A lot of the comments in my recent post on the implicit association test asked for a defense of why society should be hospitalizing suicidal people in the first place. If people have, after much thought, decided they prefer death to life, isn’t that their right?

I am extraordinarily sympathetic to this position, which has been most eloquently defended by Sister Y of The View From Hell. Sister Y lists many harmful effects of suicide prohibition and many reasons why rational people might want to end their lives. She suggests a policy of legalizing fatal doses of barbituates for people who want them, allowing people tired of existence to leave the world without grisly suicide attempts that might leave them permanently injured or cause collateral damage to bystanders. I can’t find her opinion on whether these should be provided on demand or whether you should have to undergo a psychiatric assessment first.

If she in fact believes the latter, then I think that position is defensible, and for professional reasons I won’t publicly say anything further than that. But this post is to explain why it should require one hell of a psychiatric assessment and why the overwhelming majority of real-world suicide attempters would and should fail such an assessment.

Again, my point of disagreement is not on the ethics involved of letting some hypothetical perfect philosopher commit suicide – nor even on the fact that perhaps some cases genuinely are these perfect philosophers including Sister Y herself. I am trying to emphasize the practical point that in the real world, attempted suicides are rarely perfect philosophers and almost always people who have made sudden, impulsive, and very bad decisions.

The greatest burden of suicide is of course to the friends and family of the person involved. But you don’t have to be a Randian to think it’s morally abominable to require someone in pain to continue living solely to please other people, so this post will focus solely on the welfare of the person involved.

What Does Youth Suicide Tell Us About Adult Suicide?

Start with the clearest case. About 4% of teenagers attempt suicide at some point (there are some much higher values from the CDC, which is usually pretty trustworthy, but some of the comments point out reasons why their estimates here are pretty hard to believe.)

I’ve gotten to observe some teenagers admitted to hospitals for attempted suicide. Some have incipient mental disorders that no one has noticed or considered treating. Some have unbearable home lives. Others have the standard litany of teenage problems – broke up with their boyfriend/girlfriend, bullied by the popular kids at school, got into a fight with their parents. Many have a combination of all three.

Some were the classic “cries for help” that were never meant to actually end in death, but others were entirely serious. A tragic few intended to take enough of an overdose to make Mom scared but not enough to actually kill them, but muddled their pharmacology in the most permanent possible way.

And I think most people agree that teenage suicide is terrible and requires treatment. Heck, most people won’t even let teenagers make the decisions of whether or not to purchase alcohol, let along the decision to end their own lives. But I think aside from the inherent tragedy of teenage suicide it illuminates something about adult suicide as well.

These people have only the tiniest glimmer of knowledge about the likely happiness of their future lives. Most of their problems – the bullying by popular kids, the failed first relationship, even the awful families – are eminently wait-out-able. “It gets better” is not just for gay people (who, by the way, have a suicide rate up to 15x that of the straight population).

And yet teens attempt suicide at staggering rates.

There are certain depths of despair dark enough that the knowledge that the despair is completely temporary cannot penetrate them. It is this state, defined by the clouding of rationality by suffering, that I think most teenage suicides occur in.

And it would be very strange if this suddenly changed as soon as the victim hit eighteen.

Connection Between Suicides And Mental Disorder

It is generally reported that about 90% of suicides have some mental disorder. No, this isn’t an artifact of psychiatrists assuming anyone who commits suicide must have a mental disorder – various half-decent methodologies have all converged around the same number, including a multitude of controlled studies (where psychiatrists evaluate a subject’s mental status based on notes before knowing whether the person committed suicide) and prospective studies (where people only count as mentally disordered if they were diagnosed before the suicide occurred).

Sister Y has tried to poke holes in these statistics. First, she noted that the controlled studies showed 37% psych diseases even in the control population. But this number is probably correct – NIMH estimates that about 26% of people have mental disorders in a given year, and no doubt that number is significantly higher among people who make good controls (ie are matched on demographic factors) for suicides. Second, she pointed out that the number included what she considered relatively “minor” disorders like alcohol dependence.

So first of all, alcohol dependence probably septuples your chance of committing suicide and something like 25% of suicides include alcohol. So I don’t think it’s unfair to include that in the list of how suicide is influenced by mental disorder.

But second of all, let me give totally anecdotal and probably unrepresentative examples of some other ways mental disorder can affect suicide.

As stereotypical as it sounds, the voices in people’s heads do tell them to kill themselves a lot. Voices in people’s heads are huge jerks and occasionally people will do what they say just to make them shut up. The tragedy here is that antipsychotic drugs are pretty good at dealing with this if people can just get access to them. Among schizophrenia patients (the group most commonly identified with these sorts of symptoms), almost half attempt suicide and 10% complete it. Since schizophrenics make up 1% of the general population, that’s a non-negligible fraction of total suicides.

You know what’s an even less fun form of psychosis? Psychotic depression. This is where people get so depressed they start hallucinating about how horrible they are. I will never forget the patient who stopped eating because she believed her digestive system was rotting away and infested with maggots. And a lot of the time these people’s self-hatred reaches completely bizarre proportions in which they will confess to causing the Holocaust or the 9-11 attacks just because it seems like the sort of thing someone as horrible as them might do. If you believe you caused the Holocaust, this seems like a pretty good reason to kill yourself in the name of justice, and sadly this is what many of these people do. And again, this is tragic because psychiatry is actually not so bad at dealing with this kind of over-the-top depression (the rotting-intestines woman became much better after a short course of electroconvulsive therapy, but some people will get better just on medications).

Borderline Personality Disorder is another common cause of suicides. It intensifies emotions so that anyone so much as making a mildly critical remark makes you think everyone will hate you forever and you deserve to die. And then six hours later someone smiles at you and you feel like the world is perfect and beautiful. But if you commit suicide at one of the low points, then that’s it. And Borderline Personality Disorder, again, is sorta amenable to therapy, and even without therapy half the time it just goes away after a few years to a decade.

Alcohol and drug abuse is another big one. Some of it is that abusers have worse lives – poor health, financial issues, more likely to have trouble at work. But a big part of it is just lowered inhibition. If a sober person is walking on a bridge after some life crisis, they might have fleeting thoughts of jumping but suppress them after thinking of the future. If a drunk person is walking on a bridge after some life crisis, the frontal lobes that would normally suppress those urges are partly out of commission.

And then there’s depression. I’m trying not to make a big deal about it because everyone associates suicide and depression when in fact the correlation is no higher than many other mental illnesses (although the greater number of depressed people does make absolute numbers higher). I guess all I’ll say here beyond what everyone already knows is that Major Depressive Disorder (classic depression) is an intermittent disease. The average depressive episode lasts less than six months, and the average person with MDD has only four depressive episodes in their lifetime (these numbers are even better if you’re on medication, which many depressed people fail to be). There’s a thing called dysthymia, which is like having depression all the time, but it is thankfully less common and less severe and not where most suicides are coming from.

I am certain that six months feels like an eternity if you are depressed. And no doubt knowing that you’re going to have to deal with the same thing a few more times in your life (ALTHOUGH SERIOUSLY, MEDICATION DOES HELP WITH THIS) must also be, well, depressing. But the average depressive suicide is not a Perfect Philosopher who has calculated, while healthy, that the possibility of another six month depressive episode is too much to bear.

The average depressive suicide is someone in the middle of one of their episodes who, like the teenagers above, is in the place so dark that they’ve forgotten the existence of hope. They’re somewhere so dark that “this will probably go away in a couple of months” has no meaning. Somewhere so dark that one of the main side effects of effective antidepressant drugs is suicide, because a few weeks after starting the patient finally has enough energy to go kill themselves, but doesn’t consider waiting a month or so for the drug to take full effect.

I want to end this section with a study – small, but encouraging – that cognitive-behavioral therapy (aka That One Type Of Psychotherapy That Sometimes Works) reduces suicide 50% in at-risk populations. Think about that. What percent of suicides do you think haven’t had cognitive-behavioral therapy? 80%? 90%? Whatever that percent is, half of them would have been fine if they had just had access to a good psychologist.

Empirically, Suicides Regret It

People who commit suicide can’t change their minds. But attempted suicides can and do, and we can analyze these changes both in their actions and in their words.

In terms of revealed preferences, most people who are prevented from completing their suicide do not go on to kill themselves. Sister Y critiques a study saying only 4% later go on to kill themselves, and offers as counterpoint a study she prefers claiming 13% do (she finds a way to round up to 19%). I have also heard 10%, although I can’t remember where. Do you know what the numbers 4%, 10%, 13%, and 19% all have in common? Yes. They are all significantly less than 50%.

It is somewhat harder to find good studies on what percent attempt suicide again. By eyeballing some other statistics and trying to fit them together, I believe it is greater than 25% but less than 50%. One textbook whose studies I have not been able to verify says that 30% of untreated and 15% of treated suicide attempters try again. 15% and 30% are also among the many numbers that are less than 50%.

And keep in mind what these data don’t show. They don’t show that the 25-50% who try again have lives so constantly miserable that they continue wanting to die. Remember that intermittent depression from before? Imagine a world in which depressive episodes last one day each, and people only have two of them in their lives. Other than those two days, they live happy lives and are grateful to be alive. Doesn’t matter. This pattern would still be consistent with 25-50% of attempted suicides making repeated attempts, if that second day of depression was bad enough

(out of fairness I should mention this data also doesn’t show that 50-75% of people get over their suicidality; it’s consistent with them just being tired of suicide attempts not working and settling for continued existence. I guess what I’m saying is that the data don’t prove very much)

So moving from boring data to the much-more-fun domain of anecdote, a surprising number of suicide attempters change their mind during the suicide attempt. One particularly famous case is that of Kevin Baldwin, who survived jumping off of America’s favorite suicide spot. He says that while still in the air “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable—except for having just jumped.”

Most realizations are slightly less dramatic, but my work in a psych ER taught me that many 9-1-1 calls about suicides are from the victims themselves. I remember one patient, a typical case, who overdosed on pills. As she lay on the ground starting to feel sick, she thought about her problems a little more deeply, thought about how her family would feel, and decided she preferred to live. She called 9-1-1, they sent an ambulance over, and the hospital managed to keep her alive until the drugs passed out of her body. This is quite common. It also contradicts one of Sister Y’s strongest arguments – that the reason many people avoid suicide is out of fear of making the attempt. A non-negligible number of people who have already made the attempt and just have to sit back and day find themselves changing their minds and actively working to save their own lives.

But most of the stories I can generate from my personal experience are nothing more dramatic. It’s people who were found by their parents or partners or friends, dragged kicking and screaming to the hospital, treated for a couple of days, and by Day 3 they’re saying oh my god I made a horrible mistake I can’t believe what almost happened.

And I know what the response will be – that of course they’d say that to their psychiatrists, they’re trying to get judged Officially Sane so they can get discharged and maybe try again. I accept that as a possibility, but since this whole section is about totally useless anecdotal data, let me just say I don’t feel like that was what was happening. I met people who were going out of their way to look for and thank their psychiatrist when he was busy in his office after the discharge papers had already been signed and they were on their way out. One time I met a patient at the bus stop a few days after she had been discharged, and she asked me to thank my boss and the rest of the team for what must have been the umpteenth time.

Finally, I have some personal friends who have attempted suicide. In every case I am incredibly glad they remain alive, and more importantly, usually they are as well. And I know there’s social pressure here – that psychiatrists aren’t the only ones you have a vested interest in appearing cheerful to – but some are very close to me indeed and I do not believe they would lie about something this important.

Psychiatric Care Probably Helps

One of the most common objections to sending people who attempt suicide to psychiatric hospitals is that it is a terrible punishment, that we are essentially locking up and drugging and torturing people whose lives are already apparently pretty bad.

But mental hospitals for people who attempt suicide (actually almost always just the psychiatry floor of a regular hospital) are not like that one in One Flew Over The Cuckoo’s Nest. I can’t repeat that enough. I know that as a psychiatrist-in-training I have no credibility on this issue, so take it from a former psychiatric patient. Your problems are much more likely to be along the lines of a terrible selection of books in the ward library than torture by sadistic nurses (I do not deny the latter occurs, just as some schools have torture by sadistic teachers, but it is extremely rare and nowhere near for example what goes on in nursing homes).

According to the CDC, the average length of stay in a mental health ward is one week (this brief by an organization I’ve never heard of says 8 days). That includes catatonic people and people who have long animated conversations with the Devil, so the average suicidal person isn’t going to be the one bringing up that average.

In practice I have a pretty good guess for the exact length of stay the average suicidal person without associated mental disorders will experience, and that is 72 hours. That’s the maximum amount of time a hospital can legally commit someone against their will. After that they have to get a court order allowing them to hold the patient longer, and this requires swearing that the patient is mentally incompetent to make their own decisions, and most doctors will not do this without reason.

But if you don’t trust doctors’ benevolence, at least trust their self-interest: it takes a lot of paperwork, it requires them to go all the way to a courthouse, and the hospital management is going to be breathing down their back the whole time about how they could really use an extra bed on Ward 4 and of course we would never pressure you to discharge any patients before they’re better, but seriously, have a bed open on Ward 4 by tomorrow. Trust me, doctors are not plotting to keep people in the hospital longer than necessary. If you like conspiracy theories, the opposite conspiracy is a much bigger cause for concern.

That’s usually just enough time to evaluate the patient for mental disease, start them on some medication, and refer them to an outpatient psychologist and/or psychiatrist. One hospital I worked at kept (mostly willing) people in a little longer to see if the drugs actually took effect, but that was a luxury they could only afford because they were a rich academic institution.

But the thing is, this really helps. If 90% of people committing suicide have some associated mental disease, and mental diseases can dectuple your risk of committing suicide, then connecting these people – many of whom have never interacted with the mental health system before – with someone who can help them (or even with a Prozac prescription) can be a really, really big deal.

I mentioned before that one specific form of therapy can decrease future suicide rates 50%. That was in a study where both groups were getting the recommended psychiatric drugs. Another study I cited above said that “psychiatric treatment” (whatever that means; I bet it didn’t include the CBT from the last study and so they’re cumulative) can also cut future suicide rates in half. There are more specific studies on the anti-suicide effect of each individual drug – lithium is an example of a particularly good one.

(fun fact which there is a small chance I will devote my life to studying: even areas with slightly higher trace amounts of lithium in the water supply have lower suicide risk.)

And even if you’re one of the depressingly high number of people who throw away their prescription and never show up to their psychiatrist, you know what? You’ve been stuck in a big building with lots of people watching you for the three days or so immediately after whatever horrible event made you become suicidal in the first place. Drugs in your system? Now you’re clean. Angry at a family member? Maybe you’re less angry now. Upset over a breakup? Maybe you’ve had a chance to think about it a little more.

I am very reluctant to get into in what situations I believe suicide is acceptable. I am scared that one day my future employers will read this post. Or worse, a future patient will read it and start arguing “You said suicide was acceptable if A or B, so I did those things”. So all I will say is that I wish Sister Y and those like her maximum utility however they define their utility function. But anyone considering suicide who has thought about it less than she has or lacks her philosophical acumen should consider getting professional help (or even non-professional help) or at least meditate long and hard on that cliche about “a permanent solution to a temporary problem”.

EDIT: Since people are missing something I said like a thousand times in the post itself, I’ll put it down here in bold. I am not claiming that suicide is never rational and that all suicides are stupid and impulsive, or that no one can ever legitimately want to die. I am saying those people make up a very small portion of suicides, and that the typical case is people who do it impulsively or in a state where they lack full decision-making capacity. And that the psychiatric system can be of huge help to this latter group, and that helping the former group is a different question which I do not want to talk about publicly for professional reasons.