It’s Not Your Fault

I am thinking about families today, and especially the families of those who have attempted or completed suicide. Suicide is the most serious consequence of having a mental illness and a suicide attempt and suicidal thoughts are always reminders of how dangerous a mental illness can be.

When someone dies of a suicide attempt, those who know and loved them suddenly become victims of the stigma that continues to plague mental illness. How does that stigma manifest itself?

The stigma is evident in the fact that most family members and friends will ask themselves, “Was there something more I should have done?” For the most part, if your mother or your sister or your child dies of cardiac arrest or cancer, you do not ponder the circumstances, concerned that you were neglectful or remiss. But suicide and suicide attempts are different in that there are always lingering doubts about what signs we might have missed. We go over final statements and conversations, finding meanings that we believe we should have caught.

I want very much for everyone reading this, who has had someone close to them lose their life because of suicide, to read the next sentence carefully, knowing it is the most important thing to remember about suicide and suicide attempts.

It’s not your fault. It’s no one’s fault. The problem is that suicide and suicide attempts are symptoms of a serious mental illness.

I wanted to emphasize those sentences and that paragraph above, but I mean this plea to be gentle, a reminder of how insidious mental illness can be. Mental illness has a different contagion. It is as if we can catch the guilt and low self esteem of our loved one from their suicide or suicide attempt. No other illness does this.

Next week, January 31, is Bell Let’s Talk Day. Already the Commercials are playing, raising awareness about mental illness more effectively than any other campaign. During the campaign, we will hear from people with great courage who speak about their mental illness, in voices that systematically work against the stigma that still marks the afflicted.

The suicide rate in Canada is 11.5 people per 100,000. The number of family members and friends affected by these deaths is too extensive to capture. Probably about one third of us have been affected by a suicide or a serious suicide attempt.

I am thinking about those of us who have been affected by a death by suicide or a suicide attempt. I am writing this so that we remind ourselves not to be infected by the contagion of stigma, not to fall into the trap of thinking that we were at fault for a death by suicide or a suicide attempt. I want us to remind each other, because I find it hard to remember this on my own.

(Note: Tabitha Suzuma is a British author of fiction for young adults. This image is from Pinterest.)

How to Manage a Suicide Pact

Recently at a Montreal high school, 62 high school students made a suicide pact. As the story broke last week, the Montreal Gazette revealed that school officials had determined the three people who started the pact, who claimed that it was a prank. The article also quoted a school official as saying that “some of the students did not know what they were signing because only the first sheet indicated that it was a suicide pact”. No doubt school personnel were trying to allay the fears of the public, and more importantly, parents of students at College d’Anjou, a private high school in Montreal’s east end.

I learned about this situation when I was asked to comment and provide advice for Global News. I found the tone of school officials, as characterized by the Montreal Gazette, to be troubling. We know too much in 2017 not to be concerned whenever news of a suicide pact emerges, especially among youth between 15 and 24 years old. During these years, suicide is the second most common cause of death.

Some of the other facts that ought to have engendered more concern are the actual statistics about suicide and suicide attempts in Canada. The Canadian Mental Health Association has found that 34% of youth between the ages of 15 and 24 have contemplated suicide – one third. Also, the actual number of suicide attempts in this population in Canada is 8%. Both the rate of contemplation and the rate of attempts increases when there is a suicide pact. The acceptance implied in a suicide pact reduces a young person’s emotional barriers to suicide and so the risk increases.

What should happen when a school learns of a suicide pact? There are 3 direct steps that might help. The first step consists of education through assemblies. Bring all concerned together, in this case the entire student body along with their parents and other interested family members, e.g. siblings. Have an experienced resource person speak to this group about what to do to reassure themselves that their family member will be okay. This person can direct the assembly to resources for Mental Health First Aid as well as to local crisis and emergency services. There will be lots of questions about both the general subject of suicide and suicide pacts and about the specific situation. The resource person and school personnel should be prepared to address these. The school personnel must be prepared to address concerns openly, without judgment, and compassionately. This is not a time to be defensive. It is a time to make sure you have support moving forward should there be a need for further mental health assistance.

The second step must involve meetings with mental health professionals for each person involved in the pact. The best scenario is that one third of these youth were contemplating suicide and it is important to reach out and find help for these young people.

Finally, it is an important time to remind everyone of these three circumstances that indicate an increased risk of suicide in a young person:
1. Increased use of alcohol and drugs.
2. Giving away one’s belongings.
3. Signs and symptoms of depression or a history of depression.

Doing all of this is a good start to preventing suicide, but suicide and suicide attempts are symptoms of a serious medical illness. People die of serious illnesses. In some cases, such as this, these deaths can be prevented.

If anyone reading this has questions, please ask. The best way to prevent suicide is to talk about it openly and without judgment.

Just Ask

I consider myself to be a very fortunate doctor because I do not often have to deal with the death of my patients. My patients usually recover from their illnesses and, because they are young, I am often able to see them live out the promise of their lives.
The deaths in my practice, however, always continue to haunt me because they are deaths by suicide and suicide is such an insidious outcome that even those of us who see it most often can forget that suicidal ideation and attempts are serious symptoms of a severe illness. We should know better, but we still forget that this severe illness is very difficult to recognize.

Severe illnesses in youth are so difficult for all of us to comprehend. Depression and suicide are even more difficult because they are symptoms that often occur in young people who can present a cheerful countenance to the world – who have a gift of helping others to feel happy. Have you not heard this? Do you not know of a situation in which this was exactly the case?

On the weekend, I read J. Kelly Nestruck’s article in the Globe and Mail about Jonah McIntosh, a young actor at the Shaw Festival who died by suicide in July. He recorded how the Artistic Director at the Shaw Festival saw Mr. McIntosh: “always smiling and making everyone around him smile”. Mr. Nestruk also documented that a death such as the young actor’s suicide was not one the theatre company had experienced, which seemed surprising to me. There is a suicide every forty seconds in the world and artists and actors have a suicide rate of 24 per 100,000, higher than physicians or teachers or nurses.

The article underlined for me once again that those of us who work in mental health fail to educate the public about how difficult it is to predict the course of depression – we have not communicated how a smiling face cannot be assumed to be an accurate reflection of mood. Many people with depression leave their friends and family, leave their doctors’ offices, with a smiling face even when they are plagued by persistent suicidal thoughts, with plans to act on their troubling symptoms. Most of these people have brought joy to their families and friends, but have never found it for themselves.
At this stage in my career, I no longer think about whether I am asking the question sensitively. I just ask, “Are you thinking of suicide?” “Do you have a plan to kill yourself?” People ask all the time if these questions could cause a person to think of suicide but this is not the case.

Just ask, I tell people. If the person you ask seems shocked, or makes some protest, just say,”I am so worried about you and I do not want to make the mistake of not asking about suicide.” We would not hesitate to ask about the serious symptoms of heart disease. We must begin to do the same for depression and suicide. We can save these wonderful lives if we ask. We can prevent suicide.

(On September 10 at 8 pm I put a candle in my window to show my support for suicide prevention and for those who die by suicide and for those who survive.)