suicide rates. The authors of those studies did not uncover clear explanations for their findings. And this new Danish study, for its part, has simply more sharply identified the precise junctures in the psychiatric care system that are most strongly linked to those increasing suicide rates.
So we are left to speculate: What might be causing these striking numbers?
There’s no doubt that being treated with powerful psychiatric drugs against your will can be traumatizing for many people. Antidepressants are known to increase suicidal feelings in youth, and other psychiatric medications are strongly linked to increased suicidal feelings shortly after people begin to take them or change dosage levels. Many psychiatric medications also can cause disruptive or debilitating side effects that can have significant negative effects on overall quality of life.
However, I suspect that the real problem is more fundamental: It’s the very idea that “mental illness” is a “brain disease.” This is what most psychiatric professionals believe, and it’s the main message they give to patients seeking their help. This widely propagated idea is a mental-emotional toxic blight upon us all that’s ultimately killing far more people than it’s helping.
It is an unproven theory that psychological difficulties are symptoms of underlying, chronic diseases of the brain that require medications as treatment. No biological markers have yet been found for any syndromes described in the Diagnostic and Statistical Manual of Mental Disorders. Yet thanks to intensive promotion of biological psychiatric theories by pharmaceutical companies, psychiatric professionals and media, most people who’ve never researched the topic themselves quite reasonably assume that it was solidly established years ago that schizophrenia is caused by wayward genes, depression is biochemically induced, and psychiatric medications balance measurable imbalances in brain neurotransmitters.
Those theories help drug company profit margins, and can provide comforting reassurance that many of society’s social ills and life’s most profound pains can be solved with a pill – but they are just theories. Conversely, one need only imagine oneself in the position of patient to see how upsetting, even terrifying or emotionally crushing such an image of “mental illness” can often be.
Picture yourself going through intense, perhaps frightening psychological struggles, and feeling extremely vulnerable, and finally turning to professionals for help. And the first doctor you encounter looks into your eyes and tells you with an aura of authoritative medical certainty that you have an incurable brain disease that will require lifelong medicating with extremely toxic, potentially debilitating drugs just to – hopefully – keep it in check.
If you were feeling despair about your situation and suicidal before that conversation, how about after it?
In this light, a recent study by Emory University and University of Texas psychologists is not surprising, and provides a measure of hope. The researchers conducted a random-controlled trial where they gave a brief science lesson to one group of youth about neuroplasticity, neural pathway development, and other ways that brains can physically, neurologically change in response to lifestyle and thought-pattern changes. The youth who received that lesson experienced significant reductions in depression symptoms.