After suicides in Acton and Boxborough, a communion of sorrow

This Boston Globe article describes the grief and the search for answers in the aftermath of a suicide cluster (six adolescents and young adults within 20 months) in the communities served by the community hospital where I practice psychiatry. While I thought it was thoughtful and searching, I had several concerns (I wrote essentially a version of this post to the reporter and the editor of The Globe).

The article mentions almost in passing the opinion of one set of parents that antidepressant use may have increased their son’s suicidal thinking and contributed to his death. This comment goes unchallenged and unexplored despite the issue being complex and far from incontrovertible. The question of the possible exacerbation of  suicidal thoughts by antidepressants has largely been put to rest, after the concern emerged about a decade ago, by substantial sophisticated research and analysis by psychiatric experts in psychopharmacology and suicidology. In rare isolated cases with particularly vulnerable patients, the agitating side effects of some antidepressants could conceivably worsen their distress to a tipping point. But, in most of the cases where a patient feels that their suicidal thinking escalated after beginning a medication, it is more simply that the medication has not yet kicked in to be the hoped-for ‘fix’ to halt the ongoing progression of their depression.

Furthermore, antidepressant prescribing has increasingly migrated from the psychiatrist’s consulting room to the primary care practice over the past few decades. PCPs, internists, pediatricians and family practitioners have briefer and less frequent visits with their patients (Big Pharma has by and large succeeded in persuading them that antidepressant prescribing is simple, does not require much attention, and will facilitate getting nuisance patients without ‘real’ medical concerns out of their offices more quickly). I have many gifted and empathic primary care colleagues but, by and large, they have less specific training and experience than mental health professionals in creating an alliance with a closed-off patient who may not be communicating suicidal distress with clarity or candor. Medical practice increasingly subscribes to the mistaken notion that simply prescribing the right medicine, outside the context of a therapeutic healing relationship, is sufficient treatment. Nevertheless, prescribing the proper medication is an efficient, some say even essential, component of treating a suicidal depression. Not proposing an antidepressant medication to such a deeply depressed patient has been seen as medical malpractice. The danger of reductively suggesting an irrefutable harmful link between suicide and the antidepressants is that it will have a chilling effect discouraging some from accepting such treatment and depriving sufferers of potentially lifesaving options. We saw this a decade ago.

Parenthetically, of far more concern than antidepressants is that suicidal patients are quite commonly given anti-anxiety medications. These include benzodiazepines such as lorazepam [Ativan], diazepam [Valium], clonazepam [Klonopin], alprazolam [Xanax] and the like. These medications act, exactly like the more familiar effect of alcohol, to lower inhibitions. Shy people socialize more comfortably, with a looser tongue, under the influence of alcohol, and anxiolytics work by the same mechanism at the same brain loci. Unfortunately, among the inhibitions they loosen are our compunctions against acting on any self-destructive impulses we may harbor. Both alcohol and anxiolytics are implicated in a high proportion of suicide attempts and successful suicides and, in my opinion and that of many responsible mental health practitioners, should be avoided when one is struggling with suicidal thoughts or urges.

Particularly in this portrait of a grieving community searching for explanations, one must recognize the impact of the social forces that impede delivery of adequate outpatient care. When we are discharging patients from our acute-stay inpatient unit at my hospital after a suicide crisis, it is outrageous that it typically takes weeks or at times months until they can get an intake with a community mental health provider, especially a psychiatrist. Staffs of inpatient units that stabilize patients in dangerous and acute crises are universally demoralized that patients no matter how motivated will be frustrated in finding adequate support to maintain their gains and their safety in the ensuing months. There are far too few providers, for one thing because insurance company reimbursement for outpatient mental health services does not make it worth many providers’ while. Furthermore, in all too many states providers are not even required to provide coverage for mental health treatment in parity to that for other kinds of medical treatment. (Massachusetts is a parity state, not that it makes that much difference.) The relationship between suicide and inadequacy of community mental health service provision ought to be clear.

I’m not actually sure  I would call the six suicides in Acton-Boxborough in the past 20 months a ‘cluster’ and I have seen similar incidences in the other nearby communities involving Lincoln-Sudbury and Concord-Carlisle high schools serviced by my hospital. We have seen a wholesale failure to halt the society-wide increase in suicide, particularly among adolescents and young adults. The article considers the possible contribution of local stresses such as academic pressure to suicide. We have grappled with suicide all too often only on the level of individual emotional factors and circumstantial psychosocial stress. However, we ignore at our peril the fact that large-scale cultural stresses and societal breakdown undoubtedly play an important part in encouraging people to take their lives. Particularly since Trump came to power in 2016, Americans have experienced a drastic acceleration in the postmodern erosion of cohesion of the social fabric, the wholesale betrayal of the expectation of the moral integrity of public figures, and relativity in what is even true on all levels. It is essential not to overlook how social breakdown impacts our young adults at times when they have not yet established a sense of the meaning of their lives, what to believe, or whom to trust. In his seminal 1897 treatise Suicide, the luminary French sociologist Emile Durkheim helped us to understand that suicide correlates not just with individual emotional factors or situational stress but with such society-wide strife and anomie. It is now a given in grappling with suicide, and one cannot ignore this level of analysis.