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Comment by anm89 | Hacker News Reader

This is the part where every one piles in posting suicide hotline numbers. I would argue most of those people do not have any experience with, or understanding of those hotlines and it's just a trite thing to throw out to show support like "fuck cancer".

You should seriously understand what you are signing yourself up for if you call one of those numbers on yourself or someone else.

For one you are volunteering that person for involuntary incarceration in a mental health facility for an unspecified and potentially unlimited amount of time.

Need to show up to work tomorrow to avoid losing your job? That probably isn't happening.

Need to pay your bills to avoid losing your house? That might not be within your capabilities for the next several months or longer.

Kids need to get to school? CPS is likely going to be handling that for the indefinite future if they don't have another guardian because you aren't going to be around to do it and you are no longer fit to be a legal guardian anyway.

I'd probably rather end up in Jail than in that system.

Simply put, in our society indicating you are suicidal is a defacto crime and you should never do it(including and maybe especially to a psychiatrist/psychologist who maybe taking on legal risk if they don't institutionalize you after the admission) unless you are ready to suffer the consequences.

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This article is from the UK, so we should be clear about consequences for the UK audience.

The Samaritans hotline (a general distress helpline) is there to listen. Nothing else. They do not provide treatment, judgement or the like. Sometimes that is enough. More importantly its anonymous. You will not be sectioned by phoning them

To be sectioned (ie detained against your will), you _have_ to be assessed by a doctor within 24 hours. You need to be deemed a risk to yourself or others(by at least two doctors) before you can be held any longer.

You cannot be fired for being sectioned in the UK.

So whilst the UK is very far from being perfect in terms of mental health (lord knows we have a multitude of problems, some alluded to in the article) it is not as bad as described in the parent thread.

Do you still collect your normal pay while being sectioned in the UK? If not, may as well have been fired…

Depends on the employer, but at the least you will be entitled to statutory sick pay(SSP). Most employers will cover the first 5 to 10 sick days without any changes to your pay. After a certain time period this may drop to 80% of wages and then after another defined period of time SSP kicks in, which is usually significantly reduced pay but you are paid and your job will remain open for you to return.

And to clarify further for the US audience, this first 5-10 days doesn't come out of holiday (vacation) time/pay, there isn't combined "PTO" in the UK; sick days and vacation time are treated separately.

In fact, you even still accrue vacation time while off sick, I was off sick for a year and when I came back HR came to me with the news that I had extra holiday to use the next year because it been rolled over from when I was off sick.

If you're sick while on holiday you can even try to claim the days back although most people don't as that's seen as taking the piss a bit.

The UK also has welfare, depending on how high flying your finances currently are, you may not even find yourself falling that far down the ladder. Obviously not great, and non-trivial, but it's a much softer rock bottom than it could be.

The welfare system has been deliberately broken though. The bureaucratic hoops erected in thr last 10 years make it harder for regular people who need help to get while doing little to nothing about fraud.

I think in many parts of the world, it's abnormal to stop paying someone just because they're unable to work. Often companies try to take care of their employees, especially during their rough times.

It depends on length of stay.

But in general you will be paid full wages for intermittent sickness (ie three days -> couple of weeks)

As you are sectioned you will have a doctor's note by default, so there is no chance of being fired. (employment tribunal will back you up on that. However there is a cost(capped at £750) to that nowadays [thanks david cameron, you utter shitfacewankstain])

There are a number of rights for returning to work as well after a long sickness.

Should that fail, there is still nominally a safteynet of universal credit. However that has become rather inhumane recently (thanks again David you shitbag.) but it is not as inhumane as unemployment insurance in the US.

Feeling obliged to leave my story here:

Three years ago I made a plan to take my own life. Instead of pushing through I contacted a local suicide hotline, it was completely anonymous. I just talked for a bit, but that little moment helped me to find the courage to talk to a family member and that led me to go into therapy which I completed a few months ago.

Initially I was very scared telling my therapist about being suicidal, exactly sketching those horror scenarios. But when I finally talked about it, nothing happened. I remained into complete control of my own therapy the whole period. It helped me turn my life around and I'm incredibly happy I took the leap of faith to start talking about it.

Nice one mate, so happy for you. This must have been incredibly difficult to work through.

Thanks for posting that for the world to hear.

Unfortunately, judging by the prevalence of the opposing situation happening in articles (in reputable newspapers too) online, you have essentially been lucky (or never got into a conflict with your therapist).

The odds of someone dying through suicide after a suicide attempt is very small (only 2%), but those odds greatly increase if inpatient treatment is provided, instead of reducing. There is a reason for that, and clearly your experience doesn't provide that reason. The stated reason psychiatrists give for this is that only the very serious cases get committed, but research doesn't back that, and for specific institutions (and you have no control over where you end up) it is definitely not true.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710249/

Suicide after inpatient treatment in a psychiatric facility is actually getting close to enter the top-10 causes of death. Whilst that doesn't directly contradict what you're saying, it comes pretty close.

In the Netherlands, it is now actually true that more than 50% of suicides happen with psychiatric help, which mostly means getting locked up. Given that less than 1.5% of the population ever gets committed (but rising fast, especially for kids), that's pretty incredible.

And in a bunch of published cases it isn't even the case that people were committed for a suicide attempt, but for an outburst that was then diagnosed, for example as autism. Suicide came, years later, after years of treatment, a progressively worsening situation, and months in isolation in such a facility, in one case with the person locked up without his glasses.

Is their evidence that psychiatric inpatient treatment is causing high suicide rates among those who leave?

Wouldn't "the system is mostly good at only putting extremely high-risk people into those facilities" cause the same correlation if it were the case?

Would it be surprising if "people leaving any general hospital" were more likely to die of whatever they had been there for than "people who didn't need to go to hospital"?

Yes, in the sense that due to the funding situation of such facilities a bunch of people get refused entry (or because of "complex" problems. E.g. suicidal + addicted? No help for you). So you can study the group that gets helped and the group that doesn't and compare them.

Of course the criticism is that they only take the worst problems (even though refusing "complex" cases obviously contradicts that more than a little bit in my opinion). Likewise other studies that assess the ability of professionals to predict who will commit suicide keep coming with very disappointing results, so frankly, I find it hard to believe they could select the serious cases even if they fully intend to do so.

But the group that gets help has a bigger suicide rate compared to the group that doesn't. Quite a bit bigger. So it depends what you believe.

1) do you believe the criticism that they are able to select serious cases (but are unable to prove that in studies specifically checking that) ? Then it is unknown how effective their treatments are, and until they quantise "seriousness" it is impossible to check how effective they are.

2) do you believe the selection process is mostly random and the criticism is invalid? Then the treatments are counterproductive and they cause suicide. That does not (necessarily) mean they mistreat patients. For example, often the inability to leave gets blamed for job, family, and generally the future prospects to evaporate, which in turn causes suicide, which seems to me to find support in the observation that it's most often just after treatment ends that the actual successful suicide happens. The treatment causes suicide, but not directly.

We should make the exceptions that there are plenty of studies about specific institutions where abuse of patients does happen and it is definitely the institution itself that causes suicide.

I agree with your general sentiment, but speaking as someone who has been in jail and also involuntarily committed on multiple occasions, jail is much much worse.

All the downsides you listed apply to jail time also, but the food is more terrible, the environment more restrictive, and the opportunities for extricating yourself (if you are reasonably cogent) are greatly reduced.

Also, ironically, being in jail on suicide watch is preferable to being in general population.

Thanks for the perspective. I have never experienced either directly so at best I'm speculating although I've been around many people who have been through both.

My basis for making that comment is that at least ostensibly you get due process in the legal system.

Hope you came out the other side in a good place.

Involuntary commitment from mental health is a min. 72 hours here, but I think you can be in and out of a drunk tank faster than that, which is usually just a few hours to sober up. I could see a bail hearing happening quick enough that you get in and out before 72 hours, but I don't know how common that is.

Arraignment in most places is max 48-72hrs after arrest (except possibly for legal holidays) and unless the crime is serious you will usually be released after that.

It's true that you'll be stuck in the mental hospital for at least a week (those are 72 business hours). I couldn't afford bail, though, so I was stuck in jail for 3 months[0]. There were plenty of other inmates there in similar situations. YMMV.

[0] That's how long it took for me to get a court date at which point I was released with time served (2 weeks). Getting out of the mental hospital never even required a lawyer (though I'd still recommend retaining one if you're ever in this situation).

>"I couldn't afford bail, though, so I was stuck in jail for 3 months[0]. There were plenty of other inmates there in similar situations"

Some justice here. Instead of singing songs about rights abuses in whatever country they decided not to like at the moment why don't they look and fix things under their own fucking noses.

Why in hell are there things called "bail" and "time served" that apply to mental treatment? Do they think it's some kind of crime that has to be punished?

c22 is "speaking as someone who has been in jail and also involuntarily committed on multiple occasions". The bail and time served are regarding the jail time, not the mental treatment.

Having worked in emergency psychiatry services, I can say it's super common for people to wake up or become lucid and immediately think they're in jail.

Man, what. Psychiatrists have to commit you if they think you're an immediate danger to yourself. I'm sure shitty ones do it in situations where they shouldn't, but speaking as someone who has actually experienced being suicidal, my psychiatrist was the only person I actually fully trusted to help me get what I needed.

Maybe I'm just lucky to have ended up with psychs who will take on more risk to avoid having to commit people, but it's at least a little more complicated than you imply.

Suicide is a human right. Interfering with someone's basic right to self-determination is absolutely despicable, no matter how ill the person is.

Cannot agree more. Just like many other acts which are punished today, but should be rather dealt with by showing support, self harm should definitely be taken off the list of acts that are treated like a crime. I can only guess, but it feels like the current approach only makes things worse for those who are already suffering.

What if that self-determination is a fleeting thought?

Plea insanity as a defense?

It's not quite as simple as that. One of the reasons the suicide rate is so high in the US is because of how easy it is to access firearms. This suggests that peoples' propensity to commit suicide is at least somewhat dependent on their environment. Given that, do you want to make their environment more or less likely to cause them to commit suicide? I'm in the latter category.

As for the concern about basic rights, I fundamentally agree. For some people, perhaps, they will never get better and in those cases we should have a path to assisted suicide. In all cases, we should do our best to help suicidal people, who are ultimately suffering a lot. I don't think most people who are suicidal want to specifically die more than they want an end to their suffering, to which they see no realistic alternative other than death (which I assure you remains quite scary even when you're really depressed.) I think giving them an escape other than death is morally obligatory and humane, where it's possible.

>One of the reasons the suicide rate is so high in the US is because of how easy it is to access firearms.

Is this actually true? I know it's said quite often, but there are countries with much much higher suicide rates where firearms aren't nearly as ubiquitous. Eg Lithuania.

Or Japan...

Japan has a bit lower rates than the US. https://data.worldbank.org/indicator/SH.STA.SUIC.P5?most_rec...

In general one usually gets more meaningful results when a) comparing geographically and/or culturally similar countries for things like these. E.G the UK has half the mortality rate of the US, Canada and the EU have 2/3 of the US rate. And b) compare trends, not single values. E.G. US rates are rising (which I as a layman would interpret as speaking against the firearms thesis), while the rates of Lithuana and Japan are falling.

> I know it's said quite often, but there are countries with much much higher suicide rates where firearms aren't nearly as ubiquitous. Eg Lithuania.

The rates in the US are high because of access to guns. It's well understood in public health that easy access to means and methods is one of the factors driving high rates of death.

The rates in Lithuania are high because of a number of other factors -- high alcohol misuse probably being important. Also, there are plenty of guns in Lithuania, and firearms are one of the most frequently used methods.

The suicide attempt rate is only marginally higher in the US than in other developed countries (something that can be explained by other factors much easier than access to guns)

The amount of people who die to suicide is higher in the US because you are much more likely to actually die if you use a gun to commit suicide than other common methods. Higher access to guns increases the rate of people who successfully kill themselves. (Which is probably a bad thing. In general those who survive suicide attempts are happy that they lived.)

Another excellent example of this is removing carbon monoxide from ovens, which instantly reduced suicide numbers. Suicidal impulses are rarely a considered decision, so removing the opportunity immediate opportunity is very impactive

The suicide by gun rate is higher in the USA. Not the overall suicide rate. It's just as easy to off yourself using transport (CO, intentional crash, jumper), ligature strangulation (bedsheets, scarf, belt), exsanguination, or overdose of almost anything and all of those things are widely available all around the world.

someone who suffers from suicidal tendencies as a result of mental illness is in no capacity to make these decisions, they're as incapable of making actual decisions as a minor, probably more so and should be institutionalized.

The right to self-determination derives from an assumption of someone being in a clear state of mind, that's why we have plenty of conditions under which we withdraw that right.

How wonderfully tautological this is: those with suicidal tendencies are deemed incapable of making the choice due to "mental illness". How can you tell if they're mentally ill? You look for symptoms of course, symptoms like "they have suicidal tendencies".

no, it's not tautological at all. There are categories of suicide that are clearly defensible, like euthanasia for end of life patients who have made the decision that any quality of life is irredeemably lost, for example.

But the 38 year old husband, the subject of the article, who was in an unstable mental state to the point where his wife felt threatened and left for the safety of their children was certainly not in command of his mental faculties.

Someone who is schizophrenic and bipolar and experiences a psychotic break after drastically changing their medication regimen is not in a sound state of mind, and they would be the first to admit it once their condition improves.

But why doesn't "not being in command of one's mental faculties" qualify as a valid reason to want to end one's life? If that is ongoing, and unlikely to ever improve, I can well imagine wanting to off myself, rather than continue within that nightmare.

> If that is ongoing, and unlikely to ever improve

Well, that's an enormous 'if'. Yeah, maybe it's different in that case. But it's not the common case.

Ok then: if the 38yo husband took his increasingly unaffordable meds of choice and told you in a period of lucidity that he wants to die rather than suffer a lifetime of violent psychosis, drug-induced delirium and likely debt, or as you might call it "any quality of life is irredeemably lost", would you let him? Do you have another excuse for why he still cannot make that choice for himself, why he will never be able to make that choice for himself?

First you said they can't do it because they're mentally incapable of making the choice, now you're discussing whether a suicide is "clearly defensible". It doesn't matter if a suicide is "clearly defensible" or not. People don't have to defend their choices to you. That's the point of having the freedom to choose.

> increasingly unaffordable meds

Where did you get that idea? This happened in the UK, which has a public health system.

The article mentions that the man preferred treatment and his choice of meds from private insurance that eventually ran out. I know the UK has a public health system, that was the system that he died in.

Hmm, okay, I see what you're saying. There should have been affordable medication available, but not necessarily his particular choice.

Sounds like a catch-22.

You will therefore agree that those who do not suffer from mental ilness have a have a right to kill themselves.

Anyway, I didn't consent to being born, why shouldn't I be able to choose to stop living?

I agree with this in the abstract, but someone's right to self-determination isn't being infringed if 99% of the time they don't want to do something and you stop them from doing it in the 1%.

This is particularly true if they call you during the bad 1% and directly ask you to stop them from doing the thing.

Uh yes it is being infringed. If I steal money from you against your will that one time, would you be okay with it on account of the fact that you willingly gave me money 99 other times? I've never heard of rights being only applicable 99% of the time.

That's not a good analogy, because if I steal money off you today, you'll be angry with me tomorrow, and indefinitely into the future. You are against me stealing from you 100% of the time.

Consider instead the case where you're a recovering gambling addict who's asked me to make sure you don't gamble again. One night I find you in the pokies room, so I take your wallet and tell you I'll give it back tomorrow morning. I agree that this is theft and possibly morally wrong; however, I don't agree that it breaches your right to self-determination, since most of the time you seem pretty determined not to gamble.

So if someone consistently tells you that they want to die, if they consistently get angry at you and authorities for intervening, you're saying that you'll support their right to self-determination?

Yes. If someone demonstrates a consistent determination to die, when asked at random times, and over a long enough time period to rule out episodic mental health issues, and they've made appropriate arrangements for their family, I don't think they should be stopped from killing themselves.

I disagree with the claim that many suicides are like that, I don't think the suicide from the article was like that, and the word "consistently" is doing a lot of heavy lifting.

Appreciate your honesty and consistency. Likewise, I think the phrase "mental health issue" does a lot of heavy lifting for you. I don't think many mental health issues disqualify you from making a self-respecting decision over your own body. Few truly want to impose such extended blanket restrictions on other life or death decisions like critical treatment-refusal, military action, many types of self-destructive behavior or (controversially) abortion. Something about suicide brings out people's inner autocrat.

Yeah, episodic is the differentiator for me in terms of what should be prevented. With someone suffering episodes of severe depression, there's a clash between what the individual wants while not suicidal vs while suicidal.

Intuitively I feel that it's like two different people are making decisions about the one body, and the finality of suicide means the suicidal part of someone is wiping out the future for both, and should thus be prevented.

Again, though, the majority of suicide victims aren't suicidal for large periods of their lives. I feel that in the cases where someone is only briefly suicidal during the worst troughs of mood, the suicidal 1% of a life would wipe out the non-suicidal 99%, which is a monumental loss to inflict.

In light of this idiotic take ("interfering is absolutely despicable no matter how I'll") I feel like I should share my own experiences with frequent suicidal impulses, and how thankful I am that someone was there and willing to help me, on many occasions.

I'm bipolar, and when I was untreated I would frequently (as on every other day) spend hours locked in a doom-spiral of self hatred, incapable of breaking myself out of it. I could recognize what was going on at some level, and that if I were pulled out of the spiral I would be fine, but in the moment trying to escape that pain seemed to only have one solution, even if I knew I normally wouldn't want to die.

I would basically have to try and hold myself together long enough for my wife to find me and help me back to sanity. Each time I got a little closer to failing. Getting access to medication was life changing.

I am enterally thankful she took away deadly instruments, encouraged me to find reasons to live and recover, and ultimately seek treatment. Whereas you would have just left me to irrevocably take my own life in response to temporary problem that had a medical solution readily available.

Hi friend. Fellow bipolar here. I don't want to really type up my stories, but I can relate. Glad to see you're doing better now, me too.

> Whereas you would have just left me to irrevocably take my own life in response to temporary problem that had a medical solution readily available.

For the record, I never wrote, said, or claimed that, and your claim is inaccurate. Please refrain from making false claims about me.

It mostly depends on the state.

The fundamental problem there is that plenty of people have won lawsuits against hospitals/doctors when their loved one mentioned suicide in some way, was not involuntarily committed and then proceeded to kill themself. The amounts involved in those lawsuits tend to be high. In contrast, very few people have won lawsuits against hospitals/doctors who involuntarily committed them when they probably shouldn't have been, and even if they do, the monetary harm that they can recoup is probably pretty small.

This results in very perverse incentives for the institution. In your case either the people involved in your care had a very high personal risk tolerance, or it happened in a state where there is less precedent on handing over megabucks to the families of people who commit suicide.

A true US problem: you get sued for X, therefore that is the outcome avoided at all cost. Bad policy, bad legal system, Bad effects for everyone.

Perhaps this is a regional difference, but you might be confusing the suicide hotline with a petition for involuntary admission. The suicide hotline provides someone to talk to. The person might not even know your name or address. What you’ve described is involuntary admission. Any adult can petition for another person to be brought to a hospital and evaluated, but the hospital decides if the person is admitted and/or placed on a 72 hour hold.

I think the person you are replying to is claiming that the hotline operator will initiate the process for involuntary admission, or at least start a chain of events (e.g. calling local PD for a welfare check) that leads to that outcome.

(No idea if that is true, but it is the claim.)

One of the many things needing overhauling in our mental health system. I avoided seeking help for a long time because I was interested in jobs that would likely require government security clearances, and (I don't know how true this is) I had heard from multiple sources that a history of seeking help for mental health issues may disqualify you. Which is a little backwards in practice. If there's an issue I want to address it and manage it. Because of my desire for those jobs, I let the problem fester for longer.

I also found when I finally broke down and sought help (not for suicide, granted) the process of trying to take advantage of my company's resources like paying for short-term counseling, etc. was incredibly frustrating. You couldn't get a hold of the people at the company we paid for the plan, everything on their site was outdated and badly maintained, they only covered certain therapists, and they happened to be therapists who make a point of specializing in treating pretty much anything with drugs, etc. Had I been on the edge of suicide or unable to eventually just pay for the care I needed directly, I can only imagine trying to navigate this process could've finished me off, emotionally.

Company resources are next to useless. They are meant to be short term and are encouraged to turn you around in a few sessions. If you can, go private, since it's more open ended and the process of over over the basics of your life story are tedious.

Agreed. I eventually found a very good counselor for my situation.

But I'm extremely fortunate that I'm both very well off and wasn't suicidal. And it was very apparent to me that if I was different in either respect, I perhaps wouldn't have been able to turn things around.

> the process of trying to take advantage of my company's resources like paying for short-term counseling, etc. was incredibly frustrating.

If you can afford it at all, it can make a lot of sense to do this privately, to avoid a lot of this.

> I was interested in jobs that would likely require government security clearances, and (I don't know how true this is) I had heard from multiple sources that a history of seeking help for mental health issues may disqualify you

FWIW, you heard correct. This is true. (I don’t have any clearances myself, but I did work for a major defense contractor in the past, and a family member has some sort of above-top-secret clearance for his work.)

This is precisely what they do. Fun fact: whilst Lifeline in Australia says that they will treat all calls as anonymous, they in fact do not. If you speak about killing yourself to a counsellor, then they will call the police and trace your number, despite whether or not you turned off caller ID.

Don't trust phone counselling services. Ever.

I did not know that. I would like a reference for that info if you have one?

Lifeline Australia Limited Privacy Policy

https://www.lifeline.org.au/media/igzp1al2/lifeline-australi...

Eaxctly.

Consider this: if the providers of these suicide hotline numbers actually cared about this stuff, they would provide an as pseudonymous as possible way to contact them that makes it as impossible as possible (in a mathematical/cryptographical sense) to identify the caller (think about Tor).

Additionally, the hotline operators would advocate very strongly for a right to encrypt and right of privacy.

But this is not the case, which should convince any rationally-thinking person that all of these claims of anonymity are fraud.

If you don't mind me asking, is there anywhere I can read more about this aspect of the system?

This comment seems really extreme and it's a perspective I haven't really seen anywhere else.

I'll hunt around but one thing that came to to the top of my head:

https://slatestarcodex.com/2018/03/22/navigating-and-or-avoi...

I don't know if he's considered to be a controversial figure or not generally but he is a real psychiatrist so I'd argue he knows what he is talking about

Thank you very much for posting this article, I'm reading it now.

This paragraph really resonated with me and with the initial thoughts I had whilst reading your comment; I'm pasting it here as I think it provides a very worthwhile perspective:

"And my second excuse is that in the end, this is not an adversarial enterprise. Psychiatrists commit people because they’re scared. They’re scared because they can’t predict what the patient is going to do – and on another level, they’re scared because they might get sued if they don’t follow the rules. If patients who aren’t going to hurt themselves know how to explain that they aren’t going to hurt themselves in a way that reassures their psychiatrist, and in a way that doesn’t leave their psychiatrist legally liable for not committing them, then everybody can be more comfortable and get on with the hard work of actual treatment."

So speaking as someone who has worked in psychiatry and mental health care, I can say it's basically true. It's not the intent of those working in it, but I think like a lot of things it's sort of what has emerged through the system.

I had a colleague, now retired, who was the president of state mental health associations, etc. who made the argument that most suicide treatment programs are really designed to protect practitioners and healthcare providers, not the patients. At the time I understood what he was saying, but didn't really understand it until later.

The way it came up with him was more about prediction and risk. He was talking about it because there's basically no way to know if someone is actually imminently suicidal. Most people who talk about it never even make an attempt, and there are lots of people who commit suicide suddenly without saying a word to anyone else ahead of time.

My colleague's point was this: if saying X is totally unpredictive of Y in reality, why react so strongly to saying X? The reason is because it's not really about preventing Y -- you can't -- it's because it legally and morally absolves you of responsibility.

I feel weird writing this because it sounds so cynical, but its a sad truth about the poor state of care of our fellow human beings in contemporary society.

Anyone seeking help with a minor physical disorder from the local urgent care facility here (California) is promptly asked: "Have you had thoughts of harming yourself or anyone else?".

Immediate tingling of danger -- but wondered if my suspicions might be little more than the product of a cynical mind. Didn't think so -- but thanks for the confirmation!

I always thought of suicide as incomprehensible, then I encountered it used as a coping mechanism: "It's not so bad, I could always kill myself." (A person who has come to rely on that must not have kids!)

>> My colleague's point was this: if saying X is totally unpredictive of Y in reality, why react so strongly to saying X? The reason is because it's not really about preventing Y -- you can't -- it's because it legally and morally absolves you of responsibility.

If it's actually unpredictive, then shouldn't committing someone -- taking full control of their life -- make the doctor more responsible for them and not less? Responsible for them not being able to work, pay their bills, etc. and ultimately making their life situation more precarious, thus increasing their mental stress.

Have you experienced this process? There is a very good point why everyone has learned the "get help" mantra. There is only one suicide you need to do, and game is over. If that can be averted with quick intervention (as often is the case) then all the better.

Interventions cannot help all suicidal persons, but being acutely suicidal means one should get help _now_. It's exactly the same thing as a with a stroke or other imminent medical emergency.

… and … on the other hand, actually going through with it, is about the biggest “f**k you” that can be given to a family.

This is something that I have had personal experience with, in family, friends, acquaintances, and even enemies, that I wished dead, then was not so thrilled, when my wish came true.

I hang out in circles that experience a lot of … “out of band” … issues. It’s a long story, and not one I feel like sharing on HN. Suffice it to say that I have seen this kind of stuff many, many times.

Getting treatment for mental health issues —and there are very many types of issues, and types of treatments— is important. One way to support people going through this stuff, is to avoid feeding the “shame machine,” and try to realize that we may not have the answers, so we can help people connect with those who do.

I think the best part is the dance you do when looking for a therapist where you try to say you really need help, but you have to temper that severity by saying that you aren't in such bad shape that you are suicidal for fear that they commit you to protocol or something.

In reality mental healthcare feels like only a slight step up from antiquated methods from days long gone. Trying the medication roulette is like spending months at a time throwing darts blindfolded to see if anything helps, hurts or does nothing at all. Waiting months to see professionals who are burned out or just trying their best to not be completely overwhelmed by the demand but are unable to give meaningful care because of how overwhelmed they are. Or not even being able to see a therapist at all because it is cost prohibitive. And then consider basically having to do that on the side while you have your other obligations that you have to tend to. I wouldn't be surprised if only a fraction of people who need help get it, and of that fraction, only a fraction of them see a benefit. It basically boils down to society not caring, or barely caring at most.

In the end I suspect that the efficacy of mental healthcare has its limits, after all it is like trying to fix people after they have been broken, which is way harder than supporting people before they break, but that depends on social structures and support groups that are increasingly weak and strained.

And the medicine dart board assumes your psychiatrist doesn't make mistakes. Ie you will have to look up the information on the medicine roulette and the combinations yourself.

The only way, still, to determine which of a mess of conditions you have, all called depression, is to see which, if any, medication seems to help. It is as if you present with a broken bone, but they have to try splinting one after another until they hit on the broken one. And, you might actually have more than one. And, some doctors have a favorite bone, and won't try the others.

Try to imagine a Random Controlled Trial protocol for a new depression medication. It is miraculous that any have been approved. It is why you are always seeing articles insisting, idiotically, that RCTs prove depression medications are no better than placebo. Splinting the left shinbone helps only a small fraction of patients who have a fracture.

For validity, RCTs depend utterly on reliable sortative diagnoses. RCT fetishists (which exist, and are common) are mentally unable to process that fact.

> why you are always seeing articles insisting, idiotically, that RCTs prove depression medications are no better than placebo

You mean Kirsch & Kirsch 1997? Like, that particular study found a really, really small effect in the data submitted to the FDA (so the data chosen by the pharma companies). Even this went away when they used placebos with side effects.

More recent work has suggested that they work for severe depression, which is great but the trouble is that the vast majority of people with a diagnosis of depression don't have MDD (major depressive disorder).

I do agree that mental health is in it's leeches phase right now, and I am deeply concerned for people who end up having to engage with this system.

Pharma companies demonstrating that they are no better at impossible things than anybody else does not tell you anything new. Or, did you have a point?

You said:

> It is why you are always seeing articles insisting, idiotically, that RCTs prove depression medications are no better than placebo.

I responded to your claim with a little more colour on that particular trial in order to perhaps start a discussion around what we mean as depression.

Clearly, I didn't succeed at my aim, my apologies ;)

Edit: it's particularly the framing of the trials as "idiotic" that spurred me to reply, so I'd be interested in why you believe this.

I am mystified that we are having this conversation. To me the central statement in my original posting was:

> For validity, RCTs depend utterly on reliable sortative diagnoses

So, are you saying you believe an RCT can demonstrate a fact when whichever medication is being tested addresses the actual condition of only a tiny fraction of the participants, and even exacerbates some of the others' various conditions?

Such trials are not idiotic, except as a waste of money. Reporting their results as if meaningful is what I called idiotic.

Or, are you saying you know how to design the protocol for an RCT when you have no idea which, if any, of the participants actually suffer the condition your medication is supposed to treat?

> For validity, RCTs depend utterly on reliable sortative diagnoses

Huh, that's a really good point (which I somehow missed in your original post).

That being said, it's incorrect that it's essential for RCT's to function, they'll still work, but with an attenuation based on the actual treatable population.

> Or, are you saying you know how to design the protocol for an RCT when you have no idea which, if any, of the participants actually suffer the condition your medication is supposed to treat?

Well I don't design said protocols, but I suspect the vaccine manufacturers may be able to point you in the right direction.

I think that your point about reliability of diagnosis is interesting, gonna need to think about it a bunch more, but in general, no diagnosis is without error (as most diagnoses are implemented as checklists, and there's some room for arbitrariness).

Just to note, if your point is correct then it's basically all mental-health, expectancy, placebo, psychotherapy RCT's are essentially worthless, which I suspect is not the right approach to take.

Does it matter if we can diagnose people effectively? Of course.

Does it make it impossible to run an RCT in the absence of effective diagnosis? Not impossible, but it definitely adds an interesting layer of complexity, as well as massively increasing the sample size required.

OK, thank you.

Consider a pre-trial objective: "We will be testing this medication on patients who have already indicated that it helps with their affliction. Participants will be sorted into groups that get one of (a) a placebo, or (b) reduced, (c) increased, or (d) unchanged dosage relative to the dose they have reported to be effective enough relative to side effects." Such a trial could actually be useful, but good luck getting the epistemology sticklers to sign off on it.

Also, antidepressants characteristically have history-dependent effects. Often, suddenly going off one renders it ineffective if resumed. So good luck with the ethics.

Also: I would like to see the word "affliction" in more medical papers.

I hope you will find gruntling, in time.

Sheesh, that's fucking terrible. I had naively assumed that suicide hotlines would ring to someone who would really listen to you and try to give you some perspective in a non-intrusive manner, which is what I imagine myself needing if I was in that position. Although I guess it's not terribly surprising to hear it's the bog standard pattern of friendly-faced leadgen that passes off execution to a misincentivized backend.

They do listen. They are well intentioned.

But, they are required by law to escalate the issue if they believe self-harm is imminent.

I came here to post what you say not to, and was informed by your comment. Serious question though: what _should_ one say or do to help those who may be suicidal, both in the public and personal? I’ve known several people who committed suicide, and I wish I’d been able to do or say more for them. I know some now who struggle with suicidal thoughts and mental illness. What is the best, right thing to do and say both to friends/family and in a forum like this?

Every situation is unique but often it’s best not to “say” anything. It’s best to just listen. Like really listen. And offer to continue listening.

Encourage others to do the same.

Most importantly, Resist the temptation to give advice (unless it’s solicited).

Don’t ask “have you tried X?”… instead ask “what can I do to help you get through this”.

>This is the part where every one piles in posting suicide hotline numbers. I would argue most of those people do not have any experience with, or understanding of those hotlines and it's just a trite thing to throw out to show support like "fuck cancer".

As long as we keep rewarding it by pressing the "rightthink" button when we see it it will keep happening, just like every other cheap gesture that appeals to the lowest common denominator.

I agree with your first sentence, I find those annoying and assume that they're pointless and unhelpful, just posturing; but the rest of your comment... what?

Top post on HN discouraging use of suicide prevention hotlines. The fuck is wrong with you people.

People need to know what could happen when they call that hotline. I'm guessing people think it goes something like this:

  "I'm feeling suicidal, let me call the hotline."

  "I called the hotline and now I feel better, everything's great."

In reality, at least in the US, it could be like this and this is codified in law (Duty to Warn):

  "I'm feeling suicidal, let me call the hotline."

  "We've notified law enforcement. The police are on their way."

I'm guessing the reason it isn't always done the 2nd way is because actual therapists know how bad this can be to the patient. Realize therapists are taking a legal risk in not reporting. In the US, the only tool government has for most problems is, "call law enforcement." The only tool law enforcement has it, "take them to jail." If you do some research, you come to realize what a bad tool that can be.

https://en.wikipedia.org/wiki/Suicide_legislation#United_Sta...

If it were me, I would call a professional therapist before calling a government hotline in the US. This is not medical or legal advice.

None of the outcomes listed are worse than the actual suicide.

Afraid CPS will take your kids away? Well guess who goes to the orphanage if you bloody off yourself!

Yes but if someone were contemplating it and they are looking for someone to help them off the edge (which is the purpose of the hotline), all these things would probably have the opposite effect.

Going to jail is probably better if suicide was inevitable, but if it's inevitable, a person probably wouldn't be calling the hotline.

I think if the hotline was anonymous and untraceable and directly connected a person to a therapist who specialized in that sort of thing with no strings attached, it would be an invaluable tool. Unfortunately it is not that. It certainly could be.

> None of the outcomes listed are worse than the actual suicide.

This is 1000% missing the point. They've already decided that being dead is better than being alive with their current life situation. And you're saying they should voluntarily make their lives worse?

Can you imagine: You're at rock bottom, thinking about taking your life. Then someone comes along and says "Hey what if you don't and we lock you up and take your kids. Want to live now?"

Do you see how ridiculous that sounds?

That's exactly what the poster goes. Spreading FUD to dissuade people contact suicide hotline.

Not every contrarian take makes sense even if it blows your mind on the first reading.

Do you think people deserve to know that the police may be called on them if they call a hotline?

Do you think that people deserve to know that they can be involuntarily held if someone even thinks they're going to kill themselves?

I'd rather make this known and push for laws to be changed. Because I'm telling you that a massive number of people don't reach out to people because of these (real, valid) fears.

All of that is patently untrue in jurisdiction I live. Suicide hotlines are anonymous here.

Even if it's true in the United States, it may or may not be as severe as the OP suggested. Could depend on the state or county or whatever. The OP write with position of authority that he lacks on a subject that is literally life or death.

Genuinely curious about this - if you call one of these numbers and say you are thinking of self harm but you are not actually going to hurt yourself and you do not want them to call whomever to your home are they likely to do it anyways?

Can’t speak for all of those numbers, but Samaritans won’t tell anyone or even try to talk you out of it if you don’t want them to.

A friend's husband called one of the suicide lines and he wasn't committed or visited by the police, so it's not a 100% chance. I don't know the details of what the husband talked about, but it may have been because it wasn't a recurring problem. He'd just had an especially awful time at work for a few weeks, and eventually had a breakdown and called a hotline.

He quit his job a couple of days later and has been fine since, so maybe the person on the phone can make a judgement call on whether it's a recurring issue that needs professional help, or something that is an extreme response to an isolated incident and the person will be fine after they're "talked down from the ledge".

Companies that drive people to suicide are really something else. I hope he showed his colleagues that there is a way out.

You absolutely might not have any issues. But you absolutely might. It could come down to if the operator has had their lunch break yet.

So the question is do you want to play roulette with your physical freedom.

Great, that sounds like a perfect pitch talk discourage anyone from calling such a number or talking to someone about a difficult time in their life.

I really hope you are very wrong about what you wrote, otherwise you live in a really cold and frightening place. There sure is a hotline where you can just talk to someone, without losing your job, right? right...?

> Great, that sounds like a perfect pitch talk discourage anyone from calling such a number or talking to someone about a difficult time in their life.

But it's mostly true. Do you just want people not to talk about the flaws in the system?

As long as involuntary detention for suicidal people is law, I would never ever ever tell anyone about any suicidal tendencies.

Not being honest about what happens when you call a hotline is also horrible. "Haha! Got you! Police are on the way!"

I can't imagine the dread if that happened to me, knowing my life is about to get way worse even though I'm already at my bottom.

Anyone saying "well suicide is worse!" is completely missing the point.

Your post is dead on

I have what is essentially a terminal illness and the fuck cancer resonates

You just want to turn to those people and say "I'm dying". While they are trying to be supportive but they completely miss the mark because they don't get it

Similar things can be said about people regarding addiction

Serious question. I’m signed up for cryonics myself, and in these instances I try to ask, as gently as possible, if they’ve heard of or considered cryonics as an option. I see it as potentially saving lives, although I don’t know anyone else who has actually followed through on the suggestion. But would you view this genuine suggestion to be as asinine and tasteless as I worry it sounds?

I don't think jail is the other choice.

Being dead is still a better choice than being trapped in that system and carrying the stigma your whole life IMO. It becomes a permanent problem that you cannot escape.

It seems pretty tautologically impossible for being “trapped in that system” to be a more permanent problem than death.

Seems like a matter of perspective or belief, no? For the observer of death it seems permanent; whereas a corpse lacks the same ability to perceive their own death the same way as the observer after it happened (i.e. a few moments, modulo anyone's beliefs surrounding after-life) if going by measuring brain activity via something like EEG and blood flow through the body.

Where as "trapped in that system" could be as long as a few decades before one eventually dies.

A problem can follow a person all the way up until the day they die. Death is sometimes the only true escape.

I wasn't implying it was, simply stating my relative perception of the two events.

I was in jail for eight years. I would say a large majority of people are in jail due to various mental health issues.

Thanks for sharing that. Hope things are well for you now.

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