The suicide of Robin Williams has shocked the nation. Many people, including me, will wonder: “Surely something could be done. How could this happen?” The death of Robin Williams is particularly startling because he was a “comic genius” who evoked a mood so far from depression.
How suicide happens does not have a simple answer. Suicide is extraordinarily personal. It results from an internal thought process that is unique for each person. Depression may cause intense suffering that is not obvious to others. It commonly leads to a “negativistic thought bias” – essentially, a tendency to see the glass as half empty. Relatively neutral events may seem very problematic if they are interpreted through a lens of pessimism, guilt, hopelessness, and low self-esteem. Problems may seem insurmountable. Add to that the very complex qualities of personal relationships, the possibility of conflict with friends or family, and distortions in the interpretation of others’ caring. There may be job or career stresses. Sometimes, even the most successful person feels that he or she has not met his or her own aspirations and expectations. Substance use – initially, a means of escape – may worsen some of the stressful realities and further impair one’s judgment and perspective. Ultimately, substance use may lower inhibitions to permit a lethal act.
Even those who are closest to the person may not be aware of those internal beliefs and thoughts. After all, our most troubling internal psychological conflicts are often the ones we try to hide from others. When we are aware of an internal struggle, we may not suspect that suicide would be a choice. And, a person who is fully determined to end his life may deliberately mislead others so they don’t interfere.
The survivors are left with guilt, wondering how they could have prevented the suicide. It is almost always possible to imagine a slightly changed behavior on one particular day, or one particular hour, that seemingly would have averted a tragedy had one intervened. The doctors and clinicians caring for the patient have these same thoughts.
My patients will come and talk to me about these suicides, for reasons ranging from shock or thoughtfulness to fear for their own safety. For a person with depression, or a person worried about a family member, are there any lessons?
Depression is a very serious disorder and a real disease that can cause extreme disability. It affects the entire cognitive construct of the self in a way that is not rational. That is, in part, the reason why it is very difficult to understand suicide from the outside. Psychological or psychic distress, hopelessness and shame are some of the core symptoms of a major depression disease. Those symptoms are difficult to uncover, hard to challenge, and uncomfortable for others to witness and to help with. These are also the symptoms leading those affected to isolate, regress and become reluctant to seek out treatment.
Even one suicide shocks us and even one suicide is too many. According to the CDC and National Center for Health Statistics, suicide is among the top five leading causes of death in those 10 -54 years old. It is the tenth leading cause of death for all ages. However, it is also true that suicide is relatively rare considering the incidence of depression. Five to ten percent of adults will develop depression, and suicide occurs in 0.01 percent of adults each year.
Most people with depression are helped with treatment. The public debate about the effectiveness of antidepressants is itself “a glass half empty or half full” argument. Even if we agree that our treatments are not good enough, the fact is that our treatments are very good.
Across the world, fewer than half of people with depression seek treatment. Access to treatment, and willingness to seek treatment, are forces that have a much larger effect on the outcome of depression than nuances about the effects of different treatments.
Some of the prominent suicides in recent weeks seem to defy these facts. When we hear about successful people who commit suicide despite loving friends or families, we will naturally recognize that we cannot help everyone, no matter how hard we try and no matter how much we care. Know that these news events are shocking precisely because they are so unusual. It DOES matter to care about our friends and family, it IS important to recognize the signs of depression and suicide risk, and it IS important to seek treatment.
Awareness of depression and the risk of suicide is perhaps the only good thing that can come out of these tragedies. If you are worried about someone in your life, please do what you can to urge an evaluation by a competent clinical professional.
Reach out to us with any questions or concerns. Learn more about Pediatric Psychiatry at the University of Vermont Medical Center and Adult Mental Health Services at the University of Vermont Medical Center.
Bob Pierattini, MD, is the chair of Psychiatry at the University of Vermont Medical Center and professor and chair of the Department of Psychiatry at the Larner College of Medicine at UVM.