Suicide prevention

Day 655

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When I first came to the UK, a couple of myths in my mind about this country were busted within the first week.

  1. Education is free, so everyone must be literate and educated.
  2. The government looks after people who are unable to work, so everyone must be happy.

I was puzzled by the fact that at least 1 in 3 patients I saw before an operation were on regular antidepressants. Some patients took St John’s Wort. I had never heard of that before. Some didn’t admit to having any problems with their health but on a closer look at their notes, were taking antidepressants.

Over the last 10 years, the use of antidepressants has doubled in the UK. Some science tells us that these drugs have a history of proven efficacy and some other science tells us that the benefits are marginal and short term. Occasionally the effects are very harmful. One such effect is ‘Akathisia’, defined as a movement disorder characterised by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting. People with akathisia are unable to sit or keep still, complain of restlessness, fidget, rock from foot to foot, and pace.

‘The Pill That Steals Lives’ is a book written by documentary maker Katinka Blackford Newman. It is one woman’s terrifying journey to discover the truth about antidepressants.

In it she talks about one year of hell that she lived through after being started on Escitalopram(Lexapro). She describes the thoughts of violent acts that crept into her mind while on that drug. She got full blown delusions about having killed her two young children. She had to be hospitalised and was put on multiple medications that made her loose the ability to look after herself or her children.

More than 10 years ago America’s National Institute of Mental Health set out to measure the effectiveness of antidepressants. They found that only 26%of patients responded positively to these meds and at the end of one year only 6% were well. Conclusion: ‘the findings revealed remarkably low response and remission rates’.

Saagar was started on Citalopram (a drug used for unipolar depression and unsuitable for young people) 4 weeks before his death. The dose was doubled from 10 to 20 milligrams per day, 2 days before his death. The riskiest time is when they are started, when they are stopped and when the dose is changed. How much did these medicines contribute to his death? We will never know.

Day 653

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A note out of Saagar’s memory book from University:

“So, I have a memory I’d like to share. We were in the room above Saagar’s on C Curve and somebody was jumping up and down on the floor.
Jack (big guy, played guitar with Saagar in Lenny and the Mandem) said to them, ”No, no. Don’t jump up and down like that. It makes the floor wobble.” And he jumped up and down a few times himself to demonstrate.

Thirty seconds later Saagar comes storming into the room, HOLDING A LIGHT FITTING, saying, “I think this is pretty f***ing funny. Don’t you?” and nursing a rather nasty bump on the head. We laughed for about 10 minutes. And once we told him what had happened I think he saw the funny side too. You couldn’t make up comic timing like that.

I’ll remember Saagar for his magnificent drumming, (I’ll certainly remember him when I have to get premature hearing aids thanks to how loud he was!) nights spent watching those awful BBC 3 trashy medical shows, recoiling in horror and sympathy at various horrible interventions on men’s gentleman’s areas; and he really liked my multi-coloured shorts.

Truth be told though, I owe Saagar more than those memories(although I’ll always hold on to those). I february this year, I hit a nadir of my own and I reached a point where I seriously considered ending my own life as well. Not that I wanted to. I never wanted to. But when you have mental health problems it’s like civil war erupting inside your head where the other side persuades you that ending your own life is the right thing to do. And it does that by making you believe that things are never going to get better. At the point when, in your mind, suicide becomes a realistic option, you really genuinely believe that.
The thing that stayed my hand when I reached that point was Saagar. I had seen the fallout from when somebody takes their own life. I knew I mustn’t do that to my family(and a second time for many of my friends). It was that that made me stop and seek help and now I have made a full recovery.

In a way, I owe Saagar my life.

If Saagar hadn’t killed himself, I almost certainly would have done and perhaps it would be my name on the stone and him writing a message in a book to my family.
I want to thank him for my continued existence and apologise more than words can convey to his family that this is the way things happened.”

Bless!

Day 652

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Of all developed nations, Japan has one of highest suicide rates, third only to Hungary and South Korea. In the year that Saagar died, 25,000 people died of suicide in Japan, making it 70 people per day! Shockingly, this number is more than 3 times that in the UK. Male to female ratio is nearly 2:1 in Japan as compared to 4:1 in the UK.

Why is it so?

Japan’s long tradition of “honourable suicide” makes it a noble thing to do. It is perceived as people taking responsibility for themselves.

“Isolation is the number one precursor for depression and suicide,” says Wataru Nishida, a psychologist at Tokyo’s Temple University. This is particularly applies to elderly people. Many lone deaths of elderly people are never fully investigated by the police. The almost universal practice of cremating bodies here also means that any evidence is quickly destroyed. This also means that suicide is underreported.

The Oxford English Dictionary has recently added the word hikikomori . In Japanese this term describes a type of acute social withdrawal in which a person does not leave their home or room for a period of at least 6 months. In 2010, roughly 700,000 people were living as hikikomori in Japan. Their average age was 31 years. A recent survey of young Japanese people’s attitudes to relationships and sex by the Japan Family Planning Association, it found that 20% of men aged 25-29 had little or no interest in having a sexual relationship. Technology may be making things worse, increasing young people’s isolation.

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Japan is a very rule-orientated society where young people have no way of expressing their anxiety or frustration. There is an acute shortage of psychiatrists. Treatment is essentially by medication as professional psychological support of good quality is not easily available.

Until the late 1990s, depression was not widely recognised in Japan as an illness. An advertising campaign run by a pharmaceutical company called it ‘a cold of the soul’ which helped raise awareness but is now blamed for employees faking depressive illness to take time off work.

This cartoon by Torisugari is his ‘manga therapy’ according to his psychiatrist but it does help improve the broader understanding of the condition.

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{“The world that had supported me up until now is breaking up and falling away! I can’t even stand up any more!” says the character, Watashi (whose name means “I” in Japanese).}

 

The suicide figures have started to fall over the past 3 years but the absolute numbers still remain alarmingly high.

 

Day 650

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A brain surgeon, Paul Kalanithi got diagnosed with terminal lung cancer at the age of 36. Suddenly he found himself on the other side of the table. He wrote a ‘rattling, heartbreaking, beautiful’ book about his life as a doctor and then as a patient before he died. It is called “When breath becomes air’. In it he tactfully dissects the walls that exist between doctors and patients. Having found myself on either side of the table – first as a physician and then as the mother of a severely ill child, I can completely relate with this excerpt below.

“The reason doctors don’t give patients specific prognoses is not merely because they cannot. Certainly, if a patient’s expectations are way out of the bounds of probability – someone expecting to live to 130, say, or someone thinking his benign skin spots are signs of imminent death – doctors are entrusted to bring that person’s expectations into the realm of reasonable possibility. What patients seek is not scientific knowledge that doctors hide but existential authenticity each person must find his or her own. Getting too deeply into statistics is like trying to quench a thirst with salty water. The angst of facing mortality has no remedy in probability.”

“I had to face my mortality and try to understand what made my life worth living and I needed Emma’s (my doctor’s) help to do so. Torn between being a doctor and being a patient, delving into medical science and turning back to literature for answers, I struggled, while facing my own death to rebuild my own life – or perhaps find a new one.”

I cannot imagine what one’s options would be when diagnosed with a severe/ terminal mental illness. Saagar was unable to access his own life as he knew it and perhaps chose to find a new one.

Day 648

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Patient safety skills in primary care, a national survey of GP educators by Ahmed et al was published in 2014. This study aimed to determine the views of General Practice Educators regarding the qualities and attributes of a safe General Practitioner (GP) and the perceived trainability of these ‘safety skills’ and to compare selected results with those generated by a previous study of hospital doctors. This graph represents the perceived importance of safety skills:

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It is interesting that 6 to 7 out of ten GP educators thought ‘leadership’ qualities to be unimportant or inconsequential. Being a good doctor means more than simply being a good clinician. Every day, doctors provide leadership to their colleagues, and vision for the organisations in which they work and to the profession as a whole.

The definition of leadership has undergone an evolution in recent years. We recognise that some doctors are formal leaders who are accountable for the performance of their team, department or organisation. However some confusion exists between the terms ‘leadership’ and ‘management’.

Hospital doctors often have clearly defined leadership roles as part of clinical teams at the frontline and also as part of clinical directorates at managerial level. This may make leadership in respect to safety a more recognised construct within secondary care.

Important but subtle differences exist between what primary care and secondary care doctors perceive as core safety attributes. As the burden of avoidable harm becomes better understood in primary care, such safety skills training will ensure that current and future GPs possess the necessary competencies to engage in efforts to enhance the safety of healthcare.