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cm2012

Great summary of the suicide literature. This is why it's okay to restrain suicidal people against their will - it's temporary madness most of the time

If your happy but very drunk friend wanted to tapdance on the edge of a tall building, would you restrain them if necessary? Or if someone high on shrooms was trying to drink bleach?

A suicidal mind is often one caught in the temporary throes of delusion and irrationality, even if it comes from internal wiring going haywire instead of external substances.

Preventing someone from killing themselves is in their best interest most of the time for that reason. Suicidal impulses are most often fleeting relative to normal lifespan.

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It would be interesting to talk to these people and ask if it was the suicide attempt itself that made them not attempt again. If you prevent the attempt will it have the same effect?

I know people who have said the primary reason they don't attempt suicide again is not that they feel life is improving or worth living, but because each attempt further reduced their QoL and they're terrified of what another unsuccessful attempt might yield.

I attempted suicide at age 17. I have been hospitalized twice on a suicide watch.

For me, yes, the failed attempt has served as a deterrent. Due to various intractable issues, my life has sucked for a long time. Adding more scars, more people thinking I'm merely crazy and more medical bills won't in any way enhance my life.

I don't want to survive another failed attempt and I'm usually in no position to make sure I succeed.

So, for me, yes, it's been a factor.

/Anecdata

Speaking for myself, virtually all self administered methods used can be quite painful with an uncertain outcome, due to imperfect information. As I started going through an attempt, as the pain increased, I backed off and realized I had no idea what I was doing and needed to stop. I suppose people that attempt suicide don't see another way of solving whatever they perceive to be the doomsday singularity in their life.

I think it probably depends on whether they tried because they lost all their coping mechanisms or because they were angry. I'm one of the former and I don't think I'd ever attempt it again but it seems people who attempt as an act of rage are more likely to repeat.

I'm not confident that stopping someone would have the same effect as them living through it.

In my opinion the misconception is that suicidal ideation means no will for self-preservation. On the opposite, the urge to think, speak and act on suicidal ideation is at odds with various other emotions and instincts.

One way of threading this needle is to perform attempts which are obviously going to fail, maybe eben intentionally so.

It may take any kind of attempt, be it intentionally or accidentally unsuccessful to lead to treatment or at least the acknowledgement of all parties involved that the problem is actually bigger than a bout of self-pity or lack of character.

I remember working through rounds of depression and constantly confused and doubting my interpretation of .... anything / everything.

It was hard to understand the differences I perception when depressed and not.

One day a doctor almost as an aside said "When you are depressed, you don't see the world the way it is, but you also can't comprehend that entirely or maybe at all."

I finally understood why it was just so different on either end of the depression and non depression world and also how far "off" my ability to understand certain things were.

What is the difference? I mean, the world is the world and the things that happen don’t change just because one sees them in a different way.

Put another way, even if I wasn’t depressed, I’d still be single, diabetic and have a ton of debt. What about that would change?

Optimism for one thing. Non-depressive people usually think their problems are conquerable and they can find some enjoyment here and there.

For another, the perception/prediction of effort is very much different. In a depressive episode patients will estimate all tasks as fundamentally harder, leading to huge problems in motivation and making decisions. It's quite analogous to how increased gravity on another planet would affect your movements and decisions about your movements.

When the capacity for enjoyment or positive emotions is reduced, you won't be seeking enjoyment as much. Which is a vicious cycle, of course.

So yes, depressive symptoms are a big hindrance, even if you have other big problems, none of which I would want to diminish.

My therapist also tries to explain the difference between a “depressing” thought and a “depressive” thought. The first is just sad: “my ex started dating my roommate and that makes me feel uncomfortable”. The latter snowballs into morbid or hyperbolic predictions of the future: “now I’m going to be ostracized from my social group because they won’t want me making things weird. I also work with him and my professional life is going to fall apart. Ill have no safe space and I’m going to crack & burn all bridges i have here. I’m going to need to restart my life somewhere across the country”

Another comparison would be those trait controllers they had in Westworld. The writers/engineers could move sliders on a flexible sheet for different character traits.

In depressive episodes the sliders for "optimism", "motivation", "thrill seeking", "social behavior" would be significantly lower than they are normally.

But the idea that those traits are not constant goes much against our cultural programming, I think.

The language around this is messy because not all depressive symptoms are shared, but I would say it's in how you view it.

In your example, being single and having a lot of debt can change over time. But if you were in the throes of a depressive episode, then you might believe absolutely that neither of them can ever change because they haven't changed yet/they'll take so long/it's impossible for you to expend the effort needed to change them/[...].

The facts are the same, but the conclusions you draw are different.

some people still see these problems are not damaging enough to be sad

- failing love relationship can also be pain, some love the peace of being single

- diabetic may be managed (maybe your case is harder though, I cannot assume it's easy)

- some can find support to fill debt and like to rise above it as a challenge

Much in life is interpretation, and accepting damaging emotions as truer than neutral or positive is not my favorite choice.

Best wishes

1) your ability to cope with it would change

2) your ability to seek help to cope with it would chang

3) your perception of time is often different during an acute suicidal episode - time stretches out which makes this particular moment feel all-encompassing.

The alternative is that you can _only_ appreciate the true state of the world when you are depressed, and everybody else just walks around in a little stupor thinking somehow they and their world matters, when we are all the effect of a run-away accidental chemical experiment.

Or may not, I don't know, but I would be weary about assertions about depression from a person who isn't, even if that person is a doctor.

It is certainly easy to go down that rabbit hole and get all myopic when you're depressed and belive that the only thing you can see is "true". I don't blame anyone for it as it is hard not to, but it's still a problem.

While it is different to compare while depressed, I don't think it is hard to understand that other people who have similar problems / life situations are doing fine... and maybe they know something / do things differently.

That alone doesn't fix anything, but it is a place from where you can evaluate and understand that the world, possibilities, etc, while depressed, shrinks to some extent.

> This is why it's okay to restrain suicidal people against their will

Well, it isn't.

If you believe that, then you should also be willing to exempt anyone who has given notice in advance (let say 2 weeks).

If you are not, then please don't go and lord your believes about peoples lives over them.

i agree to a large degree, though even 1/10 is an appalling rate of suicide vs the general population of 1/5000~

Risk prediction is really tricky. We think the best predictor of risk is a previous suicide attempt, or a previous self harm attempt.

About half of people who die by suicide have a history of self harm, and in the year after attending A&E for self harm people are at 30* to 50* the risk of dying by suicide.

We need the short term intervention to save life, and we need an intense package of community support for the next few months addressing the full range of bio-psycho-social needs of the patient.

We're not getting this right in the UK at the moment. I can't speak about the US.

Would you mind defining self harm? Is it auto-mutilation strictly, or does something like smoking/drinking/other_drugs also count?

For self harm here the definition comes from NICE guidance.

https://www.nice.org.uk/guidance/qs34

> The term self‑harm is used in this quality standard to refer to any act of self‑poisoning or self‑injury carried out by a person, irrespective of their motivation. This commonly involves self‑poisoning with medication or self‑injury by cutting. Self‑harm is not used to refer to harm arising from overeating, body piercing, body tattooing, excessive consumption of alcohol or recreational drugs, starvation arising from anorexia nervosa or accidental harm to oneself.

This definition excludes drug use, but that would be covered elsewhere. For example, the front page of NCISH (National Confidential Inquiry into Suicide and Self Harm, previously NCIS and Homicide by MH patients) has this (under "improving safety in mental health services"): https://sites.manchester.ac.uk/ncish/

> Reducing alcohol and drug misuse

> We recommend there are drug and alcohol services available that work closely with mental health services for patients with mental illness and alcohol and drug misuse.

> Our evidence

> Only a minority of patients who died by suicide between 2006 and 2016 were in contact with specialist substance misuse services, despite alcohol and drug misuse being a common antecedent of patient suicide in all UK countries. In England, there was a 25% fall in rates of suicide by patients in those NHS Trusts which had put in place a policy on the management of patients with co-morbid alcohol and drug misuse. Guidance

It looks to me like you are comparing a lifetime figure against a yearly figure.

Suicide figures are usually given on an annual basis, but we often mistake the figures for lifetime risk, and we are then surprised with how common suicide is within our own experience/extended acquantancy.

thats true, but my statement remains correct regardless.

correct me if i fudge my math. 1- 1/5000 =.9998. .9998^72 = .985702, thus <1.5% chance of suicide over a life time.

.1 is still appallingly high vs .015 (and I think 1/5000 is actually a generous estimate, rates are age adjusted so its hard to apples to apples, but according to wikipedia its 13.42 / 100k - much less than 1/5k).

From the numbers it could very well be that a lot of the ones who die in a subsequent attempt could be bipolar or have some other serious comorbidity in addition to "just" major depression.

There are multiple conditions which can lead to depressive symptoms and suicidal tendencies. Some are more malign than others, which is a strange thing to say about conditions that make you want to kill yourself. But basically, suicidality in bipolar patients can only be significantly reduced by exactly one specific medication.

Are you referring to Lithium or just saying they need one more medication, on average, to get them out of their very deep hole?

They get out of their deep hole very much on their own, usually within weeks or months. But that's actually the problem in bipolar disorder. They can go from total depression to a much more energetic state in days or a few weeks, such that suicidal ideation and feeling like shit can overlap with high motivational energy. And that's the most dangerous time for suicidal tendencies. In a very deep depressive episodes, suicide is just too much effort.

And yes, I was referring to Lithium as the only medication which significantly reduces the incidence of suicide attempts in bipolar patients. But that effect is only visible long-term.

You made quite the leap of logic there.

The article is about people whose suicide attempts failed, and ended up with them alive in hospital. Of these people, only about 10% will successfully suicide later.

There is no connection between these incidents and your justification for restraining suicidal people against their will. I am certain that there is evidence to support your claim, but this is not it.

I see your point, but I also don't see much of a leap.

If 90% who survived suicide did not attempt suicide again it sort of does suggest that had more people survived their suicide impulses they would also be one-timers. Sadly, sometimes one impulse is the last.

I read about bridge jumpers who survived (I think it was the Golden Gate Bridge, FWIW) and most said the instant they left the bridge they had a rush of clarity and profoundly regretted what they had just done.

Haunts me still to think about the ones that didn't survive but likely had that same moment of horror.

>If 90% who survived suicide did not attempt suicide again it sort of does suggest that had more people survived their suicide impulses they would also be one-timers.

It might also suggest that those who survived a suicide attempt used half-hearted measures because it was an impulsive act, while at least some (though we'll likely never know that actual proportion) of those who did not survive their attempt went to greater lengths to ensure their death because their act was more premeditated and planned out than impulsive.

What about the other 10%? Was there a second impulse, then a third one? Sad as it may be to contemplate, not all suicide is a spur-of-the-moment thing, some people will go to great lengths to get their affairs in order and ensure their own death.

I think the point is that they have to execute to get the release from the insanity.

Pulling people back from the brink might stop them trying this time, but perhaps it’s that moment of clarity after all the noise and chaos inside their head has finally been resolved by making a decision and following through, that leads them to recognise the more sensible decisions they should have taken.

You really don't need "supportive evidence" to stop someone from hurting himself using whatever power you have. You just need to be a human being with a functioning heart.

A human being with a real "functioning heart" would not stop somebody from trying to kill themselves.

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