Transcript: Kay Redfield Jamison on Understanding Suicide | Feb 03, 2001

A slate with two Doric columns reads "Doctor Kay Redfield Jamison. Psychology, Johns Hopkins University. 'Night falls fast: Understanding suicide.'"

[applause]

A picture shows an outdoor sign that reads "Centre for addiction and mental health."

Then, Kay Redfield Jamison stands behind a lectern in a dimly lit room and addresses an unseen audience. She's in her early forties, with short blond hair. She's wearing a burgundy blazer and a pearl necklace.

A caption appears on screen. It reads "Doctor Kay Redfield Jamison. Johns Hopkins University. Author of 'Night falls fast: Understanding suicide.'"

Kay says THANK YOU VERY MUCH.
I'M DELIGHTED TO BE BACK
IN TORONTO AND I'D LIKE TO
THANK RANDOM HOUSE AND THE
UNIVERSITY OF TORONTO
FOR INVITING ME TO
SPEAK THIS EVENING.
I'M GOING TO SPEAKING ABOUT
A TOPIC THAT IS, ON THE FACE
OF IT, A GRIM ONE AND
ONE THAT IS NOT PUBLICLY
DISCUSSED NEARLY OFTEN
ENOUGH, BUT IT'S ALSO A
TOPIC OF GREAT HOPE, BECAUSE
IN FACT THE SCIENCE AND THE
CLINICAL KNOWLEDGE THAT WE
HAVE ABOUT HOW TO PREVENT
SUICIDE IS VAST.
WE KNOW A LOT.
IT'S WHAT WE DON'T PUT
INTO PRACTICE THAT KILLS.
WHAT I'D LIKE TO DO THIS
EVENING IS START AND FINISH
ON A PERSONAL NOTE ABOUT MY
OWN INVOLVEMENT WITH SUICIDE
AND MENTAL ILLNESS AND MY
OWN MOTIVATIONS FOR BEING
PARTICULARLY INTERESTED
IN THIS FIELD.
AND START WITH A DISCUSSION
ABOUT SOME OF THE
COMPLEXITIES OF THE WHOLE
SUBJECT OF SUICIDE.
AND THEN IN THE MIDDLE OF MY
TALK, SHOW SOME SLIDES TO
TRY AND GIVE YOU A SENSE OF
THE ENORMITY OF THE PROBLEM
IN TERMS OF THE SHEER
NUMBERS, AND WHO'S AFFECTED,
AND WHAT WE KNOW ABOUT WHY
AND WHAT WE KNOW ABOUT THE
ILLNESSES THAT
LEAD UP TO SUICIDE.
AND MOST IMPORTANTLY, WHAT
WE CAN DO TO TRY AND MAKE A
DIFFERENCE IN
THE DEATH COUNT.
AND AS I SAY, I'D LIKE TO
THEN END ON A MORE PERSONAL
NOTE ABOUT SOME OF THE
FRUSTRATIONS AND PROMISES OF
SOCIETY AND WHAT SOCIETY
DOES, AND UNFORTUNATELY DOES
NOT DELIVER ON THE SUBJECT,
AND THEN LEAVE AS MUCH TIME
AS POSSIBLE FOR QUESTIONS
OR COMMENTS THAT ANY OF YOU
MIGHT HAVE.
SO I'D JUST LIKE TO START
WITH THE PROLOGUE TO MY
RECENT BOOK ABOUT SUICIDE.
SEVERAL YEARS AGO, I WENT
PUBLIC, AS IT WERE, ABOUT MY
OWN MANIC DEPRESSIVE ILLNESS
AND I DECIDED AT THAT TIME,
YOU KNOW, I WOULD NEVER
WRITE A BOOK THAT HAD
ANYTHING THAT PERSONAL IN
IT AGAIN BECAUSE IT WAS NOT
SOMETHING I PARTICULARLY
ENJOYED DOING, GOING AROUND
TALKING ABOUT MY
DIFFICULTIES IN PUBLIC.
I DID IT BECAUSE I THOUGHT...
I HOPED THAT IT MIGHT MAKE
SOME DIFFERENCE.
BUT ONE OF THE THINGS THAT
HAPPENED ON THIS KIND OF
BOOK TOUR FROM HELL THAT
WENT ON AND ON AND ON WAS
THAT EVERYWHERE I WENT
SOMEBODY WOULD COME UP WITH
A PICTURE OF A 14-YEAR-OLD
OR AN 18-YEAR-OLD OR A
FATHER OR A MOTHER OR
BROTHER OR SISTER OR FRIEND
OR COLLEAGUE, WHO HAD
COMMITTED SUICIDE.
AND I COULDN'T GET THAT OUT
OF MY HEAD, AND I COULDN'T
GET IT OUT OF MY MIND
AND EYES AND EVERYTHING.
AND SO WHEN I SPOKE TO MY
EDITOR I'D ACTUALLY BEEN
PLANNING TO WRITE A
QUITE DIFFERENT BOOK.
I DECIDED TO WRITE A BOOK
ABOUT SUICIDE INSTEAD
BECAUSE IT JUST SEEMED LIKE
THE ENORMITY OF THE PROBLEM
WAS SO SO HUGE AND THAT
THE SCIENCE WAS MOVING SO
QUICKLY AND THE SCIENCE IS
ACTUALLY VERY EXCITING AND
HAS MOVED, EVEN IN THE LAST
FOUR OR FIVE YEARS VERY, VERY
RAPIDLY INDEED.
SO LET ME START WITH THE
PROLOGUE TO THAT BOOK.
SUMMER EVENINGS AT THE
BISTRO GARDENS IN BEVERLY
HILLS TENDED TOWARD THE
LONG AND LANGUOROUS.
MY FRIEND JACK RYAN AND I
WENT THERE OFTEN WHEN I
LIVED IN LOS ANGELES, AND
I INVARIABLY ORDERED THE
DUNGENESS CRAB AND A
SCOTCH ON THE ROCKS.
NOT SO INVARIABLY BUT FROM
TIME TO TIME JACK WOULD USE
THE OCCASION TO
SUGGEST WE GET MARRIED.
IT WAS AN IDEA WITH SUCH PATENT
POTENTIAL FOR CATASTROPHE THAT
NEITHER OF US HAD MUCH
OF AN INCLINATION TO
TAKE THE RECURRING
PROPOSAL WITH TOO MUCH
GRAVITY, BUT OUR FRIENDSHIP
WE TOOK VERY SERIOUSLY.
THIS PARTICULAR EVENING I
FOUND MYSELF KNOCKING THE
ICE CUBES AROUND
IN MY WHISKY GLASS.
THE CONVERSATION WAS
MAKING ME UNEASY.
WE WERE TALKING ABOUT
SUICIDE AND MAKING A BLOOD...
IF EITHER OF US AGAIN BECAME
DEEPLY SUICIDAL WE AGREED,
WE WOULD MEET AT JACK'S
HOME ON CAPE COD.
ONCE THERE, THE NON-SUICIDAL
ONE OF US WOULD HAVE A WEEK
TO PERSUADE THE OTHER
NOT TO COMMIT SUICIDE.
A WEEK TO PRESENT ALL OF THE
REASONS WE COULD COME UP
WITH FOR WHY THE OTHER
SHOULD GO BACK ON LITHIUM,
ASSUMING THAT HAVING STOPPED
IT WAS THE MOST LIKELY
REASON FOR THE
DANGER OF SUICIDE.
A WEEK TO CAJOLE THE OTHER
INTO A HOSPITAL, TO INVOKE
CONSCIENCE, TO IMPRESS UPON
THE OTHER THE PAIN AND DAMAGE
TO OUR FAMILIES THAT SUICIDE
WOULD INEVITABLY BRING.
WE WOULD, WE SAID, DURING
THIS HOSTAGE WEEK, WALK
ALONG THE BEACH AND REMIND
THE OTHER OF ALL THE TIMES
WE'D FELT AT THE END OF HOPE
AND SOMEHOW HAD COME BACK.
WHO, IF NOT SOMEONE WHO HAD
ACTUALLY BEEN THERE COULD
BETTER BRING BACK THE
OTHER FROM THE EDGE?
WE BOTH, IN OUR OWN WAYS,
AND IN OUR OWN INTIMATE
DEALINGS WITH IT,
KNEW SUICIDE WELL.
WE THOUGHT WE KNEW HOW WE
COULD KEEP IT FROM BEING THE
CAUSE OF DEATH ON OUR
DEATH CERTIFICATES.
WE DECIDED THAT A WEEK WAS
LONG ENOUGH TO ARGUE FOR LIFE.
IF IT DIDN'T WORK, THEN
AT LEAST WE HAD TRIED.
AND BECAUSE WE HAD YEARS OF
CUMULATIVE EXPERIENCES WITH
LIFESTYLES OF SNAP
IMPETUOUSNESS, AND WE KNEW
HOW QUICK AND FINAL A
SUICIDAL IMPULSE COULD BE,
WE FURTHER AGREED THAT
NEITHER OF US WOULD EVER BUY
A GUN, NOR WE SWORE, WOULD
WE UNDER ANY CIRCUMSTANCES
ALLOW ANYONE TO KEEP A GUN IN
ANY HOUSE IN WHICH WE LIVED.
WE SEALED OUR FORAY INTO THE
PLANNED AND THE RATIONAL WORLD.
STILL I HAD MY DOUBTS.
I LISTENED TO THE DETAILS,
HELPED CLARIFY A FEW, DRANK
THE REST OF MY SCOTCH AND
STARED AT THE TINY WHITE
LIGHTS IN THE
GARDENS AROUND US.
WHO WERE WE KIDDING?
NEVER ONCE DURING ANY OF MY
SUSTAINED BOUTS OF SUICIDAL
DEPRESSION HAD I BEEN
INCLINED OR ABLE TO PICK UP
A TELEPHONE AND ASK
A FRIEND FOR HELP.
NOT ONCE.
IT WASN'T IN ME.
HOW COULD I SERIOUSLY
IMAGINE THAT I WOULD CALL
JACK, MAKE AN AIRLINE
RESERVATION, GET TO AN
AIRPORT, RENT A CAR, AND
FIND MY WAY OUT TO HIS HOUSE
ON THE CAPE.
IT SEEMED ONLY SLIGHTLY LESS
ABSURD THAT JACK WOULD GO
ALONG WITH THE PLAN,
ALTHOUGH HE AT LEAST WAS
VERY RICH AND COULD GET OTHERS
TO HANDLE THE PRACTICALITIES.
THE MORE I THOUGHT ABOUT THE
WHOLE ARRANGEMENT, THE MORE
SKEPTICAL I BECAME.
IT IS A TRIBUTE TO THE
PERSUASIVENESS REVERBERATING
ENERGIES AND ENTHUSIASMS
AND INFINITE CAPACITY FOR
SELF-DECEPTION OF TWO MANIC
TEMPERAMENTS THAT BY THE
TIME THE DESSERT SOUFFLES
ARRIVED, WE WERE UTTERLY
CONVINCED THAT OUR
PACT WOULD HOLD.
HE WOULD CALL ME.
I WOULD CALL HIM.
WE WOULD OUTMANOEUVRE THE
BLACK KNIGHT AND FORCE HIM
FROM THE BOARD.
IF IT'S EVER BEEN TAKEN UP
AS AN OPTION HOWEVER, THE
BLACK KNIGHT HAS A TENDENCY
TO REMAIN IN PLAY,
AND SO IT DID.
MANY YEARS LATER, JACK HAD
LONG SINCE MARRIED, AND I HAD
MOVED TO WASHINGTON.
I RECEIVED A TELEPHONE
CALL FROM CALIFORNIA.
JACK HAD PUT A GUN TO HIS
HEAD, SAID A MEMBER OF HIS
FAMILY, AND PUT A BULLET
THROUGH HIS BRAIN.
NO WEEK IN CAPE COD.
NO CHANCE TO DISSUADE.
A MAN WHO HAD BEEN INVENTIVE
ENOUGH TO EARN A THOUSAND
PATENTS FOR SUCH WILDLY
DIVERSE CREATIONS AS THE
HAWK AND SPARROW MISSILE
SYSTEMS USED BY THE
UNITED STATES DEPARTMENT OF
DEFENCE, TOYS PLAYED WITH BY
MILLIONS OF CHILDREN AROUND
THE WORLD, AND DEVICES USED
IN VIRTUALLY EVERY HOUSEHOLD
IN AMERICA, A YALE GRADUATE,
AND A GREAT LOVER OF LIFE,
HUGELY SUCCESSFUL BUSINESSMAN.
THIS REMARKABLY IMAGINATIVE
MAN HAD NOT BEEN INVENTIVE
ENOUGH TO FIND AN
ALTERNATIVE SOLUTION TO
A VIOLENT
SELF-INFLICTED DEATH.
ALTHOUGH SHAKEN BY JACK'S
SUICIDE, I WAS NOT SURPRISED
BY IT, NOR WAS I SURPRISED
THAT HE HAD NOT CALLED ME.
I, AFTER ALL, HAD BEEN
DANGEROUSLY SUICIDAL MYSELF
ON SEVERAL OCCASIONS SINCE
OUR COMPACT, AND I CERTAINLY
HAD NOT CALLED HIM, NOR HAD
I EVEN THOUGHT OF CALLING HIM.
SUICIDE IS NOT BEHOLDEN TO
AN EVENING'S PROMISES, NOR
DOES IT ALWAYS HARKEN TO
PLANS DRAWN UP IN LUCID
MOMENTS AND BANKED
IN GOOD INTENTIONS.
I KNOW THIS FOR AN
UNFORTUNATE FACT.
SUICIDE HAS BEEN A
PROFESSIONAL INTEREST OF
MINE FOR MORE THAN 20 YEARS,
AND A VERY PERSONAL ONE
FOR LONGER.
I HAVE A HARD-EARNED RESPECT
FOR SUICIDE'S ABILITY TO
UNDERMINE, OVERWHELM, OUTWIT,
DEVASTATE AND DESTROY.
AS A CLINICIAN, SCIENTIST
AND TEACHER, I HAVE KNOWN OR
CONSULTED ON PATIENTS WHO
HANGED, SHOT OR ASPHYXIATED
THEMSELVES, JUMPED TO THEIR
DEATHS FROM STAIRWELLS,
BUILDINGS OR OVERPASSES,
DIED FROM POISONS, FUMES,
PRESCRIPTION DRUGS, SLASHED
THEIR WRISTS, CUT THEIR THROATS.
CLOSE FRIENDS, FELLOW
STUDENTS FROM GRADUATE
SCHOOL, COLLEAGUES AND NOW
CHILDREN OF COLLEAGUES HAVE
DONE SIMILAR OR THE SAME.
MOST WERE YOUNG AND SUFFERED
FROM MENTAL ILLNESS.
ALL LEFT BEHIND A WAKE
OF UNIMAGINABLE PAIN AND
UNRESOLVABLE GUILT.
LIKE MANY WHO HAVE MANIC
DEPRESSIVE ILLNESS, I HAVE
ALSO KNOWN SUICIDE IN A MORE
PRIVATE, AWFUL WAY, AND I
TRACE THE LOSS OF A
FUNDAMENTAL INNOCENCE TO THE
DAY THAT I FIRST CONSIDERED
SUICIDE AS THE ONLY SOLUTION
POSSIBLE TO AN UNENDURABLE
LEVEL OF MENTAL PAIN.
UNTIL THAT TIME, I HAD TAKEN
FOR GRANTED AND LOVED FAR
MORE THAN I KNEW A
TEMPERAMENTAL LIGHTNESS
OF MOOD AND A FABULOUS
EXPECTATION OF LIFE.
I KNEW DEATH ONLY IN THE
MOST ABSTRACT OF SENSES.
I NEVER IMAGINED IT WOULD BE
SOMETHING TO ARRANGE OR SEEK.
I WAS 17 WHEN IN THE MIDST
OF MY FIRST DEPRESSION I
BECAME KNOWLEDGEABLE ABOUT
SUICIDE IN SOMETHING OTHER
THAN AN EXISTENTIAL
ADOLESCENT SORT OF WAY.
FOR MUCH OF EACH DAY, DURING
SEVERAL MONTHS OF MY SENIOR
YEAR IN HIGH SCHOOL, I
THOUGHT ABOUT WHEN, WHETHER,
WHERE, AND HOW
TO KILL MYSELF.
I LEARNED TO PRESENT TO
OTHERS A FACE AT VARIANCE
WITH MY MIND.
FERRETED OUT THE LOCATION
OF TWO OR THREE NEARBY TALL
BUILDINGS WITH UNPROTECTED
STAIRWELLS, DISCOVERED THE
FASTEST FLOWS OF MORNING
TRAFFIC, AND I LEARNED HOW
TO LOAD MY FATHER'S GUN.
THE REST OF MY LIFE AT THE
TIME... SPORTS, CLASSES,
WRITING, FRIENDS, PLANNING
FOR COLLEGE... FELL FAST INTO
A BLACK NIGHT.
EVERYTHING SEEMED A
RIDICULOUS CHARADE TO
ENDURE, A HOLLOW EXISTENCE
TO FAKE ONE'S WAY THROUGH
AS BEST ONE COULD.
BUT, GRADUALLY, LAYER BY
LAYER, THE DEPRESSION LIFTED
AND BY THE TIME MY SENIOR
PROM AND GRADUATION CAME
AROUND I HAD BEEN
WELL FOR MONTHS.
SUICIDE HAD WITHDRAWN TO THE
BACK SQUARES OF THE BOARD
AND BECOME ONCE AGAIN
SIMPLY UNTHINKABLE.
OVER THE YEARS, MY MANIC
DEPRESSIVE ILLNESS BECAME
MUCH, MUCH WORSE AND THE
REALITY OF DYING YOUNG FROM
SUICIDE BECAME A DANGEROUS
UNDERTOW IN MY DEALINGS
WITH LIFE.
THEN WHEN I WAS 28 YEARS
OLD, AFTER A DAMAGING AND
PSYCHOTIC MANIA, FOLLOWED
IN TURN BY PARTICULARLY
PROLONGED AND VIOLENT SIEGE
OF DEPRESSION, I TOOK A
MASSIVE OVERDOSE OF LITHIUM.
I UNAMBIVALENTLY WANTED TO
DIE, AND I VERY NEARLY DID DIE.
DEATH FROM SUICIDE HAD
BECOME A POSSIBILITY, IF NOT
PROBABILITY, IN MY LIFE.
UNDER THE CIRCUMSTANCES,
I WAS DURING THIS A YOUNG
FACULTY MEMBER IN THE DEPARTMENT
OF ACADEMIC PSYCHIATRY.
IT WAS NOT A VERY LONG WALK
FROM PERSONAL EXPERIENCE TO
CLINICAL AND SCIENTIFIC
INVESTIGATION.
I STUDIED EVERYTHING I COULD
ABOUT MY DISEASE AND READ
ALL I COULD FIND ABOUT THE
PSYCHOLOGICAL AND BIOLOGICAL
DETERMINANTS OF SUICIDE.
AS A TIGER TAMER LEARNS
ABOUT THE MINDS AND MOVES OF
HIS CATS, AND A PILOT THE
DYNAMICS OF THE WIND AND
AIR, I LEARNED ABOUT THE
ILLNESS I HAD AND ITS
POSSIBLE ENDPOINT.
I LEARNED AS BEST I COULD
AND AS MUCH AS I COULD ABOUT
THE MOODS OF DEATH.
THERE ACTUALLY IS... THERE
ARE FEW THINGS IN LIFE MORE
MOTIVATING TO LEARN
SOMETHING THAN TO BE GIVEN A
DISEASE AND NOT TO KNOW
ENOUGH ABOUT IT, AND I IN
FACT DID GET VERY MOTIVATED
AND LEARNED AS FAST AS I
COULD, AS MUCH AS I COULD.
SUICIDE, WHEN I WAS, AS
IT WERE, GROWING UP IN
PSYCHOLOGY AND PSYCHIATRY,
SUICIDE WAS REGARDED AS A
RARE EVENT, AND THAT'S
SORT OF THE GENERAL PUBLIC
PERCEPTION AND IT'S STILL
SORT OF A PHRASE THAT YOU
HEAR LOBBED AROUND
IN MEDICINE.
SUICIDE IS RARE.
I'D LIKE TO MAKE IT REALLY
CLEAR, SUICIDE IS NOT RARE,
AND IT'S AN EPIDEMIC.
IN MOST COUNTRIES IN THE
WORLD IT ACCOUNTS FOR ONE TO
TWO PERCENT OF ALL DEATHS,
WHICH MAKES IT A RELATIVELY
COMMON CAUSE OF DEATH, AND
IT'S RESPONSIBLE FOR ABOUT
A MILLION DEATHS
EACH YEAR WORLDWIDE.
IN WOMEN IN THEIR PEAK
REPRODUCTIVE YEARS, BETWEEN
THE AGES OF 15 AND 44, IT IS
THE SECOND CAUSE OF DEATH,
SECOND ONLY TO TUBERCULOSIS.
IN A SERIES OF SURVEYS THAT
ARE DONE EVERY COUPLE OF
YEARS BY THE CENTRES FOR
DISEASE AND CONTROL AND
PREVENTION IN ATLANTA
GEORGIA, THE CDC, IT'S BEEN
SHOWN THAT ABOUT 8
PERCENT OF HIGH SCHOOL
STUDENTS SAY THAT THEY HAVE
ATTEMPTED SUICIDE IN THE
PRECEDING TWELVE MONTHS.
THIS IS A HUGE NUMBER.
EVERY YEAR THERE ARE 500,000
SUICIDE ATTEMPTS IN THE
UNITED STATES THAT ARE
SERIOUS ENOUGH FROM A
MEDICAL POINT OF VIEW TO
WARRANT TREATMENT IN AN
EMERGENCY DEPARTMENT.
SO LET ME JUST TRY AND
GIVE YOU SOME SENSE OF THE
ENORMITY OF THE PROBLEM AND,
AS I SAY, A LITTLE BIT ABOUT
WHAT WE KNOW CAUSES IT AND
WHAT WE CAN DO ABOUT IT.
COULD I HAVE THE
SLIDES, PLEASE?
OH.
GOT THEM.

A graph appears on a giant projection screen to her right. It shows the death in males, 35 years or younger, between 1955 and 1995. A peak in 1970 reads "Vietnam War." In the late 80's suicide accounts for roughly the same number of deaths than the HIV-AIDS epidemic.

Kay continues ONE OF THE WAYS I TRY TO
CAPTURE THE ENORMITY OF THE
PROBLEM OF SUICIDE WAS TO
TRY AND TAKE TWO EVENTS IN
RELATIVELY RECENT AMERICAN
HISTORY THAT WE KNOW ARE
RESPONSIBLE FOR
DISPROPORTIONATE LOSS OF
LIFE IN YOUNG MEN.
AND ONE OF THEM IS THE HIV
AIDS EPIDEMIC AND THE OTHER
ONE WAS THE VIETNAM WAR.
AND WHAT WE KNOW IS THAT THE
VIETNAM WAR, ALTHOUGH MOST
OF THE DEATHS IN THE VIETNAM
WAR WERE ONLY DURING ABOUT
HALF OF THE YEARS OF THE WAR
ITSELF, THAT TWICE AS MANY
YOUNG AMERICAN MEN DIED BY
SUICIDE IN THE UNITED STATES
AS DIED IN THE WAR.
AND WE ALSO KNOW THAT FAR
MORE PEOPLE HAVE DIED FROM
SUICIDE DURING THE SAME
PERIOD OF TIME OF THE AIDS
EPIDEMIC, AND FORTUNATELY
BECAUSE OF THE EARLIER
RECOGNITION OF AIDS AND
THE MUCH MORE EFFECTIVE
TREATMENTS THAT WE HAVE NOW,
YOU CAN SEE THERE AT THE END
OF A LESSENING IN THE
DEATH RATE OF SUICIDE.
BUT WHAT I REALLY WANT TO
FOCUS ON IS THAT HUGE MASS
OF... IN RED... OF SUICIDE
DEATHS AND YOU CAN SEE A
COUPLE OF THINGS.
ONE IS JUST THE ENORMITY OF
THE NUMBER OF DEATHS THERE,
BUT YOU CAN ALSO SEE THE
SHARP INCREASE IN THE NUMBER
OF DEATHS OVER RECENT YEARS.
AND IN FACT THERE HAS BEEN
IN THE LAST SEVERAL YEARS A
DECREASE, A BEGINNING TO
TURN DOWN IN THAT DEATH RATE
FROM SUICIDE, AND I WANT TO
GET BACK TO THAT LATER AND
THAT'S ALMOST CERTAINLY
BECAUSE OF SOME VERY
AGGRESSIVE PROGRAMS THAT
HAVE BEEN IN PLACE.
BUT THE NUMBER OF DEATHS IS
STAGGERING FROM SUICIDE.
IN THE UNITED STATES EACH YEAR
30,000 PEOPLE DIE BY SUICIDE.
IF YOU LOOK IN THE AGE
RANGE, 15 TO 19, IN FACT
SUICIDE KILLS MORE PEOPLE,
MORE YOUNG PEOPLE, THAN
CANCER, HEART DISEASE, LUNG
DISEASE, AIDS, STROKE AND
ALL THE OTHER NATURAL
CAUSES OF DEATH COMBINED.
WE DON'T DO SO GREAT
AT HOMICIDE EITHER
AS YOU MIGHT NOTE.
IN TERMS OF SUICIDE,
ATTEMPTS IN HIGH SCHOOL
STUDENTS... AGAIN, ABOUT A
MILLION ADOLESCENTS EACH
YEAR IN THE UNITED STATES
ATTEMPT SUICIDE AND ABOUT A
THIRD OF THOSE ATTEMPTS ARE
SERIOUS ENOUGH TO WARRANT
TREATMENT IN AN
EMERGENCY DEPARTMENT.
WHAT DO WE KNOW ABOUT THE
ASSOCIATION BETWEEN SUICIDE
AND MENTAL ILLNESS?
THE SAFEST, STRONGEST
STATEMENTS THAT YOU CAN MAKE
THAT IS BACKED UP BY THE
SCIENTIFIC AND CLINICAL
LITERATURE IS THAT THE MAJOR
ASSOCIATION WITH SUICIDE IS
PSYCHIATRIC ILLNESS.
SEVERE PSYCHIATRIC ILLNESS.
FIVE ILLNESSES
IN PARTICULAR.
MANIC DEPRESSION,
DEPRESSION, SCHIZOPHRENIA,
SUBSTANCE ABUSE AND
ALCOHOLISM, VERY SEVERE
ANXIETY DISORDERS AND SOME
OF THE SEVERE PERSONALITY
DISORDERS LIKE ANTISOCIAL
PERSONALITY DISORDERS AND
BORDERLINE PERSONALITY
DISORDERS.
BUT THE MOOD DISORDERS,
DEPRESSION AND MANIC
DEPRESSION, PARTICULARLY
WHEN COUPLED WITH A DRINKING
PROBLEM OR WITH DRUG ABUSE,
WHICH MANY FORMS OF MOOD
DISORDERS ARE, PUT PEOPLE
PARTICULARLY AT RISK
FOR SUICIDE.
UNTREATED ILLNESS.
WORLDWIDE, COUNTRY AFTER
COUNTRY, STUDY AFTER STUDY,
90 TO 95 PERCENT OF SUICIDES
ARE ASSOCIATED WITH MAJOR
PSYCHIATRIC ILLNESS.
SO THE SINGLE GREATEST PREDICTOR
THAT WE HAVE FOR COMPLETED
SUICIDE IS A HISTORY OF A
SUICIDE ATTEMPT AND THEN
AFTER THAT YOU CAN SEE THE
MOOD DISORDERS...

A bar chart shows rates of attempted suicide: 1 percent for those with no lifetime history of mental disorder; 18 percent for those with major depressive disorder; 24 percent for those with bipolar disorder.

Kay continues AGAIN,
SUBSTANCE ABUSE, SCHIZOPHRENIA.
THE TERMINAL ILLNESSES TURN
OUT... I MEAN I THINK WE ALL
TEND TO THINK IF WE HAD A
TERMINAL ILLNESS LIKE CANCER
OR SOMETHING, WE MIGHT BE
INCLINED TO KILL OURSELVES.
IN POINT OF FACT, TERMINAL
ILLNESSES ACCOUNT FOR LESS
THAN TWO PERCENT OF ALL
SUICIDES, AND MANY OF THOSE
PEOPLE HAVE DEPRESSIVE
ILLNESS AS WELL WHO ACTUALLY
KILL THEMSELVES.
MOST PEOPLE WHO HAVE
LIFE-THREATENING ILLNESSES
DON'T KILL
THEMSELVES AT ALL.
IT'S VERY UNUSUAL.
OKAY.
ONE OF THE COMPOUNDING
PROBLEMS, AS I SAID, IS THE
CO-EXISTENCE OF A DEPRESSIVE
ILLNESS WITH ALCOHOL AND
DRUG ABUSE, AND ONE OF THE
PROBLEMS IS THAT WE KNOW
THAT MANIC DEPRESSION AND
DEPRESSION PUT PEOPLE AT AN
ELEVATED RISK FOR SUICIDE.
BUT WE ALSO KNOW THAT THESE
PEOPLE, PARTICULARLY PEOPLE
WITH MANIC DEPRESSIVE
ILLNESS, ARE FAR MORE LIKELY
TO USE ALCOHOL AND DRUGS,
USUALLY AS A FORM
OF SELF-MEDICATION.
IN FACT, 60 PERCENT OF PEOPLE
WITH MANIC DEPRESSION HAVE
A HISTORY OF DRUG
OR ALCOHOL ABUSE.
SO THAT THE PEOPLE WHO ARE
ALREADY AT GREATLY INCREASED
RISK FOR TAKING THEIR OWN
LIVES BY VIRTUE OF THEIR
MOOD DISORDER ARE THEN MUCH
MORE LIKELY ON TOP OF THAT
TO HAVE A DRUG OR ALCOHOL
PROBLEM THAT THEN GREATLY
INCREASES THE RISK
OF THEIR SUICIDE.
OKAY.
WHY DO... WHY IS IT THAT
SUICIDE SEEMS TO REALLY
TAKE OFF IN ADOLESCENCE?
WHY IS THERE THIS JUST...
SUICIDE BEFORE PUBERTY IS RARE.
IT HAPPENS, BUT IT'S RARE.
BUT AFTER PUBERTY, THE
SUICIDE RATES REALLY BEGIN
TO TAKE OFF,
AND WHY IS THAT?
AND PROBABLY THE SINGLE
SIMPLEST EXPLANATION FOR IT
IS THAT WE KNOW THAT ALL
OF THE MAJOR PSYCHIATRIC
DISORDERS HAVE THEIR AGE
OF ONSET IN ADOLESCENCE,
THEIR AVERAGE AGE OF ONSET
IN ADOLESCENCE OR IN THE
EARLY TWENTIES.
THE AVERAGE AGE OF ONSET FOR
BIPOLAR MANIC DEPRESSION IS
17 OR 18 YEARS OLD.
FOR SCHIZOPHRENIA
IT'S ABOUT 19.
FOR SUBSTANCE ABUSE
IT'S SLIGHTLY YOUNGER.
FOR MAJOR DEPRESSION
IT'S SLIGHTLY OLDER.
SO THAT ALL OF THE ILLNESSES
THAT ARE MOST ASSOCIATED
WITH COMMITTING SUICIDE ARE
ALSO MOST LIKELY TO FIRST
OCCUR DURING LATE ADOLESCENCE
AND THE EARLY TWENTIES.
WE ALSO KNOW... AND THIS IS
ONE OF THE MOST HORRIFYING
TERRIBLE THINGS ABOUT
SUICIDE IS IF YOU HAVE
DEPRESSION OR MANIC
DEPRESSION OR SCHIZOPHRENIA
YOU'RE MUCH MORE LIKELY TO
COMMIT SUICIDE EARLY ON IN
YOUR ILLNESS THAN LATER ON.
SO WHEN YOU ARE LEAST LIKELY
TO BE DIAGNOSED PROPERLY,
WHEN YOU ARE LEAST LIKELY TO
BE IN TREATMENT, WHEN EVEN
IF YOU ARE IN TREATMENT
YOU'RE LEAST LIKELY TO BE
COMPLIANT WITH TREATMENT, YOU'RE
MOST LIKELY TO KILL YOURSELF.
SO THAT HAS VERY REAL AND
PROFOUND CLINICAL IMPLICATIONS.
IT MEANS IN ADDITION TO
EVERYTHING ELSE, YOU
OBVIOUSLY WANT TO IDENTIFY
VERY EARLY PEOPLE WHO ARE
GOING TO BE AT RISK FOR
SUICIDE AND YOU WANT TO
TREAT THEM IN A VERY
INTENSIVE MANNER WITH ALL OF
THE INTERVENTION THAT YOU
CAN BECAUSE THAT'S WHEN THEY
REALLY ARE AT
RISK FOR SUICIDE.
OKAY, SO WHAT ARE THE MAJOR
TREATMENT AND PREVENTION
STRATEGIES THAT WE
HAVE FOR SUICIDE?
ONE IS TREATMENT OF
THE ILLNESSES THAT ARE
RESPONSIBLE FOR SUICIDE, AND
SO THE FIRST ONE KIND OF IN
TERMS OF TREATMENT IS
REALLY YOU HAVE A PATIENT
IN YOUR OFFICE.
YOU'RE A CLINICIAN.
WHAT DO YOU DO?
THE PERSON IS SUICIDAL.
HOW DO YOU DEAL WITH IT?
WHAT DO WE KNOW ABOUT
PREVENTING SUICIDE AT THE
INDIVIDUAL PATIENT LEVEL?
SO WE'LL TALK
ABOUT THAT FIRST.
WHAT DO WE KNOW ABOUT
TRYING TO EDUCATE DOCTORS?
THIS IS NOT ALWAYS
THE EASIEST OF TASKS.
I SAY THAT IN THE CONTEXT OF
BEING SOMEONE WHO ACTUALLY
TEACHES YOUNG DOCTORS AND
WHO HAS ENORMOUS RESPECT FOR
THE MEDICAL SCHOOL
IN WHICH I TEACH.
BUT DOCTORS ARE REALLY
OVERBURDENED IN MEDICAL
SCHOOL WITH KNOWLEDGE.
I MEAN THEY JUST GET THROWN
EVERYTHING AT THEM AND THEY
HAVE A LIMITED AMOUNT OF
TIME TO LEARN, AND SO THE
QUESTION IS HOW CAN YOU
EDUCATE DOCTORS AND DOES
IT MAKE A DIFFERENCE.
IF YOU EDUCATE DOCTORS MORE
INTENSELY ABOUT DEPRESSION,
DOES IT REALLY MAKE
ANY DIFFERENCE?
AND THEN ISSUES OF PUBLIC
EDUCATION, ISSUES OF STIGMA.
HOW DO YOU TRY AND
DESTIGMATIZE THE ILLNESSES
ASSOCIATED WITH SUICIDE SO
THAT YOU CAN GET PEOPLE INTO
TREATMENT AND THEN THE
GENERAL PUBLIC HEALTH MEASURES.
I'LL JUST GO THROUGH
EACH OF THESE BRIEFLY.
IN TERMS OF TREATMENT,
WE KNOW SEVERAL THINGS
ABOUT TREATMENT.
ONE IS IF YOU'VE GOT
SOMEBODY IN YOUR OFFICE,
YOU'VE GOT... THAT HAS,
SAY, DEPRESSION OR
MANIC DEPRESSION.
YOU KNOW A COUPLE OF THINGS.
ONE IS THAT YOU HAVE AN
ACUTE EPISODE OF DEPRESSION,
AND YOU'VE GOT TO TRY AND
TREAT THAT EPISODE OF
DEPRESSION, OKAY.
YOU ALSO KNOW THAT
DEPRESSION AND MANIC
DEPRESSION ARE RECURRENT
ILLNESSES AND IF THEY'RE NOT
TREATED, THEY WILL RECUR.
SO YOU HAVE TO HAVE A
STRATEGY NOT ONLY FOR
TREATING THE ACUTE EPISODE
OF THE ILLNESS, YOU ALSO
HAVE TO HAVE A CLINICAL
STRATEGY FOR TREATING THE
LONG-TERM COURSE OF THE
ILLNESS TO MINIMIZE THE
RECURRENCE AND TO MINIMIZE
THE RISKS OF RECURRENCE OF
FUTURE EPISODES.
BECAUSE IF MANIC DEPRESSION
IS LEFT UNTREATED, FOR
EXAMPLE, WE KNOW THAT IT
WILL RECUR AND IT WILL TEND
TO GET WORSE OVER A LIFETIME
AND IT WILL RECUR MORE
FREQUENTLY AND
INCREASE IN SEVERITY.
SO YOU REALLY WANT TO TREAT
THE INDIVIDUAL EPISODE BUT
YOU DON'T WANT TO DO
ANYTHING THAT'S GOING TO
JEOPARDIZE THE LONG-TERM
COURSE OF THE ILLNESS.
NOW WE HAVE VERY EFFECTIVE
TREATMENTS FOR MOST OF THE
MAJOR PSYCHIATRIC DISORDERS.

A slide reads "Primary treatments for bipolar disorder.
Mood stabilizers: lithium, divalproex Sodium (Depakote®), Carbamazepine (Tegretol®), Lamotrigine (Lamictal®), Gabapentin (Neurontin®), Topirimate (Topamax®).
Anti-psychotic medications.
Antidepressant medications.
Electroconvulsive therapy.
(Adjunctive) Psycotherapy.

Kay continues WE REALLY HAVE EFFECTIVE
TREATMENTS FOR DEPRESSION
AND BIPOLAR ILLNESS,
INCREASINGLY EFFECTIVE
TREATMENTS FOR SCHIZOPHRENIA.
AND SCHIZOPHRENIA HAS A
HIGH DEATH RATE, TOO.
I MEAN SEVERE FOR BIPOLAR
ILLNESS, THE DEATH RATE FROM
SUICIDE IS UP TO 20 PERCENT.
SO ONE PERSON IN FIVE.
I MEAN THAT'S AS HIGH A
MORBIDITY RATE AS YOU GET
IN MANY FORMS OF CANCER
AND HEART DISEASE.
DEPRESSION, MAYBE ABOUT
15 PERCENT, SCHIZOPHRENIA
10 PERCENT.
THESE ARE REALLY HIGH
RATES OF DEATH FROM THESE
ILLNESSES, UNTREATED.
BUT WE HAVE GOOD TREATMENTS
FOR THESE ILLNESSES.
SO YOU NEED TO TREAT PEOPLE
WELL AND AGGRESSIVELY FOR
THESE ILLNESSES BUT YOU
ALSO, WITHIN THAT INDIVIDUAL
EPISODE, IF SOMEBODY'S VERY
ACUTELY DEPRESSED, YOU NEED
TO LET THEM KNOW AND THEIR
FAMILY MEMBERS KNOW... BUT
PARTICULARLY THE PATIENT...
THAT THERE'S CERTAIN
SYMPTOMS THAT ARE
PARTICULARLY PROBLEMATIC,
THAT ARE PARTICULARLY
ASSOCIATED WITH AN INCREASED
RISK FOR SUICIDE.
AGITATION.

A new slate reads "Treatment.
Disorders: depression, bipolar illness, schizophrenia, alcohol and drug abuse, personality disorder. Symptoms: agitation, anxiety, sleep disorders, psychosis."

Kay continues IF A PATIENT IS VERY
PERTURBED, VERY RESTLESS,
VERY AGITATED, UNABLE TO
SLEEP, EXTREMELY ANXIOUS,
THESE ARE THINGS THAT NEED
TO REPORTED IMMEDIATELY TO
THE DOCTOR SO THAT THE
SYMPTOMS THEMSELVES ARE
TREATED, NOT JUST THE
DEPRESSION, BUT THOSE
SYMPTOMS WITHIN THE
DEPRESSION ARE TREATED
VERY, VERY QUICKLY.
OKAY, WHAT DO WE ACTUALLY
KNOW ABOUT MEDICATIONS...
AND I'M NOT GOING TO GO INTO
SOME LONG, DREARY DETAIL.
I MEAN I JUST WANT TO POINT
OUT THAT WE ACTUALLY KNOW
QUITE A BIT, AND THE NEWS
IS ENCOURAGING IN TERMS OF
WHAT WE KNOW.
IT'S NOT ENCOURAGING IN
TERMS OF WHAT WE DO ABOUT IT.
LITHIUM WE HAVE FAR AND AWAY
THE MOST STUDIES ON AND
LITHIUM SEEMS TO HAVE A
QUITE SPECIFIC ANTI-SUICIDE EFFECT.

A new slate reads "Effect of lithium on risk of attempted or completed suicide."
It shows that in 28 studies with an N of 17,294 the risk with lithium was 0.37 and the risk without lithium was 3.39.

Kay continues IN FACT, LOWERS THE DEATH
RATE TO A PHENOMENAL DEGREE,
WHICH IS QUITE STRIKING AND
IT'S ALMOST CERTAINLY NOT
JUST BECAUSE LITHIUM HAS
AN EFFECT ON MOODS AND
STABILIZES MOODS IN BIPOLAR
ILLNESS IN TERMS OF
DECREASING THE ODDS OF
HAVING FUTURE MANIAS AND
DEPRESSIONS, THOUGH
IT DOES DO THAT.
BUT EVEN IN THOSE PATIENTS
FOR WHOM THERE'S NOT A
STRONG MOOD STABILIZING
EFFECT, LITHIUM HAS AN
EFFECT ON THE SUICIDE
RATE IN THOSE PEOPLE.
AND THAT'S BECAUSE WE KNOW
THAT IN ANIMAL LITERATURE,
THAT THE THINGS, THE
VOLATILITY, THE VIOLENCE,
THE IMPULSIVENESS THAT WE
ASSOCIATE WITH INCREASED
SUICIDE RISK IN HUMAN
BEINGS, IN THOSE... IN RATS
THAT HAVE BEEN BRED FOR
THAT, FOR EXAMPLE, FOR
IMPULSIVENESS AND VIOLENCE,
THAT LITHIUM HAS A VERY
STRONG SPECIFIC EFFECT ON
THOSE BEHAVIOURS IN ANIMALS
AS WELL.
SO IT'S PROBABLY HAVING
A DUAL SORT OF EFFECT.
THERE'S ALSO INCREASING
EVIDENCE THAT LITHIUM NOT
ONLY HAS A NEUROPROTECTIVE
EFFECT IN THE BRAIN, BUT IT
ALSO ENCOURAGINGLY ENOUGH...
SINCE I'VE BEEN ON THIS DRUG
FOR QUITE A LONG WHILE AND
I'M ALWAYS SORT OF COUNTING
THE LOSS OF MY NERVE CELLS...
THAT IN FACT IT SEEMS LIKE
IT MIGHT ACTUALLY BE
GENERATING NEW NERVE CELLS,
WHICH IS
INTERESTING AS WELL.
LORD KNOWS I COULD USE IT.

[laughter]

Kay continues BUT WE ALSO KNOW THAT
ANTIDEPRESSANTS... WE DON'T
HAVE THE DIRECT KIND OF EVIDENCE
WITH ANTIDEPRESSANTS.
THE MAIN REASON WE DON'T
HAVE THE DIRECT KIND OF
EVIDENCE WITH
ANTIDEPRESSANTS IS IF YOU
READ PAPERS THAT LOOK AT THE
EFFICACY OF ANTIDEPRESSANTS
ON DEPRESSION, IN THE FIRST
SEVERAL PARAGRAPHS YOU
ALMOST ALWAYS FIND A
DISCLAIMER SAYING PATIENTS
WHO HAD A HISTORY OF SUICIDE
ATTEMPTS OR WHO WERE SUICIDAL
AT THE TIME OF THE STUDY WERE
EXCLUDED FROM THE STUDY.
NOW I CAN TELL YOU, IF YOU
DID THIS IN CANCER RESEARCH,
YOU WOULD HAVE THE AMERICAN
CANCER SOCIETY OUT
ON THE STREETS.
IT'D BE SORT OF LIKE SAYING
PEOPLE WHO HAVE TUMOURS,
REALLY DANGEROUS TUMOURS,
ARE GOING TO BE EXCLUDED
FROM THE CLINICAL TRIALS.
BUT WE'VE GOTTEN SO
FRIGHTENED OF HAVING
LAWSUITS AND SO FORTH, THAT
THESE PEOPLE WHO ARE AT RISK
OF DYING ARE THE ONES WHO
ARE EXCLUDED FROM THE TRIAL.
SO IN ANY EVENT, WE HAVE
ONLY INDIRECT EVIDENCE
RATHER THAN DIRECT EVIDENCE,
AND THE INDIRECT EVIDENCE IS
ONE THING THAT WE KNOW IS,
FOR EXAMPLE, IN THE
UNITED STATES FROM 15 TO 19
YEAR OLDS...

A line chart pops up with the title "Adolescent suicide rates (15-19 year-olds) 1964-1996."

Kay continues AGAIN, A VERY HIGH
RISK GROUP... IF YOU JUST
LOOK AT THE RED LINE THERE,
THAT IS THE TOTAL
SUICIDE RATE.
YOU CAN SEE IN THE LAST
SEVERAL YEARS THAT THAT LINE
IS ACTUALLY TAKING...
BEGINNING TO GO DOWN, WHICH
IS GREAT AND EVEN THOUGH IT
LOOKS LIKE IT MAY BE ONLY A
MOMENTARY BLIP OR A
STATISTICAL ARTIFACT, IN FACT,
MOST EPIDEMIOLOGISTS
ARE CONVINCED THIS
A REAL PHENOMENON.
IT'S NOT JUST AN ARTIFACT.
ANOTHER THING THAT WE
KNOW IN TERMS OF INDIRECT
EVIDENCE FOR THE EFFICACY OF
ANTIDEPRESSANTS ON SUICIDE
RATES IS THAT IN FACT IF YOU
LOOK AT THE PRESCRIPTION
PATTERNS OVER THE LAST
SEVERAL YEARS DURING THAT
BLIP DOWNWARD, THAT
THE RATE OF PRESCRIBING
ANTIDEPRESSANTS IN THAT AGE
GROUP HAS GONE UP IN A VERY
HIGH... IN A VERY DEFINITE
RATE, HAS DEFINITELY GONE UP.
THE PUBLIC HEALTH OFFICIALS
IN HUNGARY HAVE TAKEN A VERY
CONCERTED APPROACH TO
TRAINING PHYSICIANS TO
RECOGNIZE DEPRESSION, THE
SYMPTOMS OF DEPRESSION, AND
TREATING IT QUITE
AGGRESSIVELY WITH
ANTIDEPRESSANTS, SO AGAIN IN
THE BEIGE LINE, YOU CAN SEE
THE ANTIDEPRESSANT
PRESCRIPTION PATTERN RATES
GOING WAY UP AND THE SUICIDE
RATE BEGINNING TO GO DOWN
QUITE SHARPLY.
OKAY, WE HAVE ONE OTHER DRUG
THAT LIKE LITHIUM SEEMS TO
HAVE A QUITE SPECIFIC EFFECT
ON SUICIDE RATES AND THAT IS
CLOZAPINE, WHICH IS AN
ANTIPSYCHOTIC MEDICATION
THAT'S USED WITH
SCHIZOPHRENIA, AND IT HAS
SHOWN IN PATIENTS WITH
SCHIZOPHRENIA A QUITE
DEFINITE REDUCTION IN THE
DEATH RATE FROM SUICIDE.
SO WE HAVE, YOU KNOW,
SEVERAL MEDICATIONS AND
CLASSES OF MEDICATIONS THAT
SEEM TO WORK QUITE WELL WHEN
THEY'RE USED PROPERLY
AND AGGRESSIVELY.
HOWEVER, AS ANYONE WILL KNOW
WHO HAS A MOOD DISORDER, OR
HAS BEEN AROUND ANYBODY WITH
A MOOD DISORDER, COMPLIANCE IS
A BIG PROBLEM.
NOT TAKING MEDICATIONS,
PARTICULARLY IN YOUNG
PEOPLE, BUT IN MOST PEOPLE.
AND IN FACT COMPLIANCE IS A
MAJOR PROBLEM IN MEDICINE.
IT'S NOT JUST
PSYCHIATRY FOR SURE.
50 TO 75 PERCENT OF PEOPLE
WILL COMPLY WITH MEDICATIONS
FOR EPILEPSY AND CHRONIC
HEART DISEASE, BUT THAT
MEANS THAT, YOU KNOW, 25 TO
50 PERCENT OF PEOPLE DON'T.
AND IN FACT I'M ALWAYS...
WHEN THE RESIDENTS GET IN A
SNARL ABOUT, YOU KNOW, ONE
MORE PATIENT THAT'S GONE OFF
HIS LITHIUM OR
ANTICONVULSANT OR WHATEVER,
THEY GET UPSET BECAUSE THE
PERSON WAS DOING SO WELL AND
THEY STOPPED THEIR MEDICINE
AND THEY GOT SICK AGAIN AND
THEY'RE IN THE
HOSPITAL AGAIN.
SO THEN I REMIND THEM
THERE'S A CLASSIC STUDY IN
MEDICINE WHERE PHYSICIANS
WERE... WHO HAD UPPER
RESPIRATORY INFECTIONS WERE
GIVEN ANTIBIOTICS AND THEY
ALL KNEW THAT THEY HAD TO TAKE
A 10-DAY COURSE OF ANTIBIOTICS.
THEY ALL KNEW THAT IF THEY
DIDN'T TAKE THE 10 DAYS THAT
THEY WOULD GET SICK AGAIN.
AND THEY ALSO ALL KNEW THAT
THEY WOULD FEEL BETTER AFTER
ABOUT THREE OR FOUR DAYS AND
WOULD BE VERY TEMPTED TO
STOP, BUT THEY HAD TO KEEP
ON TAKING IT, AND UNDER
THOSE CIRCUMSTANCES, 50
PERCENT OF DOCTORS STOPPED
TAKING THEIR ANTIBIOTICS.
NOW IT PRESSES CREDULITY
THAT YOU'RE ASKING PEOPLE TO
SIGN UP FOR MEDICATIONS FOR
A LIFETIME THAT OFTEN HAVE
VERY DISTURBING SIDE EFFECTS
AND IF THE DRUG IS WORKING,
PEOPLE ARE FEELING WELL SO
THEY'RE NOT MOTIVATED TO
TAKE THE MEDICATION.
SO YOU'VE GOT ALL SORTS
OF... IT'S A HORRENDOUS
CLINICAL PROBLEM.
SO WHAT DO WE KNOW?
WE KNOW THAT FROM A LONG
SERIES OF VERY ELEGANT
STUDIES DONE BY MYRNA
WEISSMAN AND GERRY KLERMAN
AT YALE MANY YEARS AGO NOW,
THAT FOR MODERATE TO SEVERE
DEPRESSION THAT THE
COMBINATION OF MEDICATION
AND PSYCHOTHERAPY IS
FAR MORE EFFECTIVE THAN
PSYCHOTHERAPY ALONE
OR MEDICATION ALONE.

A slate reads "Percent who described psychotherapy as 'very important' to lithium compliance." It shows that it was 27 percent of prescribing physicians and 50 percent of patients on lithium.

Kay continues THERE'S VERY COMPELLING
EVIDENCE FOR THAT, THAT THE
COMBINATION... THEY DO
DIFFERENT THINGS AND IN
COMBINATION THEY'RE MORE
EFFECTIVE THAN EITHER
ONE ALONE.
WHAT HAD BEEN THOUGHT ABOUT
MANIC DEPRESSION IS IT'S SO
GENETIC, IT'S SO BIOLOGICAL,
THAT REALLY ALL YOU HAD TO
DO WAS GIVE PEOPLE MEDICINES
AND THEY WOULD SORT OF WALK
OFF INTO THE SUNSET
AND BE HAPPY AND WELL.
WELL, THIS IS
INSANE OF COURSE.
IT'S NOT TRUE.
DOESN'T WORK.
AND SO IN THE LAST TEN,
15, YEARS, PEOPLE HAVE
INCREASINGLY BEEN STUDYING
HOW CAN PSYCHOTHERAPY BE
USED IN AN EFFECTIVE WAY
WITH PEOPLE WHO HAVE BIPOLAR
ILLNESS TO HELP THEM BOTH
DEAL WITH THE TREMENDOUS
TRAUMA THAT THE ILLNESS IS
IN ITS OWN RIGHT, PLUS HELP
THEM DEAL WITH THE PROBLEMS
OF STAYING ON MEDICATION.
AND THIS IS A VERY EARLY
STUDY DONE BY SUE COCHRANE
AT UCLA FOR HER
DOCTORAL DISSERTATION.
AND IT'S PUT UP HERE... THERE
HAVE BEEN A LOT OF STUDIES
SINCE, BUT IT'S PUT UP HERE
AS A PROTOTYPIC STUDY.
IT WAS AT THE UCLA MOOD
DISORDERS CLINIC ONE GROUP OF
PATIENTS WAS BASICALLY JUST
GIVEN LITHIUM AND FOLLOWED,
YOU KNOW, IN A VERY
CONSCIENTIOUS WAY BY
GOOD DOCTORS, BUT
JUST GIVEN LITHIUM.

A slide reads "Cognitive therapy and lithium compliance (6-month follow-up)."
It displays a table of results.

Kay continues THE OTHER GROUP WAS GIVEN
LITHIUM PLUS COGNITIVE
THERAPY AND THE PATIENTS
WHO GOT COGNITIVE THERAPY,
AS WELL AS LITHIUM,
DID MUCH BETTER.
THEY STAYED OUT
OF THE HOSPITAL.
THEY HAD FAR FEWER
RECURRENCES OF THEIR ILLNESS.

A new slide reads "Family-focused treatment. 9 families received education, communication, and problem-solving training (21 sessions). Relapse rate: 11 percent.
Comparison group was followed naturalistically and treated with lithium alone. Relapse rate: 61 percent."

Kay continues AND LIKEWISE, THIS IS JUST
ONE STUDY LOOKING AT FAMILY
BASED THERAPIES WHERE
YOU HAVE VERY INTENSIVE
THERAPEUTIC INTERVENTION
WITH FAMILY EDUCATION,
INDIVIDUAL PATIENT
THERAPY AND SO FORTH.
IT WAS A VERY CONCERTED
PROGRAM AND WHAT YOU CAN SEE
HERE IS A RELAPSE RATE...
IF YOU JUST GIVE PATIENTS
MEDICATIONS, THE RELAPSE
RATE IS UP TO 61 PERCENT.
IF THEY HAVE THESE COMBINED
EDUCATION AND PSYCHOTHERAPY
PROGRAMS, THE RELAPSE
RATE IS ABOUT 11 PERCENT.
HUGE DIFFERENCE BY ANYBODY'S
STANDARDS ON THIS.
OKAY.
TURNING TO THE ISSUE OF
PHYSICIAN EDUCATION,
THIS IS SOMETHING I FEEL
PARTICULARLY STRONGLY ABOUT
BECAUSE IN ADDITION TO
EVERYTHING ELSE, DOCTORS
THEMSELVES HAVE A
HIGH SUICIDE RATE.
EVER YEAR IN THE UNITED
STATES THE EQUIVALENT OF ONE
ENTIRE MEDICAL SCHOOL
CLASS DIES BY SUICIDE.

A slide reads "Suicide in physicians. More common than in general population. Contributing factors: mood disorders, temperament, stress, sleep deprivation, competitive subculture. Easy access to highly lethal methods. Self-medication with alcohol, drugs, and antidepressants. Professional concerns: licensing, hospital privileges, patient referrals.

Kay continues AND FOR A LOT OF REASONS
THERE IS EVIDENCE CERTAINLY
THAT THERE'S A HIGHER RATE
OF MOOD DISORDERS IN DOCTORS
THAN IN THE GENERAL PUBLIC,
BUT THEY ALSO HAVE CERTAIN
KINDS OF... IT'S NOT EVEN
JUST STRESS SO MUCH AS
CERTAIN CONDITIONS
OF SLEEP DEPRIVATION.
SLEEP DEPRIVATION MAKES MOOD
DISORDERS VERY MUCH WORSE.
THEY HAVE ACCESS TO HIGHLY
LETHAL MEANS OF SUICIDE
AND IN THIS DAY AND AGE,
UNFORTUNATELY MANY DOCTORS
MEDICATE THEMSELVES WITH
ANTIDEPRESSANTS BECAUSE
THEY'RE RELUCTANT TO
GO TO THEIR COLLEAGUES
FOR TREATMENT.
AND SELF-MEDICATION
WITH ANTIDEPRESSANTS IS
DEFINITELY SOMETHING THAT IS
GENERALLY REALLY A BAD IDEA.
REALLY A BAD IDEA.
I MEAN ALL OF US WHO TREAT
MOOD DISORDERS HAVE JUST
SEEN CATASTROPHE AFTER
CATASTROPHE IN DOCTORS WHO
HAVE TRIED TO DO THIS.
ON THE OTHER HAND, GIVEN THE
PROFESSIONAL CLIMATE ABOUT
DISCLOSING MENTAL ILLNESS,
WHEN YOU RISK YOUR STATE
LICENCE, YOUR HOSPITAL
PRIVILEGES, YOUR REFERRAL
SOURCES, YOU PUT YOURSELF AT
LIABILITY FROM A LEGAL POINT
OF VIEW.
UNTIL WE CREATE A CLIMATE
THAT MAKES IT EASY FOR
DOCTORS TO SEEK OR RECEIVE
THE KIND OF CARE THEY NEED,
WE'RE NOT GOING TO HAVE,
I THINK, THE KIND OF
QUESTIONING OF PATIENTS
ABOUT SUICIDE AND THE KIND
OF OPENNESS IN DISCUSSING
THOUGHTS OF SUICIDE, PLANS
ABOUT SUICIDE, HISTORIES OF
SUICIDE ATTEMPTS, FAMILY
HISTORIES OF SUICIDE, THE
KINDS OF QUESTIONS THAT
WE NEED TO ASK
ABOUT DEPRESSION.
SO I THINK WE NEED TO START
REALLY AT GROUND ZERO WITH
YOUNG DOCTORS IN TERMS OF
EDUCATING THEM ABOUT MOOD
DISORDERS AND DEPRESSION
AND TREATMENT.
A PARTICULARLY DISCOURAGING
STUDY CAME OUT LAST YEAR IN
THE JOURNAL OF AMERICAN
MEDICAL ASSOCIATION SHOWING
THAT ABOUT 8 PERCENT...
ONLY ABOUT 8 PERCENT OF
DOCTORS WHO WERE ACTUALLY
TREATING CHILDREN WITH
ANTIDEPRESSANTS FELT LIKE
THEY HAD THE KIND OF
KNOWLEDGE BASE THAT THEY
NEEDED TO BE TREATING
THOSE CHILDREN.
THAT GIVES YOU PAUSE.
AND IT'S NOT THAT
THEY DIDN'T WANT IT.
I MEAN I THINK, YOU KNOW, I
REALLY THINK MOST DOCTORS,
MOST GPs AND INTERNISTS
WHO ARE THE ONES WHO ARE
ACTUALLY PRESCRIBING
ANTIDEPRESSANTS FAR MORE
THAN PSYCHIATRISTS ARE, THAT
MOST DOCTORS REALLY WANT TO
DO A GOOD JOB AND THEY
AREN'T REIMBURSED FOR IT.
THEY AREN'T GIVEN THE KIND
OF TIME IN THEIR PRACTICES
TO ASK THE KIND OF QUESTIONS
THAT IT TAKES TO DO A GOOD
JOB IN TERMS OF DIAGNOSING
AND TREATING DEPRESSION.

A slide reads "Physician education. A 1999 survey of pediatricians and family doctors found that only 8 percent of those prescribing antidepressants for children felt they had received adequate training in treating childhood depression."
Quoted from the Journal of the American Medical Association, 1999 (study by J. Rushton.)

Kay continues ONE STUDY THAT REALLY
PARTICULARLY LOOKED AT WHAT
IMPACT DOES IT HAVE IF YOU
ACTUALLY TAKE... IN SWEDEN,
THEY TOOK ONE ENTIRE ISLAND,
EDUCATED ALL THE DOCTORS
VERY, VERY SYSTEMATICALLY
ABOUT HOW TO RECOGNIZE SIGNS
OF DEPRESSION IN YOUNG
PEOPLE, IN CHILDREN AND
ADOLESCENTS, IN OLD PEOPLE.

A chart appears with the title "The impact of the education of general practitioners in the island of Gotland on suicide rates (per 100,000)."

Kay continues I MEAN ALL ALONG THE AGE
CONTINUUM AND HOW TO TREAT
THEM, WHAT DOSAGES TO GIVE,
HOW TO TREAT KIND OF ALL THE
PROBLEMS THAT ARE RELATED
TO TREATING DEPRESSION.
AND WHAT YOU CAN SEE HERE IS
THAT THE SUICIDE RATE IN THE
REST OF SWEDEN REMAINED
PRETTY MUCH THE SAME, AND IN
THE ISLAND OF GOTLAND, AFTER
THE DOCTORS HAD BEEN VERY
INTENSELY EDUCATED ABOUT
DEPRESSION AND HOW TO TREAT
DEPRESSION, THE SUICIDE
RATE WENT WAY DOWN.
THERE ARE A LOT OF COMMON
DIAGNOSTIC MISTAKES WHICH I
WON'T GET INTO, BUT PROBABLY
THE MOST COMMON ONE IS THAT
PEOPLE ARE DIAGNOSED AS
HAVING MAJOR DEPRESSION WHO
IN FACT MIGHT HAVE A VARIANT
OF MANIC DEPRESSION, MIGHT
HAVE MILD MANIAS THAT
ARE HIGHLY IRRITABLE AND
VOLATILE AND DON'T GET
PICKED UP, THEY GET PICKED
UP AND DIAGNOSED AS AGITATED
DEPRESSIONS OR WHATEVER.
WHAT DIFFERENCE
DOES THAT MAKE?
DOES THAT MEAN THAT IT'S
JUST PEOPLE STEWING ABOUT,
YOU KNOW, OBSESSIVE DOCTORS
GOING ON ABOUT DIAGNOSES?
IT ISN'T REALLY, BECAUSE THE
TREATMENTS ARE VERY DIFFERENT.
YOU CAN MAKE SOME PEOPLE
VERY MUCH WORSE ON
ANTIDEPRESSANTS BY AGITATING
THEM AND ALSO BY WORSENING
THE LONG-TERM COURSE
OF THE DISEASE.
SO IT'S VERY IMPORTANT TO
GET THE DIAGNOSIS CORRECT,
AND THAT'S A PROBLEM.
LIKEWISE, SOME CHILDREN
ARE BEING DIAGNOSED WITH
ATTENTION DEFICIT DISORDER
WHO, IN FACT, HAVE EARLY ONSET
BIPOLAR DISORDER.
ONE EFFORT THAT THE AMERICAN
FOUNDATION FOR SUICIDE
PREVENTION HAS TAKEN IS A
KIND OF A SIMPLE ONE, BUT
IT'S TO JUST PUT A POSTER IN
EVERY EMERGENCY ROOM IN THE
UNITED STATES THAT KIND
OF LISTS THE SYMPTOMS OF
DEPRESSION, THE SYMPTOMS OF
MANIA, PEOPLE WHO ARE AT
RISK, THE RISK FACTORS FOR
SUICIDE, BECAUSE IN FACT, IF
YOU THINK ABOUT WHERE'S THE
GREATEST CONCENTRATION OF
HIGH RISK PATIENTS, IT'S
PROBABLY IN AN EMERGENCY
ROOM, PEOPLE WHO'VE COME IN
AFTER A SUICIDE ATTEMPT.
AND SO WHAT HAPPENS IN THE
BUSTLE OF AN EMERGENCY ROOM
OFTEN IS THAT PEOPLE DON'T
THINK THINGS THROUGH AS
CAREFULLY AS THEY SHOULD AND
THEY DON'T ASK FUNDAMENTAL
QUESTIONS LIKE DO YOU
HAVE A GUN AT HOME.
NOW IN CANADA WHERE YOU
HAVE A SENSIBLE GUN POLICY,
THAT'S NOT A BIG ISSUE.
THE UNITED STATES, WHERE
WE HAVE A COMPLETELY
INDEFENSIBLE GUN POLICY,
IT IS A BIG ISSUE.
AND PEOPLE SEND PATIENTS
HOME WHO HAVE GUNS AT HOME.
SO THAT'S LIKE A
VERY SIMPLE THING.
OR MEDICATIONS THAT
MIGHT KILL YOU.
DO YOU HAVE A
FOLLOW-UP APPOINTMENT?
DO YOU HAVE A TELEPHONE
NUMBER YOU CAN CALL?
ALL THESE KINDS OF THINGS.
THESE ARE VERY SIMPLE
PHYSICIAN EDUCATION ON THE
JOB TRAINING AS IT WERE.
PUBLIC HEALTH MEASURES.
I'M JUST GOING TO
DISCUSS A COUPLE OF THEM.
ONE IS ONE OF THE MAJOR
PROBLEMS ABOUT SUICIDE, AS I
STARTED MY REMARKS, IS THAT
WE DON'T TALK ABOUT IT.
WE DON'T DISCUSS IT.
WE DON'T DEAL WITH IT.
WE PRETEND LIKE IT JUST
HAPPENS RARELY AND
IDIOSYNCRATICALLY AND THERE'S
REALLY NOTHING WE CAN DO
ABOUT IT ANYWAY BECAUSE
IT'S JUST OFF THERE.
SO IT IS SYNCRATIC.
AND WE DON'T TALK ABOUT THE
ILLNESSES THAT LEAD UP TO IT
BECAUSE OF THE STIGMA
ATTACHED TO THE PSYCHIATRIC
ILLNESSES, AND I THINK UNTIL
WE JUST SORT OF SAY, YOU
KNOW, WE'VE GOT TO MOVE ON.
THIS IS, YOU KNOW,
THIS IS THE YEAR 2000.
THESE ARE MEDICAL
CONDITIONS.
THEY'VE GOT HUGE
RAMIFICATIONS IN TERMS
OF PAIN AND SUFFERING.
AND JUST SORT OF DEAL WITH
IT AND GET A GRIP AND DEAL
WITH IT.
SO THERE ARE A SERIES OF
PUBLIC SERVICE ANNOUNCEMENTS
THAT MEAN BASICALLY IN THE
STATES, AND I ASSUME HERE AS
WELL, WHERE YOU JUST...
TELEVISION WILL CONTRIBUTE
TIME OR MOVIE THEATRES WILL
CONTRIBUTE TIME IN THE
PUBLIC CONCERN AND SO
YOU CAN GIVE MESSAGES.
AND SO ONE OF THE MESSAGES
THAT THE AMERICAN FOUNDATION
FOR SUICIDE PREVENTION, FOR
EXAMPLE, WANTED ADOLESCENTS
TO HAVE IS THE MOST COMMON
PROBLEM THAT ADOLESCENTS
HAVE IS A FRIEND OF THEIRS
MAY SAY TO THEM I DON'T WANT
TO LIVE ANY MORE.
I HAVE A GUN AT HOME.
I'M THINKING ABOUT
KILLING MYSELF,
BUT YOU CAN'T
TELL ANYBODY.
IF YOU TELL ANYBODY, YOU
KNOW, WE WON'T BE FRIENDS
ANY MORE, IN EFFECT.
AND THIS CAMPAIGN IS ONE
THAT WAS AT LOEW'S THEATRE.
THE HUGE MOVIE CHAIN
THEATRE, MOVIE HOUSE THEATRE.
IT BASICALLY GAVE TIME
BECAUSE IT REACHES VERY
YOUNG AUDIENCES, AND THE
CAMPAIGN IS A VERY BRUTALLY
HONEST ONE, WHICH IS
BASICALLY YOU'RE A LOT
BETTER OFF HAVING A LIVE
FRIEND WHO DOESN'T WANT YOU
AS A FRIEND ANY MORE THAN
HAVING A DEAD FRIEND.
AND YOU HAVE TO
TELL SOMEBODY.
YOU CAN'T KEEP
THIS TO YOURSELF.
YOU'VE GOT TO GET
HELP WITH THIS.
SO THAT'S ONE CAMPAIGN.
ANOTHER CAMPAIGN IS
Mrs. GORE, THE VICE
PRESIDENT'S WIFE, HAS
DEPRESSION HERSELF.
SHE'S BEEN QUITE OPEN ABOUT
IT AND HAS BEEN A STRONG
ADVOCATE FOR TRYING TO
DESTIGMATIZE MENTAL ILLNESS
AND TRYING TO DO
SOMETHING ABOUT IT.
AND SHE SET UP A BOARD AND
ONE OF THE THINGS THAT
SHE TRIED TO REACH OUT TO
WAS MTV BECAUSE OF THE
YOUTHFULNESS OF THE AUDIENCE
AND THE BOARD WAS SENT
THESE, YOU KNOW, CASSETTES
THAT WERE GOING TO BE SHOWN
ON MTV AND WE'RE SUPPOSED TO
RESPOND AND SAY YOU KNOW,
WHAT DO WE THINK ABOUT IT,
AND I THOUGHT THIS WAS LIKE
COMPLETELY INCOMPREHENSIBLE.
IT WAS JUST ONE OF THESE
TACHISTOSCOPIC PRESENTATIONS
OF, YOU KNOW, VISUAL
INFORMATION AND EVERY
NOW AND THEN YOU GET THE
WORD DEPRESSION AND THEN
IT WOULD JUST BE COMPLETELY
INCOHERENT AGAIN.
SO I SAID... FOR ALL I KNEW,
AS IT TURNED OUT... I SAID,
GEEPS I CAN'T, YOU KNOW,
MAYBE THIS'LL WORK BUT IT
JUST RUNS RIGHT PAST ME.
AND IT TURNS OUT THAT THEY
AIRED IT, FORTUNATELY, OVER
A LOT OF OUR CONCERNS, AND
IT HAD A MILLION HITS ON THE
WEBSITE IN THE FIRST WEEK
FROM KIDS WANTING TO KNOW
ABOUT DEPRESSION.
HUGELY EFFECTIVE CAMPAIGN.
AND SO THAT
PROGRAM'S GOING ON.
ONE OF THE MOST VULNERABLE
AGE GROUPS IS COLLEGE KIDS
AND UNIVERSITY STUDENTS.
AND, IN FACT, SUICIDE IS THE
SECOND LEADING CAUSE OF
DEATH IN COLLEGE AGE KIDS.
AND ONE OF THE REASONS, ONE
OF THE PROBLEMS, HAS BEEN
THAT KIDS WHO NEVER WOULD
MAKE IT INTO COLLEGE OR
UNIVERSITY FIVE OR SIX YEARS
AGO BECAUSE THEY HAD SEVERE
MENTAL ILLNESS, BECAUSE OF
THE VERY EFFECTIVENESS OF
THE MEDICATIONS NOW, THEY
ARE GOING INTO COLLEGES AND
UNIVERSITIES ON LITHIUM
AND ANTICONVULSANTS AND
ANTIDEPRESSANTS AND
ANTIPSYCHOTIC MEDICATIONS
OFTEN WITH VERY
SEVERE ILLNESSES.
THE UNIVERSITIES ARE
NOT GEARED UP FOR THIS.
THEY DON'T KNOW WHAT TO DO.
THEY'VE OVERWHELMED WITH
THE PSYCHIATRIC PROBLEMS.
AND THEY'RE SORT OF USED TO
RUNNING COUNSELLING SERVICES,
NOT REAL PSYCHIATRIC
ILLNESS SERVICES.
SO ONE OF THE THINGS... AS
A MATTER OF FACT, HARVARD
UNIVERSITY LAST WEEK
INAUGURATED A HUGE CAMPAIGN
FROM THE PROVOST'S OFFICE...
AND I THINK THAT'S REALLY
WHERE IT HAS TO COME FROM.
IT HAS TO COME FROM THE
CHANCELLOR'S OFFICE OR THE
PRESIDENT'S OFFICE.
IF IT COMES JUST FROM A
LOWER LEVEL, IT DOESN'T GO
ANYWHERE, BUT THE PROVOST AT
HARVARD USED TO BE THE DEAN
OF THE SCHOOL OF PUBLIC
HEALTH AT HARVARD BEFORE
HE BECAME PROVOST.
AND HE WAS APPALLED BY THE
EXTENT OF SUICIDE AND MENTAL
ILLNESS IN THE HARVARD
UNDERGRADUATE AND
GRADUATE STUDENTS.
SO HE REALLY TOOK MOST OF
THE LAST WEEK TO HAVE A
WHOLE SERIES OF LECTURES AND
TALKS AND RAP GROUPS AND,
YOU KNOW, FROM THE FACULTY
TO STUDENTS TO GRADUATE
RESIDENT ADVISORS AND SO
FORTH... A LOT OF WEBSITES
AND A LOT OF INFORMATION
OUT THERE, AND HAS DECIDED
TO BE VERY
PROACTIVE ABOUT IT.
AND I THINK THAT'S WHAT
UNIVERSITIES AND COLLEGES
ARE INCREASINGLY GOING TO
HAVE TO DO BECAUSE THEY'RE
DEALING WITH A VERY
VULNERABLE GROUP.
I'M JUST GOING TO END WITH
THE EPILOGUE TO MY BOOK AND
THEN LEAVE IT OPEN TO
WHATEVER KINDS OF QUESTIONS
YOU MAY HAVE.
I WAS NAIVE TO UNDERESTIMATE
HOW DISTURBING IT WOULD BE
TO WRITE THIS BOOK.
I KNEW, OF COURSE, THAT IT
WOULD MEAN INTERVIEWING
PEOPLE ABOUT THE MOST
PAINFUL AND PRIVATE MOMENTS
OF THEIR LIVES, AND I ALSO
KNEW THAT I WOULD INEVITABLY
BE DRAWN INTO MY OWN PRIVATE
DEALINGS WITH SUICIDE
OVER THE YEARS.
NEITHER PROSPECT WAS
AN ATTRACTIVE ONE.
BUT I WANTED TO DO SOMETHING
ABOUT THE EPIDEMIC OF
SUICIDE AND THE ONLY THING
I KNEW TO DO WAS TO WRITE
A BOOK ABOUT IT.
I AM BY TEMPERAMENT AN
OPTIMIST AND I THOUGHT FROM
THE BEGINNING THAT THERE
MUCH TO BE WRITTEN ABOUT
SUICIDE THAT WAS
STRANGELY HEARTENING.
AS A CLINICIAN, I BELIEVED
THERE WERE TREATMENTS THAT
COULD SAVE LIVES.
AS ONE SURROUNDED BY
SCIENTIST WHOSE EXPLORATIONS
OF THE BRAIN ARE ELEGANT AND
PROFOUND, I BELIEVED OUR
BASIC UNDERSTANDING OF
THE BRAIN'S BIOLOGY WAS
RADICALLY CHANGING HOW WE
THINK ABOUT BOTH MENTAL
ILLNESS AND SUICIDE.
AS A TEACHER OF YOUNG
DOCTORS AND GRADUATE
STUDENTS, I FELT THE FUTURE
HELD OUT GREAT PROMISE FOR
THE INTELLIGENT AND
COMPASSIONATE CARE OF THE
SUICIDAL MENTALLY ILL.
ALL OF THESE THINGS
I STILL BELIEVE.
THE SCIENCE IS OF
THE FIRST WATER.
IT IS FAST-PACED AND IS
LAYING DOWN PIXEL BY PIXEL,
GENE BY GENE, THE DENDRITIC
MOSAIC OF THE BRAIN.
PSYCHOLOGISTS ARE
DECIPHERING THE MOTIVATIONS
FOR SUICIDE AND PIECING
TOGETHER THE FINAL STRAWS,
THE CIRCUMSTANCES OF LIFE
THAT SO DANGEROUSLY IGNITE
THE BRAIN'S VULNERABILITIES.
AND THROUGHOUT THE WORLD,
FROM SCANDINAVIA TO
AUSTRALIA, PUBLIC HEALTH
OFFICIALS ARE MAPPING A
CLEARLY REASONED STRATEGY TO
CUT THE DEATH RATE OF SUICIDE.
STILL, THE EFFORT SEEMS
REMARKABLY UNHURRIED.
EVERY 17 MINUTES IN AMERICA
SOMEONE COMMITS SUICIDE.
WHERE IS THE PUBLIC CONCERN?
WHERE IS THE OUTRAGE?
I'VE BECOME MORE IMPATIENT
AS A RESULT OF WRITING THIS
BOOK AND AM MORE ACUTELY
AWARE OF THE PROBLEMS THAT
STAND IN THE WAY OF
DENTING THE DEATH COUNT.
I CANNOT RID MY MIND OF THE
DESOLATION, CONFUSION AND
GUILT I'VE SEEN IN THE
PARENTS, CHILDREN, FRIENDS,
AND COLLEAGUES OF THOSE
WHO KILL THEMSELVES.
NOR CAN I SHUT OUT THE
IMAGES OF THE AUTOPSY
PHOTOGRAPHS OF 12-YEAR-OLD
CHILDREN OR THE PROM
PHOTOGRAPHS OF ADOLESCENTS
WHO WILL WITHIN A YEAR'S
TIME PUT A PISTOL IN THEIR
MOUTHS OR JUMP FROM THE TOP
FLOOR OF A UNIVERSITY
DORMITORY BUILDING.
LOOKING AT SUICIDE, THE
SHEER NUMBERS, THE PAIN
LEADING UP TO IT, AND THE
SUFFERING LEFT BEHIND
IS HARROWING.
FOR EVERY MOMENT OF
EXUBERANCE IN THE SCIENCE
OR IN THE SUCCESS OF
GOVERNMENTS, THERE'S A
MATCHING AND TERRIBLE REALITY
OF THE DEATHS THEMSELVES.
THE YOUNG DEATHS, THE
VIOLENT DEATHS, THE
UNNECESSARY DEATHS.
LIKE MANY OF MY COLLEAGUES
WHO STUDY SUICIDE, I HAVE
SEEN TIME AND AGAIN THE
LIMITATIONS OF OUR SCIENCE,
BEEN PRIVILEGED TO SEE HOW
GOOD SOME DOCTORS ARE AND
APPALLED BY THE CALLOUSNESS
AND INCOMPETENCE OF OTHERS.
MOSTLY I'VE BEEN IMPRESSED
BY HOW LITTLE VALUE OUR
SOCIETY PUTS ON SAVING THE
LIVES OF THOSE WHO ARE IN
SUCH DESPAIR AS TO
WANT TO END THEM.
IT IS A SOCIETAL ILLUSION
THAT SUICIDE IS RARE.
SUICIDE IS NOT RARE.
CERTAINLY THE MENTAL
ILLNESSES MOST CLOSELY TIED
TO SUICIDE ARE NOT RARE.
THEY ARE COMMON CONDITIONS
AND, UNLIKE CANCER AND HEART
DISEASE, THEY
DISPROPORTIONATELY AFFECT
AND KILL THE YOUNG.
A FEW WEEKS AFTER I NEARLY
DIED FROM MY SUICIDE
ATTEMPT, I WENT TO THE
EPISCOPAL CHURCH ACROSS THE
STREET FROM THE UCLA CAMPUS.
I WAS A PARISHIONER THERE,
HOWEVER OCCASIONAL, AND IN
LIGHT OF BEING ABLE TO WALK
IN THROUGH THE DOOR INSTEAD
OF BEING CARRIED IN BY SIX,
I THOUGHT I WOULD SEE WHAT
WAS LEFT OF MY
RELATIONSHIP WITH GOD.
TO MAKE IT EASIER, I
PURCHASED A TICKET TO A
RECITAL THAT WAS BEING
PERFORMED IN THE CHAPEL.
I WENT TO THE CHURCH EARLY.
MY MIND WAS STILL DULL AND
EVERYTHING IN IT, AND IN MY
HEART WAS FRAYED
AND EXHAUSTED.
BUT I KNELT ANYWAY IN SPITE,
OR BECAUSE OF THIS, AND
SPOKE INTO MY HANDS THE
ONLY PRAYER I REALLY KNOW,
OR CARE VERY MUCH ABOUT.
THE BEGINNING WAS
ROTE AND EASY.
GOD BE IN MY HEAD, AND IN
MY UNDERSTANDING I SAID
TO MYSELF OR GOD.
GOD BE IN MINE EYES
AND IN MY LOOKING.
SOMEHOW DESPITE THE
THICKENING OF MY MIND,
I GOT THROUGH MOST
OF THE REST OF IT.
BUT THEN I BLANKED OUT
ENTIRELY AS I GOT TO THE
END, STRUGGLING TO GET
THROUGH WHAT HAD, AFTER ALL,
STARTED OFF AS AN ACT OF
RECONCILIATION WITH GOD.
THE WORDS WERE
NOWHERE TO BE FOUND.
I IMAGINED FOR A WHILE THAT
MY FORGETTING WAS DUE TO THE
REMNANTS OF THE POISONOUS
QUANTITIES OF LITHIUM
I HAD TAKEN.
BUT SUDDENLY THE FINAL
LINES CAME UP INTO
MY CONSCIOUSNESS.
GOD BE AT MINE END
AND MY DEPARTING.
I FELT A CONVULSIVE SENSE OF
SHAME AND SADNESS, A KIND
I HAD NOT KNOWN BEFORE,
NOR HAVE I KNOWN IT SINCE.
WHERE HAD GOD BEEN?
I COULD NOT ANSWER THE
QUESTION THEN, NOR CAN I
ANSWER IT NOW.
I DO KNOW, HOWEVER, THAT I
SHOULD HAVE BEEN DEAD BUT
WAS NOT, AND THAT I WAS
FORTUNATE ENOUGH TO BE GIVEN
ANOTHER CHANCE AT LIFE
WHICH MANY OTHERS WERE NOT.
WHILE WRITING THIS BOOK, I
KEPT ON MY DESK A PHOTOGRAPH
AND A FRAGMENT OF A POEM.
THE PHOTOGRAPH IS OF A YOUNG
GOOD-LOOKING CADET AT THE
UNITED STATES AIR FORCE
ACADEMY STANDING NEXT TO
A JET FIGHTER.
WRITING ABOUT THIS YOUNG
MAN'S SUICIDE WAS THE MOST
DIFFICULT PART OF
WRITING MY BOOK.
I STARTED THE ESSAY ON A
CLEAR WINTER DAY IN THE
LIBRARY AT THE UNIVERSITY OF
St. ANDREWS WHERE I TEACH
EACH YEAR.
I WAS ABLE TO READ HIS
MEDICAL RECORDS FOR BRIEF
PERIODS ONLY BEFORE I HAD
TO GET UP, WALK OVER TO THE
WINDOW AND LOOK OUT AT
THE NORTH SEA IN A FUTILE
ATTEMPT TO PULL FROM IT A
MEANING THAT WOULD MAKE MORE
TOLERABLE THE
AWFULNESS OF IT ALL.
I WOULD THEN RETURN TO THE
MEDICAL NOTES THAT CHARTED
OUT THE INEXORABLE COURSE OF
THE MANIC DEPRESSIVE ILLNESS
THAT WOULD KILL HIM.
THE FRAGMENT OF THE POEM I
KEPT ON MY DESK WAS ONE THAT
DREW ME TO LIFE.
IT IS THE LAST LINE
FROM DOUGLAS DUNN'S
DISENCHANTMENTS.
LOOK TO THE LIVING,
LOVE THEM, AND HOLD ON.
THANK YOU.

[long applause]

Classical music plays as the end credits roll.

Comments and queries, email: bigideas@tvo.org

Telephone: (416) 484-2746.

Big Ideas, TVONTARIO, Box 200, Station Q, Toronto, Ontario, Canada. M4T 2T1.

Producer, Wodek Szemberg.

Associate Producer, Mike Miner.

Sound, Herb Langwasser.

Executive Producer, Doug Grant.

A production of TVOntario. Copyright 2001, The Ontario Educational Communications Authority.

Watch: Kay Redfield Jamison on Understanding Suicide