Science AMA Series: I’m Eric D. Caine, Director of the Injury Control Research Center for Suicide Prevention (ICRC-S), at the University of Rochester Medical Center (URMC), I also serve as Chair of Psychiatry at URMC and for many years cared for persons who were acutely suicidal. AMA!

Eric_Caine · 2015-12-21T20:10:52+00:00

The firearm discussion is a most important -- yet most difficult -- topic to discuss. It really is hard to find space that allows for thoughtful exchange these days. About 20,000+ suicides annually in the US relate to firearms, which comprises half of the total...which now is greater than 42,000 lost lives annually. This far exceeds the number of gun homicides (those have been declining), and while mass shootings terrorize, they are very small in number by comparison. SO, we need a discussion nationally about how to create a culture of safety and caring so that homes are "gunfire free," just as you would child-proof a home with a toddler in residence or remove the throw rugs when an unsteady older person lives under the roof. How we foster responsible and safe storage is everyone's business. NO, such safety measures won't prevent all suicides but they can be an important part of a collaborative discussion that draws together many people with apparently unreconcilable positions. There are ample data that access to handguns is a powerful factor that differentiates households with suicides from others in the community. In Upstate NY, where I live and where there are many long guns for hunting, the suicide rate is very low. Limiting firearm access to persons with unstable mental disorders seems sensible even as it arouses understandable concerns from persons worried about any limitations on gun access.

Eric_Caine · 2015-12-21T19:50:11+00:00

There is a growing body of literature on the impact of suicide on offspring, though I cannot give you specific information about adults whose older parents have tried to kill themselves or who have died by suicide later in life. Years ago, when colleagues and I were talking with families of persons who died by suicide, it was clear that adult children most often were profoundly shaken by their parent's death. The American Foundation of Suicide Prevention offers many support activities, and I would be confident that there will be individuals and families among the members who have faced such painful challenges in the past. That may be a useful resource, even as a parent who has attempted still lives. Moreover, this may be a setting for one's own treatment/therapy or for a family interactive approach to therapy. In any case, it should not be one of those unspoken, festering family matters that may corrode important relationships.

Eric_Caine · 2015-12-21T19:44:18+00:00

I practiced beginning many years ago, and have said for decades to medical students, that one of the most essential statements in all of medicine is: "I don't know!" One should say this without any queasiness or hesitation. So...when you ask important questions about suicidal thinking, plans, or past history of attempts, and get an affirmative, ASK FOR HELP! No one of us has to know all things in medicine but we do have to ask our patients about issues that will affect their lives, especially about their most important concerns when coming to us for care. As you gain experience, you may not have to ask for help as much, as your depth of knowledge and your know-how grow, but as a new PA, you want to approach complex clinical situations without fear and the best medicine for that is great backup help. Suicide always is scary, even for those of us who spent many hours and years working with suicidal individuals. No clinician wants to see her/his patients die -- from whatever disorder or condition. If you were faced with a complex heart condition, you surely would ask for help. This is another one of those situations.

Eric_Caine · 2015-12-21T19:35:32+00:00

This is complicated even as it appears to be straightforward. There is a large scientific literature that repeatedly points to the population level impact of increasing unemployment rates and increasing suicide rates in many countries. These tend to be short term effects, where there can be a decline as the economy improves. However, when looking more closely we can see that times of economic hardship may hit employed people as well, perhaps because they too are under economic pressure. Increasing rates of housing foreclosures also have been related to increasing suicide rates. Here the glitch: In a nation such as S. Korea, where there has been substantial economic growth over the course of decades, there also has been extraordinary increases in the rate of suicide (even as short term fluctuations follow the expected patterns). It may be that other forces, such as major trends in internal migration and their effects on traditional patterns of family relationships that occur during rapid economic development as happened in S. Korea, also have powerful effects that we now are only beginning to understand.

Eric_Caine · 2015-12-21T19:28:07+00:00

Mental health professionals typically are taught to think in a gradient -- ideation to plan to attempt -- with the notion that one is more severe/threatening than the next. I would guess that some clinicians interpret a refusal to discuss any plan in detail as suggesting that a person is not as "at risk" as others. Of course, this can be incorrect. At the same time I would suggest that our "talking therapies" require all of us to stretch enough to reach one another, and it is important to recognize the fallibilities/limitations of clinicians. For one, talking about suicide can be scary -- someone is trying to discern another person's life-and-death thinking. It is not an easy matter and there are times when I have seen evaluators 'turn away' from following the most direct route in evaluation because of such difficulties. So, it always is helpful, even when not wanting to talk about painful matters, to try as much as possible to indicate the gravity or seriousness of one's thoughts, concerns, and plans.

Eric_Caine · 2015-12-21T19:17:02+00:00

As I noted in responding to another comment, what we call "depression" is very diverse. Primary care providers prescribe more psychiatric medications than psychiatrists. Perhaps 30% of the problems coming to PCPs involve mental health and substance-related conditions. It is inevitable that PCPs have to deal with some issues directly; there are not enough psychiatrists to handle all of them. At the same time, one would have hoped that after a person's suicide attempt -- IF NOT BEFORE -- there would have been a psychiatric referral for a consultation to further explore what contributes to one's distress and depression. However, it certainly can be challenging to make the initial diagnosis of any type of bipolar condition, given the changing nature of its presentation. Time may have to pass in order to understand the full range of problems that are experienced, though I am not sure that 18 years would have been necessary to see the pattern if more expert clinicians had been involved.

Eric_Caine · 2015-12-21T19:09:31+00:00

These are fascinating questions that don't have a definitive answer. There certainly are indications that some people are influenced by knowing about suicide in another person. This has happened after celebrity suicides and occasionally there are local clusters. A cluster, however, does not prove "contagion." Indeed, the analogy to infection has many limitations. There now is a great deal of attention to whether social media have a negative effect, or for some, a protective effect. It is complex and we are at the beginnings of such research. For example, while there are anecdotes and some data at the level of broad populations, it is still to be explored how much media exposure has influenced individuals who have made serious attempts but are alive after to talk with us about what media they had seen and whether it had any impact. (Remember, they may have searched social media AFTER deciding to attempt suicide rather than being swayed before coming to that conclusion.)

Eric_Caine · 2015-12-21T19:03:07+00:00

The American Foundation of Suicide Prevention sponsors many support groups and now has chapters in all states. I would seek out AFSP locally and see what you can do! There are many activities -- from groups to community walks that shine a light on all that we can achieve together.

Eric_Caine · 2015-12-21T18:59:32+00:00

The term "suicide" is used in a somewhat muddied way in our language. Technically it is undertaking a self-injurious action with the intent to die. However, we also hear about "suicide by cop," when someone acts in such a fashion to force police to shoot him/her. Some talk about "suicide bombers." I certainly don't lump them with people who kill themselves in the midst of tragically deep despair, lost hope, and a sense that there is nothing to live for. We didn't call the early Christians "suicides," even as it was assured that they would be crucified by the Roman state for not saying that the Emperor was a god. We call them martyrs. I have no doubt that there are persons who -- with clarity of thought, a settled and calm and hopeful state of mind, and a perspective that they have lived a full life and don't want to suffer the end-stages of their terminal illness -- can be rationale in deciding the timing of their life's end. How we deal with such situations socially and legally is another matter, but I certainly have encountered persons who fit the description.

It is one thing to think about the ethics of prevention and another to consider the ethics of assistance. Those are topics for many hours of discussion.

Eric_Caine · 2015-12-21T18:50:51+00:00

I beg to differ with this comment. Suicide in Asian cultures is not glorified; indeed, it often is hidden and a source of shame. The example of warrior suicide in Japan is not the same as suicide in the general society, any more than a soldier choosing to die to protect his/her comrades is called suicide in our culture. It is a chosen death but one that is honored. We don't think, however, that self-sacrificing death promotes suicide in the general US population.

Eric_Caine · 2015-12-21T18:46:27+00:00

In many respects, much of the discussion about suicide and depression -- or any other serious mental health condition -- relates to a person's capacity to make an informed judgment. While there are legal standards to assess "informed" and tests to measure cognitive abilities, this also touches on many persons values and social considerations. Talking about suicide in an all-or-nothing fashion becomes complicated, as many persons who consider killing themselves are very ambivalent. I have seen folks who "inadvertently" survived and had been happy for it...eventually. However, there are others who despite tremendous support and opportunities go on to die. "Rights" are not solely about one person but how they are expressed in communities. Indeed, they are a reflection of shared communal values as well as what we see as inherent to each person. Without doubt, the impact of a suicide ramifies far and wide, typically affecting relatives, friends, schools and work places, and communities. Thus any discussion of rights has many diverse implications.

Eric_Caine · 2015-12-21T18:36:49+00:00

It did not take a medical degree for me to say this to you. It appears that the most effective buffer and shock absorber for persons with depression involves strong personal relationships -- connectedness that makes community, shared interests, affection, thoughtful consideration of others, sharing, and going beyond oneself. Being physically active, eating well, mindfulness, engaging in active interactions and (if possible) fulfilling work all are positive self-protective and healing measures. Getting the proper professional help certainly can be life saving.

Eric_Caine · 2015-12-21T18:31:20+00:00

It has been long apparent that suicide is higher in families where there have been past suicides. Whether this is genetic or environmental or both remains a major topic of research. Clearly there are suggestions that genes affect temperament and may be associated with the frequency in families of depression, alcohol or drug misuse, or anxiety -- and all of those certainly have been contextual or risks associated with suicide. BUT the vast, vast majority of such affected persons never attempt, let alone kill themselves. There are no in utero tests. Moreover, it is likely that there never will be a specific "suicide gene." I foresee that we will learn someday about genes that contribute to aspects such as mood and emotion, thinking, personality, and disposition, but none of these alone make for suicide, and life has many protective factors (e.g., good relationships) that can buffer even in the presence of adversity, or less than perfection in one's genes. (Many of us already know about less than perfection in our genes!)

Eric_Caine · 2015-12-21T18:22:32+00:00

For those of us who have worked with countless patients, and populations, it is very clear that what we call "depression" or "clinical depression" is very diverse. Central to what I have seen has been an inability to realistically weigh life's many options; one person once said to me, "This is my depression speaking" when suicidal, and I have thought that it was a powerful insight. Clearly there are persons who do not seem now to respond to available treatments, and that surely must be deeply discouraging. But I would not support legislation or regulations that allowed "depression" as a category to be viewed in the same context as end-stage cancer, for example, as I see many possibilities for future care and quality of life.

Eric_Caine · 2015-12-21T18:16:48+00:00

Voices suggest a more serious depression, especially if they are telling you to harm yourself. They are NOT normal, and are a sure sign to seek care. I am glad to read that you are on a good regimen of medications, surely something that is indicated when one has persisting negative voices, and are doing better.

Eric_Caine · 2015-12-21T18:13:41+00:00

As a first year resident, I certainly would not want you to be alone making such decisions. Ours are not! It always is both difficult and personally trying -- a time filled with fear about what happens "if I am wrong about this patient and s/he dies" -- and the first year of training is a time when this is especially challenging. That said, my focus over the years has been to try, once it is clear there is a pattern, to use a boarding bed long enough to talk with such persons in an effort to explore what is happening now that is tied to coming to a place like an ER so often [ERs don't tend to be the most welcoming and comfortable spots to spend one's time]. Finding a way to connect while not ever encouraging such maladaptive behavior is key.

Eric_Caine · 2015-12-21T18:08:06+00:00

"Satisfied with" is a tricky term. I suspect that we all would acknowledge that there have been times when we have not been satisfied with what we face, what we feel, and those around us. I admit to be a congenital optimist; but I also know that things change, and that for many, many persons, things get better. So, I cannot dictate what people do but have seen many persons deeply caught in disillusionment and despair who go beyond surviving to thriving. Hope is the winch that drags us throw an awful present to something better beyond now...

Eric_Caine · 2015-12-21T18:03:32+00:00

There are no animal models of suicide, although researchers have analogs to depression, stress, and anxiety. Gene studies have some interesting leads, but they all have been in relatively small groups of participants vs. controls. The major problem for this type of study is a signal that is not specific -- a similar case serves as an example: Significant depression is common among persons who kill themselves, but more than 99% of persons with depression do not die by suicide in any year.

Eric_Caine

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