Letters to the Editor
Re: Suicide: The Persisting Challenge
The recent editorial by Dr Isaac Sakinofsky (1) and the other articles appearing in the June 2003 issue of the Journal discuss a most important aspect of psychiatric practice. People at risk for suicide are vulnerable to various situations, some of which have been identified and accepted. For example, the replacement of coal gas, with its heavy concentration of carbon monoxide, by natural gas resulted in a marked drop in suicides. The use of electroconvulsive therapy (ECT) also contributed positively to preventing suicides. Unfortunately, all innovations—such as the replacement of imipramine by the monoamine oxidase inhibitors and later the selective serotonin reuptake inhibitors—have been followed by an upsurge of suicides. I recall that, when I cautiously introduced imipramine, I was impressed by the markedly reduced number of patients requiring ECT. We had a fairly large Department of Psychological Medicine in the Teaching Hospital in Birmingham, UK, and because of a bed shortage, we developed comprehensive outpatient services and a day hospital as early as 1950. In the first year of using imipramine, we reduced the numbers requiring ECT by 50%, and in the following year, by another 50%. Thus, within 2 years, only 25% of all patients with severe depression had to have a full course of ECT. As the years passed, the number grew smaller; with the advent of lithium, we lowered them further.
We did not send these “suicidals” to the several mental hospitals in the West Midlands of England. In fact, patients with severe depression were soon much less likely to be admitted to the mental hospitals in the region (2). In my 25 years in the unit, not one of my patients committed suicide, and I have since maintained this “score.” Management is a major factor in the treatment of patients with severe depression. If the family is involved, the risk explained, and their active cooperation secured, we should be able to get the patient over the major hurdle in a week or so. Preventing suicide is a major responsibility that psychiatrists have to face. It is about the only way to lose a patient. As already noted, it requires much attention to management; in this regard, psychiatrists have to resist the interference of the team, because a team can greatly disturb the management of actively suicidal patients. I used to say that 10 people who do not know are no better than 1 person who does not know.
I abolished the practice of issuing suicide caution cards to the nursing staff. I entered the following statement in the case notes: “In my opinion, this patient can be treated in the general ward of a general hospital.” The nursing staff were most grateful, for they were no longer overwhelmed with suicide caution cards that could not guarantee more supervision. In fact, this practice led to less supervision. It meant that the psychiatrist constantly reviewed the situation and immediately introduced appropriate treatment. The patient and relatives were grateful for speedy recoveries. After she had seen me writing this opinion on the chart, I recall the ward sister saying, “But Dr Sim, you are accepting the full responsibility.” I replied that that was why they paid me more. It is much easier to follow this course, for no time was wasted in debating policy with the team, whose only advantage is to ensure that nobody is to blame.
In Canada, young men with ready access to firearms are another source of suicide vicims. The numbers are staggering, and I used them to illustrate a point when I was asked to present a paper at the 10th International Congress for Suicide Prevention and Crime Intervention (3). In 1 year, there were 150 homicides, while 1500 men under age 31 years committed suicide with firearms. They were mainly young men working on farms who had access to firearms while suffering from severe depression that was not recognized. I also suggested that the Canadian Rifle Association should be actively engaged in preventing this horrible loss and that affected young men be persuaded to hand over their weapons until they have been successfully treated. Again, a major aspect in this treatment is the capacity to manage the situation, and I am concerned that this aspect of psychiatric treatment receives little emphasis in psychiatrist training. There would be convulsions in parliament if 1500 troops were wiped out owing to poor management, but this horrible loss from suicide, which is preventable, is allowed to continue. Cosy indolence is a poor substitute for preventive measures.
Finally, drug houses should not be allowed to replace a drug that effectively treats severe depression with “pep pills” that have the capacity to release aggressive tendencies. There is much more to say—but not in a letter to the editor.
References
1. Sakinofsky I. Suicide: the persisting challenge. Can J Psychiatry 2003;48;289–91.
2. Orwin A, Sim M. The mental hospital: effects of an alternative psychiatric service. Lancet 1965;i:644.
3. Sim M. Gun control and suicide. Proceedings of the 10th International Congress for Suicide Prevention and Crime Intervention. Ottawa (ON): International Association for Suicide Prevention; 1979. p 187–9.
Dr Myre Sim MD, FRCP, FRCPsych, FRCPC FAPA
Victoria, British Columbia
|
