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.)

World Suicide Prevention Day 2016

Today from 12:00 to 1:00 I will participate in the World Suicide Prevention Day Facebook Know What to Do Event. The event will be hosted on the Facebook page of the Children’s Hospital of Eastern Ontario (CHEO).  As well as answering participants’ questions, I have a short presentation to make on talking to your child about suicide.

When I considered what to say, I realized that the most important thing for a parent to remember when they have a suicidal child is: Suicide attempts and suicidal thoughts are symptoms of serious illnesses. They are caused by many different factors. Talking about suicide with your child cannot give your child the idea to attempt suicide and so parents should never worry about raising the issue. This is important for parents, and, in fact, for all of us to remember since stigma and blaming oneself are still more implicated in suicide that the fact that it is the outcome of a serious illness.

Because suicidal thoughts and suicide attempts are symptoms of an illness, I encourage parents, friends and others to ask youth about suicide when they are worried that a person may be suffering from ideas of taking their own life. Indicate your concern and your wish to help. A young person contemplating suicide needs to understand that you care about them, that you love them and that you’re going to do whatever they need you to do to get them help.

I advise parents to ask a young person how they can help. Offer to do whatever the young person needs and be prepared to follow through. If a young person is reluctant to talk to you, find someone they will talk to.

It is important for us not to judge suicidal thinking – it is the symptom of an illness. Ask over and over what you can do to help. Remember that statements such as, “You have so much to live for” or “Think how this will affect your family” are not necessarily helpful to a person with the despair that is another symptom of depression. Suicide and suicidal thoughts are not wrong – they are the symptom of an illness.

There is no perfect way to ask about suicidal thoughts. Just say, “I’m worried about you and I need to ask whether you are having thoughts of suicide.” Say, “I’m sorry if this upsets you but I want to help.”

As I write this, I am reminded of the many young people I have cared for who suffered with mental illness and suicidal thoughts for many months and even years before treatment began to be effective. I see their troubled faces first and then their smiling faces once they were feeling better. I work with a great team of social workers, psychologists, other psychiatrists, nurses, teachers, child and youth workers, recreation therapists, occupational therapists and experienced managers and office staff. We have teams at The Royal, at CHEO and at Youth Services Bureau. We all work together to provide the treatment that is needed for serious mental illnesses and to prevent suicide.

I want to end where I began: Suicidal thoughts and suicide attempts are symptoms of a serious illness. Children and youth do take their own lives and that is a tragedy. My thoughts are with those who have lost a loved one to suicide. My thoughts are with those who are suffering because of mental illness. On World Suicide Prevention Day, this is the message: “Let’s never give up. We can prevent suicide.”


My Mental Health Message

In the last week, I have had two opportunities to provide my opinions on how I practise psychiatry. Last Wednesday, on World Suicide Prevention Day, I participated in a tweet chat with staff at The Royal, answering questions about depression and preventing suicide. https://storify.com/TheRoyalMHC/sept-10-2014-at-3-pm-checkwithbeck. Today I was Rita Celli’s guest on Ontario Today, answering questions and addressing concerns about marijuana use in youth. http://www.cbc.ca/ontariotoday/

Both events forced me to consider: what do I think is the most important thing I say to the youth that I see and their parents and the answer to this is: Never lose hope. Many youth are struggling with mental health problems and it takes a lot of work and support to overcome these, but we continue to develop better treatments and diagnostics and there is every reason to be optimistic about outcomes.

Because I work in a tertiary care health centre, it is not uncommon for me to assess and treat youth who have tried many treatment with no success. What sets my team apart is their persistence, and mine. We will not give up until we find the correct treatment for an illness.

The young people that I see are courageous and talented. They have dreams to change the world and make it a better place. Some of those young people and their parents participated in the twitter and web chats. I hope a few people will look through these and consider the strengths of those with mental illness and the families who are supporting them. I hope they all know what an important testimony they are to how we can conquer mental illness together. Hearing their stories over the phone, on twitter and online has been the highlight of my week.

As Shakespeare said, “O Brave New World, that has such people in it.”