It basically goes without saying, but here's a trigger warning. Reading about suicide when you're in a rough place can make things real, so take a moment to think about whether you want to read this post.
You may or may not have gathered that I've recently lost a friend to suicide. A 12 year friendship. I'm very uniquely lucky to still have a large group of friends that has endured from high school. This friend was someone very dear to me. We misbehaved, played pranks; I had my first drunken adventures with her and we kept eachother safe. Then we grew up and we both pursued health careers and joked about running a practice together. We also shared an understanding of mental health issues, both having mental illness ourselves and within our families. I was candidly honest with her. I had no fear of judgment from her, no fear of how she might react. I remember driving her to school everyday when we were 15 because I got my license first, and I never felt I deserved her - me, an overweight depressed girl who could be ignored in a room, her, a beautiful popular friend-to-everyone. She supported me 10 years ago when I was in the worst state I'd ever been in, and when I found myself dealing with a family crisis, only 2 years ago, I showed up at her house again. That kind of support always feels natural, even when you no longer live in the same city. Her family even supported mine, and that is something I can't say for many of my friends as my parents have never been the types to become close to my friends parents. It has been the type of friendship that didn't require daily maintenance but had such strong foundations that it could be called on at any time. It's only when you lose something that's been so effortless that you realise how rare it is.
I can't explain what it's been like to lose her. I don't think I've actually accepted it as being true yet. I look back on photos and it just doesn't seem possible that she isn't here now. It seems cruel and cold that the world goes on without her in it.
I want to write about it. Because I've been there. Because my own mental illness is what inspired me to pursue medicine. Because she won't be the last person I am close to who has mental illness. Because we all know someone suffering.
So I write this from a place of wanting to help others understand. Suicide is taboo. New Zealand has terrible youth suicide rates, absolutely abhorrent. We clearly aren't managing the burden of mental illness well. There aren't enough resources, we need more stratification of services for people at different levels on the continuum. Currently, inpatient care is reserved for those in a crisis, in the worst stages. Those patients need care, undoubtedly, but what do we do for a functional person who is suffering?
If you don't know where I'm coming from, consider the following:
A mentally ill person, with any major diagnosis e.g. depression, bipolar disorder, schizophrenia, has, generally, a chronically elevated suicide risk. What does that mean? It means over the course of their life, their suicide risk might be 10-20% (dependent on diagnosis - large variation - depression is actually lower lifetime risk than many other diagnoses). The general population suicide rate is more like 2%. So we already know someone with a diagnosis, in the course of their illness, has an overall risk that is 5-10x a non mentally ill person.
Now tell me what you'd like to do about it? Because that is the really tough part. When you're suffering with mental illness, you still have to live your life. You cannot be watched, followed. What if your depression lasts 5 years? You can't be institutionalised, you can't be put on hold. And of course we have crisis services, to phone or contact if you feel acutely unwell. Or you might think there's family and friends (and there is). But in a severe depression, every day can feel like a crisis. You begin to feel like a burden. You begin to feel like you're asking for help too often. It becomes harder to know when a day is really bad. You may not realise you're in for a terrible night, suddenly it's 11pm and you're alone and it means waking someone up to be there for you... you're 3 years in, do you still ask? It begins to feel like you're crying wolf. That's the key misunderstanding.
The final step, that final decision, is often impulsive. You have a background of a chronic suicide risk; you've already thought about it, you probably already have the means. In the depths of despair, when it seems like too much, you can make that choice. It may not take much to be put in that position. If you've never felt despair, hopelessness of that kind, I can understand why the idea might seem outlandish. I have not felt that kind of despair in 8 years, but I remember it. And I never, ever, EVER want to feel it again. It is indescribable. The impulsivity is the reason why suicide survivors often describe immediate regret, and gratefulness for being alive in the longrun. The decision to end that despair pulls at you with such force, but realising the gravity of the choice evidently hits people too late.
This is where we fail at providing adequate support for those who suffer the long haul effects of mental illness, and suffer with this long term increased risk. We need to have a way to be there for people in two ways:
1) To work on treatment: slow, continuous efforts at building resilience, coping mechanisms, finding the right medication, therapy.
2) Having a plan in place for difficult times. Having an understanding that it can be hard to identify a crisis, hard to know when to ask for help. The help someone requires in an acute moment of despair is quite different to the help someone might need long term, but #1 and #2 need to work together to overall lead to the advancement of the person.
Recovery from depression is 2 steps forward, 3 steps back, 5 steps to the side, 1 step forward, and a step bloody upside down. It is the furtherest thing from a straight line. You can be progressing, and still have a bad night. You can feel well on the way, and suddenly find yourself desperate. Just because you are continuing the fight, does not mean you are always winning. People need to be able to reach out and be well received no matter what point they're at.
If you haven't experienced mental illness, these are some things I'd like you to know:
- Suffering within yourself, without an external reason, without a cause to be fixed, is excruciating. You look to yourself to figure out what needs to be fixed. Other people try to point out what you might need to change. But often there is no specific reason, no specific one change required, it's a unique and unfortunate combination of a genetic susceptibility and environmental factors that have lead you to this place.
- You can simultaneously want to live and think about suicide 24/7. You can scare yourself. You can be afraid to be alone. You can feel like there are two of you: the you who wants to live and get better, and the sick, sad, evil you who wants to make things worse and wallow.
- While you know some of the things you say and think and feel are irrational, it does not stop you thinking and feeling them. In fact, often there is tremendous guilt associated with feeling so bad when you have no reason to i.e. "why do I feel so terrible when my life is fine"
- It can feel hopeless and beyond your control. You can wake up and the day is a bad day from the moment you open your eyes, before you've even formed your first thought. Feeling so out of control of your own mind leads to helplessness and hopelessness.
- Ultimately, you are alone. No matter how much support others give you, you have to be alone with your thoughts. No one can take your burden, no one can live your depression. It's on you.
I realise this post feels heavy, it feels sad, it feels scary. Maybe this is why no one talks about suicide. We don't want to think about it. And I get that. We worry talking about it will trigger more. We have strict media laws for this reason.
I want to offer something practical. I don't want to leave you with this feeling of confusion and uncertainty. What can you do for someone who you're supporting with mental illness or an expressed suicidality?
- A new admission of suicidality needs to be referred to a doctor. I.e. the first time they've admitted it/said it. A chronic risk isn't something to be determined by us as friends and supporters. Any desire to end ones life needs to be assessed urgently.
- When you know someone has thought about suicide before and has been mentally ill long term, look out for changes in their patterns of behaviour, as this is often the only sign that something has changed that could change their risk. They may be uncannily happy, all of a sudden. They may say strange things.
- Don't be afraid to ask someone if they have thought about suicide. It's a question we don't ask eachother, but we should. If someone tells you they have or are, refer above. It is not information to be sat on.
- Keep crisis numbers handy, make a plan for a crisis, help the person make a plan of go-to methods of coping. Being prepared can lessen the risk of an impulsive decision to end the despair.
- Self harm is generally not a suicide attempt. However, self harm is an important thing to seek treatment for.
- Compassion fatigue is real. It's hard to care for someone when the same problem rears itself over and over and over again. It goes without saying that you care for them very deeply, but the practicality and day-to-day reality of supporting someone who feels this way long term is taxing. You might not even notice the frustration building. It's important not to be someone's only lifeline.
- Remind those suffering that despair is temporary. We can't be at rock bottom forever, we just can't.
- There is ALWAYS hope. I've heard of patients with severe schizophrenia, patients who haven't left the house in years, patients whose lives have fallen apart, who have been under the care of specialists for years... and suddenly they make a significant life change and make a meaningful recovery and build a life again, even completely ceasing to need specialist care.
I hope this post has helped, in some small way. It was difficult to write, but it's important. If my experience and career-choice/training can be of use, then I want it to be.
Rest in peace my angel, you fought the good fight, we will miss you terribly x