When people we know kill themselves

Burying or cremating them is the easy part

By Beverly Ackerman

Free radical effects may prove significant in understanding mood disorders. Rethinking the causes and treatment of mood disorder Complex aggregate of genetic and environment factors Last November. the Institute of Community and Family Psychiatry of the Sir Mortimer B. Davis Jewish General Hospital in Montreal hosted an overflow crowd of clinicians, therapists, patients and families. They had gathered to witness the awarding of The Douglas Utting Prize to Dr. L. Trevor Young, Professor and Cameron Wilson Chair in Depression Studies, University of Toronto, Physician-in-Chief, Centre for Addiction and Mental Health. This annual honour goes to an individual, working in Canada, who has made a significant contribution to the study, understanding or treatment of depressive disorders. Members of the the late Douglas Utting's family were on hand to present the award, which includes a $7,500 honorarium. The family also supports one full-time and on part-time fellowship for the study of depression, both research and clinical. RETHINKING MOOD Dr Young's keynote address was "Signaling, sprouting and neurogenesis: should we rethink the causes and treatment of mood disorders?" He emphasized that conditions such as major depression, bi-polar disorder (BPD) and schizophrenia are complex aggregates of genetic and environmental factors. He then presented several questions which animate his research. Using stressed-mouse models of depression, his research team and others have established that anti-depressants and mood stabilizers (such as lithium and its newer analogues) demonstrate neuroprotective effects, manifest as new brain cell production in the treated mice. Using microarray technology, which looks at the expression of thousands of genes simultaneously, he examined the brains of these mice, discovering about 100 different genes were turned on by the treatments. One in particular, glutathione-S-transferase, is considered protective against oxidative damage, suggesting that free radical effects may prove significant in understanding mood disorders. FROM MOUSE TO MAN These molecular results were also extended to humans. Using post-mortem brain tissue from 60 depressed, BPD, schizophrenic or control individuals, his lab established that some of the same genes at increased expression in the mouse models were affected in the mentally ill humans, too.Finally, he presented evidence that cellular damage and loss occur in the brains of those with major depression or BPD. Judging from the attendance and composition of Dr Young's audience, their questions and poignant comments afterward, there is a public thirst for information and reassurance about the new potential for treatment generated by current research. Many, indeed most, of those who attended were themselves were either afflicted with the conditions being studied by Dr Young's team or had friends and relatives who were. It can be hoped that the Institute will respond with more regular lectures in future. We will surely need them: it is forecast that by 2030, mental illness will surpass heart disease as the top cause of morbidity in the developed world.

Eli Puterman is an engaging young man with a ready smile. Currently studying clinical psychology at the University of British Columbia, he was 22 when his partner committed suicide. Stephane was found in a field behind Eli's parents' home, clutching a photo of Eli. He expired in hospital of an overdose and hypothermia. Eli had just terminated their year-long relationship, several months after having found Stephane in their apartment, the veins of one arm slashed.

Although news to Eli, Stephane had made several previous suicide attempts In the aftermath of the suicide, no counselling was offered or suggested. Says Mr Puterman: "one of the doctors was the only [person] to acknowledge that I was the partner, the boyfriend. He was the only one who asked me how I was doing, put his arm around me to see if I was okay. And let me speak for a bit. I was destroyed for awhile. I was a zombie. I had a friend, a psychologist, who called me once a week to make sure that I was okay, to see if I had gone into therapy yet. Finally she said to me 'What are you waiting for?' It took about three months for me to get into therapy. I didn't want to. I kind of thought that I should, wasn't sure, felt I could cope on my own. Therapy was the best thing I ever did in my life, to reach out and talk about it."

GETTING HELP
Caroline Smart is a facilitator with the self-help group Family Survivors of Suicide (FSOS). Many of the people she encounters had no idea that their loved one was wrestling with death; half of suicides succeed on their first attempt. "I often recommend the Kubler-Ross book On Death and Dying to our survivors, because they go through the same sort of grief process dying people experience", she asserts, referring to shock and denial, anger, bargaining, depression, and acceptance. The double stigma of suicide and mental illness differentiates the grief of survivors, however. Some survivors experience guilt-tinged relief, liberated from the stress of caring for or coping with a mentally ill person.

After the first unsuccessful slashed wrist attempt, Eli had Stephane admitted to a local hospital. After three days he was discharged. What Eli interpreted as the system's callowness has plagued him ever since. "... they let him go. There was no follow-up interview. There was nothing! And I freaked out. I begged every single person in his life except for his family -- he didn't want his family -- to take him in, because I couldn't take care of him. And no one wanted to. Everyone had helped him already, they were tired of helping him".

HELPING OTHERS
Several years later, Eli was asked to facilitate a teen survivors group. He told them, "Many people feel guilty after somebody has killed themselves; they think 'I should have been the person who brought them to the hospital. I should have been the person who made sure they went to see a psychologist or a psychiatrist'. Everyone I know who has survived a suicide has tried to help the person who committed suicide. Everyone has tried to talk to them and to convince them to get help."

Systematic study of survivors is in its infancy; Dr. Gustavo Turecki of the McGill Group for Suicide Studies hopes to develop a centre to support families and treat pathological bereavement. His multi-disciplinary group focuses on genetics, molecular biology of the brains of suicide completers (e.g. dense microarray gene expression studies) and clinical studies (e.g. psychological autopsies, family studies). Currently, support for survivors is mostly provided by self-help groups such as FSOS.

Declares Caroline Smart: "We get people, sometimes, after 30 years; they have only just decided to talk." McGill's Social Work Faculty created the group in 1988, spurred by parent-survivors. It meets bi-weekly, from September to June. Catholic Family Services provides non-denominational referral backup, helping too with administration and planning. Survivors share their experiences, or simply listen. Self-expression, in many forms, is strongly encouraged. FSOS has semi-annual open meetings, and has organized other events, such as a vernissage of survivors' artworks.

Meeting those who have managed to continue meaningful lives following suicide is a great comfort to the newly bereaved: "It shows them they can go on, and go on to have good lives, too." Caroline, a survivor herself, notes that invited speakers suffer from a credibility problem unless they too are survivors. Often what clients need most is to tell their stories. "We are trying to get the word out . . . we do get referrals from a number of sources already but don't feel that our name is out there, the way it should be" she says.

 

More die by suicide than by war and murder combined Although suicide is a rare event (Canada's rate is 12.3 per 100,000), depression, affecting 5% of the population, is not. Dr. Gustavo Turecki, Director of the McGill Group for Suicide Studies (MGSS), stresses that "the most important thing for clinicians in general is that they should ask about suicidal ideation. To anyone who is depressed. . . Often patients are not going to volunteer that information: if you don't ask, you are not going to be able to assess. [If present] try to characterize the suicidal ideation, assess risk factors: the presence of family history of suicide, the presence of substance abuse or dependence. Reasons for living, reasons for dying, social support as well as more classical epidemiological risk factors such as gender and age. There is no magic formula that will let you know who is going to die by suicide and who is not, no way of clearly, objectively predicting suicide. One day we are going to have more objective information. That is what we hope". The World Health Organization estimates there were 815,000 suicides in 2000, a greater toll than that waged by war, homicide and terrorism combined. According to Dr Turecki, "suicide is the leading cause of death for males below forty years of age and is among the ten top causes of death in Canada for all ages". A recent CMAJ article calls it "the hidden epidemic". In 1999, 4,074 suicides were documented in Canada; attempts are estimated to be 10-100 times more frequent. These numbers hint at a staggering toll of various forms of distress in our society. By comparison, there were 431 HIV-related deaths and 536 homicides in 1999. HIGH RISK PEOPLE Certain populations, such as some native groups, or young men, are at especially high risk. Eighty percent of suicides are men, but women are hospitalized for attempts 1.5 times as often. Dr. Turecki plans to pursue this "fascinating paradox" in future studies. He continues: "All suicide completers, 90% in general, meet the criteria for psychiatric diagnosis; about 50% is major depression". Many are substance abusers; a small minority have schizophrenia, or bi-polar disorder. Suicide rates worldwide have been rising since 1950, the curve angling up more sharply still after 1970. Each suicide leaves behind between 6 and 20 individuals to mourn, affecting at least 24,000 Canadians annually. Assuming these survivors live, on average, 25 years following their bereavement, at least 600,000 Canadians are living the experience of losing someone close to them by suicide.