Behind Kaitlyn’s suicide

Family questions antidepressant’s role in teen’s death (Boston Globe). Several readers have asked what I thought about this story. Readers of FmH know my position on the innuendoes about antidepressant-induced suicide. It is usually a case of inadequate monitoring by the treating physician. Here is a slightly altered version of comments I sent to the reporter who wrote the article (to make sense of this lengthy commentary, you would have to have read the Globe article, of course; for a quick summary avoiding the gory details, skip to the bottom now):

The suicide described in the article, like nearly all, leaves family and friends bereft. It is especially unbearably tragic when a child dies, survived by the parents who were supposed to precede her in leaving this world. For those who survive, life seems particularly precious and the decision to end it unthinkable. There is a temptation to deal with the inconceivability either with easy answers or a facile embrace of the mystery of the event and the futility of any attempts to understand it. Usually, neither is true, although understanding suicide requires a conceptual leap that is quite challenging and difficult for the rest of us.

In that respect, this article leaves much to be desired. First of all, understanding the psychopathology involved is crucial. Not all suicide arises from depression per se. I strongly suspect that this patient had borderline personality disorder — and not depression — as her primary diagnosis. The fact that it was only suggested rather than diagnosed in the Westwood Lodge discharge summary relates to one of my pet peeves in psychiatric care, viz. our unwillingness to call a spade a spade. Because borderlines are dislikeable (their psychopathology is largely an off-putting, enraged and enraging interpersonal disturbance when they get into intensive clinical interactions with caregivers; they are unconsciously motivated to hurt and punish those who would dare to care about them, probably because of how they felt they were treated by their original caregivers), and psychiatrists by nature and training are largely uncomfortable with disliking patients, they cling to the idea that it is politically incorrect to call someone a borderline. The term is grossly underused and we miss the opportunity to diagnose someone in a meaningful way that allows us to properly understand their behavior, prognosis and appropriate treatment.

The mood disturbance in borderlines is usually secondary. In fact, sometimes the borderline instability is only held in check by the inertia and lassitude of a superimposed depression; then when that is treated, the core impulsivity, irritability and lability emerge. For this reason, borderlines are often best treated with mood stabilizers, which help control mood swings, reactivity, irritability and impulsivity. If she warranted the borderline diagnosis as I suspect, it appears to be an oversight not to treat her with a mood stabilizer. Many psychiatrist shy away from them especially in adolescents, at least sometimes because they can cause weight gain (we have evidence from the article that this patient was concerned with losing weight… but then, who isn’t at that age?).

I suspect that the reporter does not make much of the borderline personality allusion because s/he does not understand its implications and did not have a knowledgeable psychiatric consultant behind him/her in writing it. S/he seems to have conferred with ‘experts’ (although IMHO Dr. Joe Glenmullen is an expert mostly in his own mind, a grandstander trying to attract attention by taking a controversial stand against antidepressants with his overblown and irresponsible book, Prozac Backlash) only to obtain memorable soundbite quotes around the narrow, currently ‘sexy’, issue of whether this suicide is attributable to the Zoloft. The reality is far far more complex but, hey, what sells newspapers?

Instead of having limited expectations for medication used with parsimony, the psychiatrists treating patients with borderline personality disorder often put them on a laundry list of medications of multiple classes to target each of the chameleonic variety of symptoms with which this complex pathology presents. This young woman’s use of an antipsychotic medication, barely alluded to, is probably meant to address the thought slippage and distortion that occur in some borderlines some of the time, but antipsychotics are overused, perhaps out of desperation, in the treatment of borderlines. (They are, however, better than benzodiazepines, the Valium-like tranquilizers that are often a mainstay of the treatment of tempestuous and impulsive patients but which further disinhibit their self-destructive and rageful impulses…) One effect of the overuse of antipsychotics is that the recipient is ‘numbed’ or distanced from their feelings and experiences. We have evidence that being ‘numbed’ already troubled this patient, as it often does patients with borderline personality disorder (one of the diagnostic criteria for which is inner emptiness and identity diffusion). She, as many borderlines, impulsively cut herself, which along with meeting self-punitive needs is often motivated to cut through the numbing so the patient can feel something, anything, to know that they are alive and exist. I am concerned that the antipsychotic would worsen that. If one is to focus on her medications at all, it and not the antidepressant might be the primary offending medication in her case.

FmH readers already know my take on the supposed agitation caused by antidepressants like Zoloft. It is real but manageable. Doctors prescribe medications with side effects all the time; the question is whether the benefits are worth the cost, not whether the medication is cost-free. Where SSRI-induced agitation is a problem it is usually the fault of not monitoring the patient closely enough, which is something you are supposed to do when treating depression and suicide risk anyway, right? It is not a reason to throw the baby (SSRIs) out with the bathwater. The responsibility for a patient’s care is transferred from the treatment team at the hospital to the outpatient team upon discharge. The article does not say whether she had a psychiatrist’s appointment during the four days between her discharge and her suicide. This is a high-risk period, since no matter how well the hospitalization went the person is suddenly subjected to stresses from which they were insulated in the hospital — both their prior psychosocial problems and new ones arising from the fact that they have been hospitalized (their concerns about other people’s attitudes, missed time at their job or school, financial obligations from their treatment, etc.). In this instance, we know she had a visit from her ex-boyfriend, for example. The letdown on return home from the hospital is particularly crucial for those with borderline pathology, who are especially vulnerable to loss of support and whose moods are rapidly and dramatically reactive to changes in circumstances. It should be the standard of care — and once was — that patients are seen almost immediately upon discharge to reconnect with their outside team and keep a safety net under them. This has markedly eroded during the past few years; now we are lucky if we can get our patients seen within a month when we discharge them from the hospital. It is an obscene aspect of the degeneration of the quality of mental health care under modern fiscal realities. An intermediate structure of ‘partial hospital’ programming, in which patients attend treatment groups at the hospital during the day but go home each night, has emerged in recent years to transition patients back into the community after, as a rule, much shorter inpatient hospital stays in response to third party payor pressures. But, ironically, those same third party payors often deny or severely limit coverage for their clients to attend partial hospital programs. Was partial hospitalization considered in this patient’s case. especially if she remained impulsive and/or preoccupied with hanging herself? Westwood Lodge itself has a partial hospital program for adolescents…

Incidentally, it was misleading for the reporter to state that increasing the Zoloft dose from 100 to 150 mg/day puts it near the maximum for this medicine, in two senses. First, the reporter is alluding to the prescribing guidelines from the manufacturer and the FDA-approved guidelines, which go up to 200 mg. So (a) the patient went from 50% to 75% of that guideline, certainly in the UPPER HALF of the official range but is this near the top? and (b) psychiatrists are not bound by that maximum. Some patients require much higher doses. What determines dosing decisions are not guidelines in the PDR but adequate assessment of the balance between efficacy and tolerability at a given dose.

Borderline personality disorder patients are prone to self-mutilation (like cutting or scratching oneself) and mood lability/irritability, their central pathology — which is a lifelong enduring pattern of their personality — only gets better if at all with long term character-changing intensive psychotherapy. Medications play an adjunctive role only, stabilizing active symptoms sufficiently to allow them to engage in the life-changing they need to do. Likewise a hospital stay is not curative, only affording the beginnings of stabilization. Most of the work takes place after discharge, over a long long time. Furthermore, these patients are hospitalized too frequently for non-life-threatening cutting that should have been handled in outpatient monitoring, because they tend to regress, i.e. get worse, with the constant attention, the passivity and the control struggle of the psychiatric hospital setting. Because they present a false front — either false reports of how good they feel or of how badly they feel — readiness for discharge is often little better than guesswork. Because rage and rejection-sensitivity are core issues, there can often be a reaction to the rejection represented by hospital discharge. Minimizing hospitalizations in the first place is the beginning of wisdom in treating borderlines, IMHO.

Westwood Lodge, in particular, is a once glamourous and illustrious hospital which has considerably fallen from grace and into decay in recent decades under a succession of corporate owners which have bled it dry. It was bought in early 2001 by UHS, a large corporation that has been slashing-and-burning the hospital’s resources and cutting staffing levels drastically ever since. I happen to know that this is not the first recent suicide Westwood has had that may relate to understaffing or inadequacy of resources, and the Dept of Mental Health probably knows it as well. as they have had Westwood and its parent company under close scrutiny for quite some time. For-profit hospitals bow particularly low to insurance company pressure to discharge patients as soon as possible. There is also pressure to “do something” (usually interpreted as loading the patient with medications and jacking up their doses with frequent increases to give the appearance that there is active treatment going on) to justify continued coverage for the stay, even in the absence of scientific evidence of any value to some of the treatment strategies or the pace at which they are employed. Furthermore, the lack of effective collaboration with the parents, who were not notified in advance of the discharge, is egregious but unfortunately a common transgression in the modern psychiatric hospital standard of care. Certainly, an ongoing preoccupation noted in the chart notes with hanging herself throughout her stay, if true, suggests inadequate assessment of her readiness for discharge. On the other hand, hospitals do not insure ultimate safety, especially in borderlines who are often chronically suicidal. They only ensure momentary safety sufficient to discharge. There is a common misconception about hospitals that they can do more than they can in this day and age. The parent’s impression of inadequate care may have alot to do with the Westwood Lodge treatment team’s failure to articulate to them how little they might realistically expect to be achieved during their daughter’s hospitalization, in terms both of the realities of modern hospital care and the chronic instability of the borderline state. Typically, ‘consumer satisfaction’ is more correlated with such realistic articulation of expectations than with doing more.

When planned, suicide can serve any of a number of different purposes in the disturbed judgment of its would-be perpetrators; and, of course, sometimes it succeeds even when unplanned. Suicides in borderlines are usually impulsive acts, not deliberated. It is sometimes thought of as a highly fantasized escapist exploit without recognition of its finality. There are intriguing suggestions in the article that Kaitlyn was planning not on dying but on running away; I cannot say without reading the actual note she wrote, which is only excerpted in the article. Hours before her death, the article notes, Kaitlyn still had a sense of a future. There are also suggestions that she may have felt she was not so much ending her life as exacting angry retribution on her ex-boyfriend, which is another purpose suicide serves especially for internally rageful borderlines. Furthermore, we have mostly the parents’ word that her primary stressor was the ex-boyfriend (whom she had, it seems put behind her). We do not hear his perspective or even the perspective of many others around her. Yes, we do have her journals but, again, these were only excerpted. Loss and the threat of loss of relationship are core issues and crisis points with borderlines, because part of their pathology is that they cannot fully feel they exist without dependence on or merger with another. Which prompts me to ask, what about the relationship with the parents? While I understand they are grieving and in general I avoid the time-honored abusive psychiatric habit of blaming the parents for the ills of the child, it was after all them to whom she went home. And I am always more than a little bit suspicious of families who want to point the finger elsewhere — at the drugs, at the inadequate care, at the premature hospital discharge. Everyone gets defensive after a suicide, but some defensiveness is more warranted than others. Even if the boyfriend was controlling and the relationship with him unstable, what was the parents’ responsibility for monitoring their minor daughter? She began dating this boy when she was 14??!

By the way, nowhere is the issue of substance abuse mentioned in the article, except to note that the coroner is waiting for toxicology. This is often a complicating factor in borderline personality disorder (an aspect of their impulsivity and self-destructiveness, and unfortunately while under the influence their impulses are often further disinhibited).

The article suggests that the temptation to blame the antidepressants is compelling in the face of what would otherwise be an unfathomable mystery. Complicated it is, but it need not —and should not — remain unfathomable. There is an intensive process of inquiry after a suicide — called a psychological autopsy — that in fact often makes sense of the act, drawing attention in proper balance to the formulation of the patient’s personality, any biological mental illness, historical factors, psychosocial stressors, and the strengths and weaknesses of the treatment decisions made along the way, with the participation of all the pertinent parties. It is a healing action for those — family and caregivers — left behind, and can often improve care in similar instances in the future. All of the reductionistic speculation of the article and indeed of this response from me is useless; there must be a fullscale, sophisticated psychological autopsy. Probably, the investigation underway by the state Dept of Mental Health (DMH), which is the licensing agency for psychiatric hospitals like Westwood and has the power to close it down or impose oversight, restrictions on its ability to admit, or sanctions if its care was found wanting, will not do the trick, as it is in the context of a longstanding political struggle between DMH and the parent company of Westwood Lodge to limit the latter’s grandiose ambitions and heavyhanded influence in the Massachusetts mental health system. The psychological autopsy is usually done with a prominent suicidologist as a consultant; Boston is particularly well-endowed with a number of top-notch suicidology experts at Harvard Medical School. While it used to be standard in cases in which there is any question about the adequacy of the care received, unfortunately it is a procedure that is slowly but surely going by the boards in our era of pecuniary psychiatric care. After all, who is going to pay for the time of all the professional participants?

This is very speculative, of course, indeed it is irresponsible if taken as anything more than speculation, since I know nothing of the case beyond the Globe article and have neither reviewed the medical record, met the patient or talked to anyone involved in her care. Perhaps it is best to consider it a fictional account of how a similar situation might be considered if it arises in some parallel universe.

Addendum: The fine weblogger at Secretly Ironic gives this précis of my argument above. Thank you for the distillation; it is right on target and far more succinct:

“Dammit, I’ve said this before: inadequate staffing, for-profit insurance-gaming, misdiagnosis, inadequate supervision, overestimating the usefulness of drugs, poor explanation of illness and treatment, and sensationalized journalistic coverage all lead to death, disaster, and scandal.”