Why some people kill themselves twice: what causes the suicide cycle

What did you do with the odd-matched socks in your drawer the last time you cleaned it out?  If you're like me, if it didn't have a mate you tossed it out.  If something doesn't belong, we generally just get rid of it.  This, and not depression, is the primary reason people commit suicide.

Contrary to common belief, suicide is not caused by depression, but by a lack of belonging.  Depression exacerbates it, makes it worse, of course, but by itself it is rarely enough to make a person decide life isn't worth living.  If someone feels like an odd one for long enough, like a shoe without a mate, eventually they will want to remove themselves from the equation.  Doesn't it seem like a solution for the odd one, while bringing balance back to the rest who belong?

Yet it isn't.  In studies investigating the longterm effects on desire to survive and thrive after suicide attempts, it was found that over 90% of people who attempt suicide and survive regret their decision the moment that they attempt. 

Maslow's Hierarchy of needs describes our basic human needs in tiers.  First, above all else, we must be physiologically stable.  We need oxygen, water, food.  It's kind of important to have the basics right?  After physiological needs comes the need for safety.  Our brains have built in trip sensors that prevent us from doing a lot of things it knows will cause physical harm to the body.  If we are both physiologically stable, and physically safe, we must feel like we are loved, or at the very least, belong.  The last two categories our needs fall into are esteem and self-actualization.  Why am I rambling about psychology?

As soon as our brains manage to trick us into thinking that our lack of belonging or love is more important than our physical safety, we make the decision to commit suicide.  This is almost always (94%) an impulsive decision made in an hour or less.  The moment an attempt is made, that more natural, overpowering need for physical safety takes over again, and the hopelessness and resolve are replaced with fear and regret.  Because of that, the survivor seeks medical help.

When a patient comes to the emergency department admitting to suicidal ideation, the standard protocol in place across the board is to immediately remove as many risks to the patient's safety as possible.  This means removing anything that could directly injure the patient by asphyxiation, laceration, or ingestion, as well as anything that a ligature risk (sheets, belt, rope, etc) could be tied to and used as a noose.  It means removing all the patient's clothes and belongings, including cell phone, and giving them scrubs made out of a material that tears under any stress.  Lastly, they are legally prohibited from leaving the hospital until they are transferred to a treatment center.  These are all important, necessary measures given the environment and resources of the emergency department.

However, removing these things (phone, belongings, freedom) from the patient removes the last few semblances of belonging they have.  In addition, lacking a sense of belonging makes a person believe that they are an observer of the world from the outside.  This feeling worsens when the patient is placed in a room with an open glass wall with a patient observer who does nothing but watch the patient to prevent injury.  Again, these are necessary to protect the patient, but merely worsen the very issues that drove the patient to suicide.  

This limbo can last anywhere from a day to a week while waiting for placement at a rehabilitation facility.  In a facility, a psychiatrist makes rounds once a day on average, talking with a patient for a few minutes, and usually ordering a mix of meds and therapy.  Each day the doctor sees the patient for a handful of time, decides that the medications he’s ordered haven’t made a difference yet, and increases the dose.

The problem is that Selective Serotonin Reuptake Inhibiters (the most common family of antidepressants, and the typical drug regimen for suicidal patients) take up to a month to reach a functional level.  By the time the patient reaches a functional level, their dose has been increased so much that it is multiple times the dose they should be receiving.  This is counterintuitive, as the FDA has found SSRIs to increase suicidality among the majority of patients by 150% to 200%.  So the patient is taking multiple times the dosage of a drug which increases their original symptoms without improving the social structure and sense of belonging which drove them to attempt suicide.

The next time the patient arrives at the emergency department, they’ll be closer to being successful.

So what can we do to change a nation-wide system treating a growing epidemic which merely cycles the same patients through the broken system?  My next installment on the topic will discuss possible changes to the way we handle suicidal cases in the emergency department, as well as rehab.