That is the Question

"There is only one really serious philosophical question, and that is suicide."

Albert Camus

Morbid though it is before the holidays, I feel obliged to finish the thought from last post, about how the ultimate ethical issue of suicide is similar to other grand queries (why be moral? why grow up?) that lack a fully satisfying theoretical answer. And in practical and clinical terms, is it possible, or even advisable to try, to dissuade someone who is seriously suicidal?

But this gives me a chance to touch on "holiday psychiatry" in general. As many hopefully are aware by now, the notion that the suicide rate increases around the holidays is a myth (it actually has a spike in the spring), although some have expressed concern that the dramatic economic downturn may generate more risk this particular year.

While many people complain about the increased stress of the holidays, and certain individuals do indeed fare worse this time of year, in my clinical experience the net effect is positive. In my years of inpatient work the unit census always dipped dramatically the latter half of December. And outpatients--again, on average--seem to coast through holiday time reasonably well.

My hypothesis is that while many may gripe about tedious or irritating family time, the social support of sheer enforced togetherness is usually a good thing (time off from work doesn't hurt either). In this way, family time can be like, well, a very different but well-known kind of social encounter: it may be far from perfect, but it is better than none at all.

At any rate, let's suppose someone is in fact driven to the brink by depression plus the holiday fanfare. As hinted above, philosophers have had a hard time coming up with solid justifications for why suicide is generally an evil. Presumably, the reason is that in order to work, such arguments have to assume too much of what they're trying to prove, that is, the absolute value of life itself.

Any philosophical argument presupposes an adequately rational auditor, and that is the problem--a seriously suicidal person, virtually by definition we say, has lost sight of his or her own vital interests and therefore cannot be considered fully rational. That is why we have involuntary commitment procedures and locked psychiatric hospital wards, because for suicidal individuals reason has broken down.

Fortunately of course, most people make it through life without being constitutionally disposed to seriously suicidal thoughts or behaviors. So native biology is our first and primary protection, but not the only one by far. What are the most common reasons not to commit suicide? The following is not scientific, but based on my clinical observations:

1. Cowardice--Fortunately most people are sufficiently averse to violence, pain, and blood that this in itself will keep many in the land of the living; there is also the associated fear of doing something halfway and winding up brain-damaged. If some absolutely painless and definite means of suicide were widely available, that would make the psychiatrist's job considerably harder. This is a visceral factor that few potential suicides need reminding of.

2. Threat of damnation--Whatever else one might say about religious belief and psychiatry, hell serves--among believers obviously--as a mighty deterrent for many would-be suicides. This consideration is also the basis for one of the most famous passages in English, Hamlet's "To be or not to be" soliloquy. However, most people for whom this rationale has force will have arrived at it long before they talk to a psychiatrist, so I wouldn't usually bring it up (if I know a suicidal someone to be a believer and yet he doesn't volunteer the damnation concern, I will usually ask something like "Have you shared this with your minister, etc.?"). In fact, suicide is such an absolute ethical issue precisely because death is, so far as we know, so final; in the broadly secular context of psychiatry, to emphasize considerations of the afterlife would be positively counterproductive for this reason (again, if someone already has a belief in hell or whatever that protects against suicide, that's great with me).

3. Effects on family--Many potential suicides will already have this preventive concern in place. But sometimes not--depression is, almost by definition, a state of self-absorption such that the ramifications for children, parents, etc. will have been overlooked. For this reason I often try, sensitively and without imputation of a "guilt trip" for their own suffering, to convey the devastation that suicide can wreak in families through the generations.

4. This too shall pass--This is the consideration that seriously suicidal people are least likely to have perceived, and therefore one that I most emphasize. In most cases depression is an episodic illness; when it flares it can be awful, but relief is likely to come (even without treatment, although treatment obviously hastens recovery). And yet the deeply depressed person, by the nature of the illness, cannot imagine this--all they can see is darkness (that's what true hopelessness is). So the way I usually think of it is that suicide is a permanent solution for a temporary problem, and I remind people that their own values and their attachment to life will recover if they will only give it time.

Okay, I've had my say on that, and will come up with something appropriately rosier tomorrow.