Monday, January 12, 2009

Suicide Rate Is Highest Just After Psychiatric Hospitalization

If psychiatric hospitalization is so effective, why is the suicide rate highest immediately after release from the hospital?

A massive study (1,185,727 patient-years) published in January ("Higher-risk periods for suicide among VA patients receiving depression treatment: Prioritizing suicide prevention efforts," M. Valenstein et al., Journal of Affective Disorders, Volume 112, Issues 1-3, January 2009, Pages 50-58) on a military veteran population being treated for depression found that suicide rates were dramatically elevated immediately following a psychiatric hospitalization.

The base suicide rate of the population was found to be 114 per 100,000 person-years. Clearly, the depressed VA patients are at a much higher suicide risk than the general population of the United States, for which the suicide rate is estimated at only 16.7 per 100,000 person-years. But the suicide rate for these depressed veterans shot up to 568 per 100,000 person-years during the 12 weeks following a psychiatric hospitalization - five times the already high base rate for the non-hospitalized depressed veterans, and 34 times that of the overall American suicide rate.

But if hospitalization were actually effective in "treating" suicidality, wouldn't we expect the suicide rate to be quite low after a hospitalization?

One problem with this line of thinking is that we might expect only the most seriously suicidal patients to be hospitalized at all. One hypothesis is that hospitalization is effective in reducing suicidality, and that the suicide rate of hospitalized depressed veterans would have been much higher if they hadn't been hospitalized. No study I am aware of attempts to compare the suicide rates of patients who meet criteria for hospitalization, but who are randomly assigned to be or not to be hospitalized. Given the widespread faith in hospitalization as a suicide treatment mechanism, to conduct such a study would probably be considered a breach of professional ethics toward the non-hospitalized group.

However, in the absence of data from such a study, I think the alternative hypothesis needs to be considered: that hospitalization is so horrible, demeaning, and above all ineffective, that it does nothing to prevent suicides and may actually increase one's resolve in that direction. Far from showing caring and compassion, forced psychiatric hospitalization demonstrates to the patient that he is a prisoner. For a prisoner, there is a clear method of escape. Yes, there are people who claim to have benefited from involuntary psychiatric hospitalization, just as there are people who claim to have benefited from childhood beatings and from those wilderness camps they send bad kids to. But there are also people who have suffered involuntary hospitalization and found it to be a life-changing, demeaning experience. In fact, I think we must be suspect of the "glad it happened" group. The psychological defense mechanism of denial, the discomfort of cognitive dissonance, contribute to people interpreting past events with unwarranted optimism. As long as you can convince yourself that the involuntary hospitalization was good for you, you don't have to admit to yourself what an insult to your dignity was done to you.

Sadly, the authors of the study are using the results to recommend yet more coercive practices. What is really needed is more intensive "treatment" following a hospitalization, they say - or a "firm connection to outpatient services," in the Orwellian words of the study's authors.

For those whose link to the study is gated, here's a Washington Post summary of the study: "With Depression, Vets Face Higher Suicide Risk."

Update: Commenter Jessa continues the discussion on coercion at her site, Made with Awesome.

Update: Zarathustra responds to my arguments here.

Update: Jim adds to the discussion here and here.

29 comments:

  1. I'm not quite sure how this jives with what you've said here, but it seems relevant, and another take on why hospitalization doesn't address suicide very well.

    In my experience of depression and mental health care, suicidal thoughts (because don't forget the refrain "suicide is a thought, not a feeling") occur not when I am at my most depressed, but when I am slightly less depressed than that. So, here I am, suicidal, very depressed, but not completely. Into the hospital I go, where "suicide is not an option." The only way I have ever been able to unify my depression with "suicide is not an option" is to believe that I am such a bad person (and I already came in with an astonishingly low opinion of myself), that I do not deserve even suicide. Suicide would be too good for me. It would relieve my suffering, which is "not an option", according to the professionals. And so, now that I am no longer suicidal, I am released from the hospital, but I am also more depressed than I was on my way in. At my most depressed, there is really nowhere to go but up, where, in that slightly less depressed place, I will become suicidal again. I bet you can guess what happens next.

    In my situation, between entering and leaving the hospital I stopped having suicidal intentions, true. But, in the bigger picture, I am worse off. I think it can be possible and appropriate to dissuade someone from suicide. This is not an appropriate way.

    By the way, I found your blog via a mention on mental nurse.

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  2. Your comment accords very well with the other finding of the study, which is that there is a somewhat elevated suicide risk for the period of time immediately following a prescription for antidepressants. This supports the well-accepted idea that when people are depressed but start feeling better (e.g., more energetic), they suddenly have the ability to commit suicide, whereas they didn't before.

    I absolutely agree that it can be appropriate to dissuade someone from committing suicide - much more appropriate than trying to convince someone to commit suicide, in my opinion. But I agree that coercion is not the way to do it.

    The Mental Nurse site seems very open-minded and serious about patients' rights. My mentor when I was a patient advocate was a psych nurse, and he was cool as hell.

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  3. "The Mental Nurse site seems very open-minded and serious about patients' rights"

    I strongly disagree. Some of them pay lip service to some of the "excesses" of psychiatric coercion, but one cannot preach rights while one coerces in practice.

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  4. I know what you mean, Steven, and I don't think participating in coercive psychiatric practices is excusable. But on the other hand I'm happy even for the lip service. A recognition that the pro-choice viewpoint even exists is more than you see in most media.

    A vegan, for instance, has a very serious objection to a vegetarian's practice of eating what the vegan sees as the products of animal slavery (milk, eggs, delicious Camembert). On the other hand, the vegetarian is at least taking steps toward the vegan's practice and way of seeing things.

    And when you hold a relatively extreme position (like my position on suicide rights), I think it's more productive to welcome any progress toward it.

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  5. "A recognition that the pro-choice viewpoint even exists is more than you see in most media."

    Perhaps.

    "I think it's more productive to welcome any progress toward it."

    I think there is an important point to be made here: of those (at that particular site) who pay lip service to freedom from psychiatric coercion, I cannot think of one who does so because they believe that the right to control one's own body is prior to any right the state has to deliver psychiatric treatment.

    Unless there is recognition of the fundamental principle of self-ownership, there cannot be any real progress towards freedom from psychiatric coercion.

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  6. Steven, I read your comment and didn't really know how to respond. I'm glad Curator was able to put what is also my position on this into words. So often when I talk to mental health care professionals I still feel like they aren't doing enough, but because they are taking steps toward the sort of understanding we seem to share, I don't want to put them off that path by criticizing them for what I still object to in their actions. It is a tough balance to strike: praising them for change on one hand, but still reminding that more change needs to be made.

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  7. Steven - I don't know much about that particular site (certainly haven't read all the back articles). I have been wanting to write about a particular problem that your comment brings up - that, in order to work in "mental health" in any capacity - in order to even get a degree - you have to buy in to the core theory, which is coercive by its very nature.

    Imagine being in a clinical psychology PhD program. Just in order to learn the material in school, you're submitting yourself to professors (whom you presumably admire) and filling your mind with their world view and, more importantly, the underlying view of the field as a whole. This happens in all domains - law, theology, comp lit - but it seems particularly harmful in the "mental health" case.

    It really is insidious that the whole field is founded on the principle that awful levels of coercion are justified. I think there is a place for psychology and medicine that is not based on coercion. We do have to keep them listening, though.

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  8. Jessa, you say "they are taking steps toward the sort of understanding we seem to share", but I'm sorry to say my experiences point to the opposite trend. Thomas Szasz puts it very well, I think: "Refining the standards for commitment is like prettifying the slave plantations. The problem is not how to improve commitment, but how to abolish it."

    Curator, you are quite right. One way to silence your critics is to enact medical license laws which send them to jail for doing their jobs.

    "We do have to keep them listening, though."

    I fear they stopped listening decades ago. The war on self-determination is not restricted to psychiatry, so I wouldn't be surprised to see it all get a whole lot worse before people begin to think that giving the government massive powers wasn't a particularly good idea.

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  9. One way to silence your critics is to enact medical license laws which send them to jail for doing their jobs.

    Also to allow doctors to be sued for not being coercive enough. Those few doctors who care about self-determination and individual liberty act in accordance with their conscience at grave peril to themselves (though not, perhaps, as grave as the peril to their patients' dignity if they do not).

    Which will change first - medicine or the law?

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  10. ZOMG Mental Nurse deleted my (completely innocuous) comment about psychological autopsy. Which is strange, considering Mr. Ian (the post's author) formerly linked to my site . . .

    Doesn't change my opinion of the site though.

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  11. Hi Curator

    Your comment has not been deleted. It simply went automatically into the moderation queue. I found it this morning and approved it for publication.

    Apologies for our slightly jumpy security settings. We've been having a lot of problems with spambots.

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  12. And Zarathustra even linked to me, when I think is big of him since all I ever do is question his opinions.

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  13. I had more than a comment's worth to say in response to this, so I sort of responded with an entire post on how to interact with mental health care professionals in a process of changing mental health care. It is here: http://madewithawesome.blogspot.com/2009/01/process-of-change.html

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  14. Jessa, I put a link to it in the post proper, thanks.

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  15. Ok, I popped over to Mental Nurse and read the posts and subsequent comments.

    The first thing I'd like to do is pose a question to those who said, "I'm so happy I was coerced into staying alive. Actually, two questions:

    1. Are you always happy about it, or just sometimes?

    2. If you had killed yourself, do you believe you'd now be UNhappy?

    Flippant question? Perhaps, but I'm more than a little chagrined that some have taken it upon themselves to foist their personal life valuations upon others through FORCE! I mean, where does this kind of thinking lead? How about poor eating choices? Smoking? Dangerous leisure activities, such as hang gliding or bungee jumping? I ride a bike every day IN TRAFFIC, and WITHOUT A HELMET. I might get hurt! Please somebody stop me!!!

    And CHRIST! I love how personal freedoms can be efficiently wrapped in in descriptors like 'libertarianism', then kicked away like a can in the path of those who know better how to run my life than I do. You may think your life is worth the ticket, but who the hell are you to prescribe how I should feel about it; or, worse yet, to try and coerce me into seeing it your way? If personal autonomy isn't a fundamental societal principle, then what the hell is? What are you saving these people for? Or, a more pertinent question...for WHOM? Yourselves?
    Or for the prevailing myth that life is, by definition, good, and that anybody who disagrees strongly enough to do something about it is 'mentally ill'?

    One more thing...in preventing suicide, you're not stopping anything-and by anything, I mean DEATH. Suck it up, folks. We all die, and many times in a more painful fashion through aging than via the direct route. All this is ultimately about timing; it's now, or later. But by and large, the medical establishment (as well as most people, for that matter) refuse to see life in those terms. It's called 'denial'. In this vanishing space between eternities of nothingness, the ofttimes difference between now or later is defined by suffering at LEAST as often as not.

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  16. BTW, I have to second Steven's comments here (wasn't it obvious? hehehe!)

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  17. I'm really enjoying the idea that I might be some kind of moderate on the issue of suicide rights. I usually feel like an extremist.

    Jim and I disagree on the issue of whether death can be a harm, as I've written in the past. I think death can be a harm to people who value their lives, but that it is not a harm to a suicide. Jim thinks death is never a harm. My ethical guidelines are grounded in respecting people's particular values, whereas I think it's fair to characterize Jim as focusing specifically on subjective experience (i.e., you're only harmed if you can experience the harm).

    Actually, I think I was somewhat dismissive in my post of people who genuinely feel benefited by forced hospitalization. I have strong emotions on this issue. I don't think that people who feel harmed by forced hospitalization are the only "correct" people or the only ones we should listen to. I just think their view is the only one that is ever reported, without a lot of perspective attached.

    To get an idea of how strong my feelings are, imagine you were working as an activist against child abuse and kept running into people who said they were beaten as children and it was a great think for their development. Or working against forced female genital mutilation of children, and you kept hearing from adult women who were glad they had the procedure performed on them as children. Wouldn't you want to say something like - "that's not really the issue"?

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  18. I'll confess, I'm not much concerned with this issue outside of the experiential paradigm. I haven't much use for deontological axioms other than as shorthand signifiers relating to the existential questions; or, as I call them, the 'real deal'. Not that I don't often lapse into thinking in those terms; it's REALLY hard to see through the layers of abstraction at times, and it's tempting to sometimes just go with the gestalt, if only for the perceived utilitarian goals behind the shiny chimera. Holy holodeck, Batman!

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  19. jim: If you sincerely want the perspective of those who are thankful for being coercively kept alive, I think you would be better off popping over to mental nurse and asking them.

    curator: I'm glad you're views are being recognized as moderate. I believe that they are. I think they only seem so radical because one side of the conceptual continuum is so heavily populated and tends to disqualify any other positions on the continuum by saying, "any one who thinks that is clearly mentally ill." In any other area the people on the heavily populated are of a continuum would only be able to say, "they are wrong/dumb/whatever" which is a less compelling argument to most people. But because this is mental health, and because that area of the continuum is full of "experts," this topic has these special problems.

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  20. Jessa:

    My somewhat rhetorical question was gleaned from some responses I read over there, and elsewhere. But my visceral feeling about the matter is that I simply don't care. I don't want other people to have the power to make decisions concerning my personal choices about my own life, period; even though later I might regret those choices. Of course, in the choice of suicide there's no subject left to experience any regret in the first place.

    I'll admit I'm not a moderate on this issue, but it's because I believe a fundamental principle of a free society is being broached here. We've become far too comfortable with governmental paternalism, I think. My previous examples weren't meant to be facetious. Isn't a logical extension of this 'it's for your own good' approach more authoritative interference regarding what we choose to eat, to drink, how we entertain ourselves, where we travel, etc.?
    We shouldn't be reasonable about this stuff- we should be outraged! It violates the very foundations of personal autonomy, IMO.

    Actually, I think Steve said it better:

    "Unless there is recognition of the fundamental principle of self-ownership, there cannot be any real progress towards freedom from psychiatric coercion."

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  21. Jessa:

    I'd like to apologize if I come across somewhat snippy here, but this condescendingly paternalistic attitude really offends me. And I'm really more than willing to find compromises around this impasse. I've offered one here.

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  22. jim:

    I rather like your suggestion of suicide centers. My vision would be that suicide that comes out of deep suffering would be allowed and accepted, that it could be done medically in a painless way, and that the suicidal could be surrounded by their family the way people can be when they are taken off life support.

    As far as government paternalism goes, I'm against it generally, however, I do recognize that, as a society, we share an implicit social contract. I am not against social contracts, I think they are necessary in order to live in society peacefully. However, I do lament the state of the current social contract. I think it needs to be made explicit and agreed to explicitly instead of implicitly because I think that will make people stop to think it through more, and I think that groups will break off like religious denominations do so that they can live under social contracts to which they feel comfortable agreeing.

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  23. James again. I've just been released after being forcibly hospitalised by my parents (whom I stupidly agreed to go along with to a psychiatrist in a hospital). I had ordered sodium pentobarbital about a month ago and it was a Fedex international package so I had to have it delivered to my house. Well it said something else on the outside but my parents were suspicious enough because it mentioned that it was a chemical compound.

    So I've been released since I never had suicidal desires anyway. The hospitalization was so undignified especially when two oafs grabbed me by my hands and forced me into the bandwagon. Inside the place I got so angry at everyone I busted both my hands against a wall and now can barely move any of my fingers. After my "visit" I want to die more than I've ever had.

    So let this be a lesson kids... be cautious, don't underestimate the selfishness of your parents (in keeping you forcibly alive) and do it right the first time.

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    1. Absolutely.

      They love you, sincerely, in a genetically-mediated selfish way, to keep their DNA alive through you. But they do feel a real concern for your survival.

      However, they are less concerned with your suffering and happiness than your survival. This isn't the highest form of love!

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  24. Cledwyn Bulbs "Raging Bulbs"July 28, 2013 at 11:44 AM

    A brilliant article, in line with my own thinking on this issue, so the narcissist in me was delighted.

    The part where you talk about "hospitalization" only serving to increase the potential suicide's resolve in that direction is only too true.

    The problem is that this is an issue that appeals more to the viscera than the intellect, stirring up emotions that in no way favour rational debate. People just ask you all sorts of emotionally freighted questions, such as, "where's your compassion?, or "oh, so I should just let my son throw himself under a train, should I?", a transparent and commonplace method for extorting a change of opinion from a person through sheer emotional pressure.

    The truth is that the professions of compassion amongst the anti-suicide brigade are just verbal cosmetics, applied to what is essentially social control and a desire to ward off any possible guilt feelings mobilized by leaving people free to top themselves, which would strike at the core of some of the values and ideals we have been nourished on and which the modern conscience in part consists of. Some may find this cynical, but I do feel there is a selfish component here.

    I also think it is based on the fear that the visible example of people killing themselves might plunge society into some sort of orgy of suicide and sow the seeds of suicidal thought, the act offering itself through its visible example as a means of escaping the hideousness of existence, until suicide becomes so popular that the herd instinct compels them to top themselves as well, after all, the popularity of a behaviour lends it a certain gravitational pull in the eyes of people, though I think I am getting into the realms of fantasy here, and possibly desire.

    Another problem as I see it is that a lot of people who are supposedly suicidal are only claiming they are suicidal as a means of getting attention, after all, it's a cruel world out there, a large percentage of the population live in perpetual isolation, the universe and society indifferent to their plight on this miserable, dirty earth, so by threatening suicide, they do so in the hope that people will give them the attention they desire. Yet the psychiatric "hospital" is a manufactory of the very problems psychiatry purports to cure, including suicide. How many people, I wonder, have gone into hospital claiming to want to kill themselves, only to come out really wanting to do so? I think I almost fit into this category.

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  25. Cledwyn Bulbs "Raging Bulbs"July 28, 2013 at 12:25 PM

    On the issue of "grateful patients", psychiatric coercers are always pulling that card.

    According to that logic, chattel slavery is good because many slaves were grateful. Illustrative in this regards is this quote by Oscar Wilde;

    "Slavery was put down in America, not in consequence of any action on the part of the slaves, or even any express desire on their part that they should be free. It was put down entirely through the grossly illegal conduct of certain agitators in Boston and elsewhere, who were not slaves themselves...nor had anything to do with the question really...from the slaves themselves they received, not merely very little assistance, but hardly any sympathy, even."

    They were often grateful and happy slaves, and according to many of the modern proponents and practitioners of involuntary psychiatry, that makes chattel slavery alright.

    In invoking the supposed gratitude of victims of forced psychiatry, such people are merely exploiting the lack of self-respect of their victims, as well as the selfishness of some patients who strategically seek to appease their oppressors in order to earn special favours and because they identify with them.

    Another reason why some people say they are happy because some people will say anything to please others, especially if they find them intimidating. This is especially common amongst mental patients, who are often so diffident that they are seemingly incapable of saying anything that might offend their interlocutors.

    Also, they are often so mired in self-loathing, born of the degradation they have been subjected to by psychiatry, the family and other social institutions and people, that it does not enter their heads that maybe they deserve a damn sight better. Self-belief and respect are two of the psychological preconditions of resistance to oppression, which is why oppressors and bullies and victimizers often work negatively on a person's self-image in order to the render them more willing to accept their treatment.

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