Suicide Prevention, 101

Psychiatrist Amy Barnhorst makes an important point in her New York Times op-ed about suicide prevention. Mental health professionals want to help people. They want to prevent suicide. And yet, they have precious little to offer. It takes more than an SSRI, and most psychiatrists have little to offer beyond medication.

She writes:

As doctors, we want to help people, and it can be hard for us to admit when our tools are limited. Antidepressants may seem like an obvious solution, but only about 40 percent to 60 percent of patients who take them feel better. And while nearly one in 10 Americans uses antidepressants, there is very little convincing evidence to show that they reduce suicide.

This is because many of the problems that lead to suicide can’t be fixed with a little extra serotonin. Antidepressants can’t supply employment or affordable housing, repair relationships with family members or bring on sobriety.

Effectively, she is on to something important. Suicide prevention and the treatment of depression require life changes. The goal should be to get the patient back into his life, to repair relationships, to get and to hold down jobs.

Nonetheless, mental health providers perpetuate the narrative that suicide is preventable, if patients and family members just follow the right steps. Suicide prevention campaigns encourage people to overcome stigma, tell someone or call a hotline. The implication is that the help is there, just waiting to be sought out.

But it is not that easy. Good outpatient psychiatric care is hard to find, hard to get into and hard to pay for. Inpatient care is reserved for the most extreme cases, and even for them, there are not enough beds. Initiatives like crisis hotlines and anti-stigma campaigns focus on opening more portals into mental health services, but this is like cutting doorways into an empty building.

I suspect that good treatment is harder to find than she imagines. Reasonably, she ignores insight-oriented and psychoanalysis-inspired treatments, but she should have had a word or two to say about the new treatments offered by cognitive therapists.

One remarks that the solutions she sees are beyond the competence of any psychiatrist.

We need to address the root causes of our nation’s suicide problem — poverty, homelessness and the accompanying exposure to trauma, crime and drugs. That means better alcohol and drug treatment, family counseling, low-income housing resources, job training and individual therapy. And for those at risk who still slip past all the checkpoints, we need to make sure they don’t have access to guns and lethal medications.

If we ignore all this, and keep telling the story that there is a simple solution at hand, the families of suicide victims will be left wondering what they did wrong.

This leads us to ask who ought to be offering these services. Clearly, psychiatrists are not trained to do so. But, this should also lead us to ask about the state of the profession itself. The leading lights of the psychology world, the American Psychological Association recently published a paper arguing that therapists ought to be trying to turn men, to take a random cohort, into women. The psycho association proposes that men get in touch with their more sensitive and vulnerable sides. Really? Do you think that a man will find the courage to take charge of his life by feeling more vulnerable, by enhancing his capacity for empathy? If men believe that therapists, mostly these days women, want to turn them into women, will this make them more or less likely to seek treatment?

And besides, not to be any more sexist than necessary, do you think that a woman suffering from depression should receive kudos for being vulnerable and empathetic. Or for feeling her feelings. Perhaps she too should be shown how to screw up her courage and to take charge of her life, to stop feeling her feelings and to take some steps, even small steps, toward getting a job, making a new friend, or taking up a new hobby. Leaving patients alone with their feelings will not prevent them from thinking about suicide. To say the least.