Chronic suicidal thoughts . . . to be or not to be . . .

The presence of chronic suicidal thoughts is one of the more difficult issues to deal with in psychiatry.  It is one of the issues that separates psychiatry from all other branches of medicine.  When patients see my colleagues, they want to get better.  Sometimes, when patients see me . . . they just want to die.  This freaks people out.  Me too, sometimes.  But it is part of the business so, I guess, I have learned to deal with it.  Part of the difficulty with it is the sense of being out of control of it.  Surgeons like to cut and sew.  If something is broken, the way to fix it surgically is pretty clear (tho’ obviously requires great skill).  Maybe it will work, maybe it won’t . . . but what to do is usually clear.  And the doctor runs under the assumption that the patient will do everything in their power to cooperate with the healing process.  Patients who present with chronic suicidal thoughts are not so simple.  This is especially true if the patient does not have clear stressors that are producing this sense of despair.  Someone who has experienced significant loss, be it job or a relative, often has difficulty re-defining himself.  That sense of loss-of-self that comes with that situation gives us a clear direction to proceed.  Most of us have had such a loss, and most of us have entertained killing ourselves.  Thoughts like that are really quite normal . . . as long as you don’t follow through on them . . . And addressing the issues is relatively straight forward.  Redefine yourself while grieving the loss. (I didn’t say it was easy . . . just straight forward).

But what about the person who has relatively little life stress?  Or the stressors are not the sort that would seem to be at the root of such a strong desire to eliminate one’s self.  This intangible state is what is most difficult for the patient, for their family, and for the health care providers that are involved.  For some patients, the presence of chronic suicidal thoughts can be the manifestation of past abuse.  It can be an indication of significant personality disorder.  But for many, it seems to be an independent entity that occurs with limited cause.  

Very scary.

Very, very scary.

But, not without a possible solution.  

More than with any other patient group, a patient with suicidal thoughts must be connected with a therapist that they trust and respect.  They must be actively working with that therapist on life skills management that includes social networking without fostering dependence, developing a pattern of activity for oneself that supports physical and emotional health, and strengthening spiritual connectedness with other people and whatever you conceive as “God”.  And, most importantly, an emotional distance between who you are and what you think.  After all, we don’t have to follow through on EVERYTHING we think about doing.  Imagine the chaos if we did!!  Even though the thought to kill one’s self can seem as irresistible as the urge to take the next breath, it is necessary to purposefully distance yourself from that thought.  Acknowledge the thought . . . but distance yourself from it.  “OK, I have the thought to hurt myself . . . I think I’ll go for a walk instead . . . ”  I encourage those patients who I see with these thoughts to develop a very clear list of things that they will do before hurting themselves.  I don’t tell them they cannot hurt themselves.  I decided a long time ago that it was foolish for me to think that my admonishment to not hurt yourself would carry more weight than someone who is close to the person.  But I do expect that they will follow through on our plan (key here is OUR plan) to keep them safe.  And one of the items on that list of to-do’s is that they MUST talk to me or their therapist.  Not TRY to reach me . . . but actually talk to me or their therapist.  The idea here is to create a system of diversions that waste time.  The more time that goes by, the more likely it is that the patient will move from the “have to hurt myself” stage to the chronic nagging stage of self-injurious thoughts that are much easier to ignore.

While this sounds a bit simplistic . . . it can work.  If the patient “works it”.  As with all of medicine, the active participation of the patient in the healing process makes a profound difference.

From a pharmacologic standpoint, what is done with chronic suicidal thoughts?  Obviously, the underlying depression or anxiety is treated.  But, in addition to that, Lithium can be used.  Of all the medicines that we have, Lithium is the only one that has been shown to decrease frequency and severity of suicidal thoughts.  Sometimes, the effect is very dramatic.  I have had patients who have had suicidal thoughts for years find resolution for these symptoms after just a few days on Lithium.  It is magic when it happens!  Both for me and for them.  

As difficult as suicidal thoughts are for the patient and for those around them, I can say that it is exceedingly rare for someone to not get better if they hang in there and work hard at it.  But it is the sort of psychiatric problem that requires openness with your mental health care provider, trust that things will get better, and resolve to do what it takes to make things better.  Most importantly, I try to instill the understanding in the patient that they are not alone.  That their life, however much they do not value it, is valuable to other people.  That the effects of suicide are much more than they can understand when they are overwhelmed by their thoughts.  The move It’s a Wonderful Life is a bit cliche and sweet . . . but every patient who has survived a period of suicidal thoughts or actions reaches a point where they say . . . “I’m so glad I’m alive”.

–Dan Hartman, MD

14 comments to Chronic suicidal thoughts . . . to be or not to be . . .

  • Very interesting post, I never really thought about it from the doctors point of view before.

  • wow, that is really good. i am diagnosed as bipolar with schizoid tendencies, borderline personality disorder AND OCD. this makes a lot of sense to me!! i was on lithium for years but i am not currently on any drugs. i am doing well, but i am becoming symptomatic latley. but i do exactly what you said…when the thoughts get loud (about hurting myself or others) i just get busy on the computer or i do housework or whatever and the thoughts are still there but they arent so loud that i cant stand them and end up hurting myself. thanks for the read, it was very good! im going to link you to my page….thanks again

  • Kelly

    Thank you for your take on chronic suicidality. My best friend has been struggling with this for 3 years . . . it seems like no amount of medication or therapy is actually helpful. She’s been hospitalized numerous times and I think the system is about to give up on her. Thank you for giving us your ideas/thoughts on how to work through it.

  • Mike

    i have been suicidal since i was 11 and am now 44. i have been in many hospitals and under care for years. i look forward to the end, i just no longer tell the docs. i do not think i would hert myself,but i do look forward to the end.

  • Lucy

    I stumbled across your article…
    You have a very interesting take on chronically suicidal patients, mostly because it appears to differ so much from many psychiatrists. It is refreshing to hear that somebody still recognises the seriousness and complexity of this, and does not discard the person as untreatable or just a plain nuisance.
    Normally I am quite skeptical about articles around chronic suicidality as they either just highlight the negatives or suggest that ‘everything will be fine, just hang on and have hope’ etc, but somehow your speech was uplifting yet not patronisingly chirpy. Congratulations!
    You’re the first person to give me hope that my chronic suicidality can actually be fixed. It’d be nice if there were more like you, particularly if you lived in England!

  • Ken

    I too have had suicidal ideation since I was 10 or 11 and have no idea where this comes from. It simply seems that suicide has always been an option on my list – very low on the list but… each time something bad happens or sometimes when something simply annoying happens I think off killing myself. I am not overly sad, have not been diagnosed with clinical depression but have had these thoughts for years and years – I am now 47 years old and have managed to survive this long but simply ignoring the thoughts ( I am sure this is much easier for some than others ). My grandfather, father, uncle and brother all killed themselves but I was not aware of this until much later in life – long after the thoughts of suicide invaded my mind. I obviously have a family history that is scary but… don’t really want to die but the thoughts are always there.

  • Ken– Scary indeed. It does seem like you have a healthy intellectualism about the situation. I wonder if a low dose of Lithium would reduce or eliminate the intrusion of these thoughts?

    –DH MD

  • This is phenomenal. Looking at this from the therapist’s point of view has given me the idea that it is possible for someone to value my life more than I do. I feel so free of these thoughts now.

  • CJ

    I just got off the phone with my 33 year old daughter, and came straight to the computer to learn what I can about her diagnosis: chronic suicidality. After two weeks of inpatient “care” she was sent back to her apartment with this crushing diagnosis and the notion that there’s nothing she can do. I don’t accept that.
    Dr Hartman has laid it out in a way that does seem to provide some hope. However, finding a doctor seems impossible. She lost her job nearly 3 years ago due to a debilitating pain disorder and despite requiring massive doses of pain meds and now psych meds, she continues to be turned down by Social Security.
    If anyone out there can help a desperate mom find a doc to prescribe Lithium to her desperate daughter in Seattle, please please let me know.

  • Hey all– I received a complaint about my choice of words on this entry. About half way through I wrote about “wasting time”. It was a poor choice of words. I should have used the word “bide” instead of waste. Every moment in our lives is precious and should not be wasted. Every moment is an opportunity to live life to the fullest. To share our gifts and talents with others.
    My thanks go out to Bonnie for teaching me a thing or two!

    –DH MD

  • Denise

    My daughter was started on lithium today. She has tried to kill herself twice in the past week. We are terrified. After reading this article I am hopeful that she can improve her mental well being. Perhaps this is Gods answer to prayer??? I remain hopeful. And yes, this is very scary….

  • mike

    I guess the key is that the patient wants to find a solution. If the patient isn’t interested, such as with chronic alcoholism or drug abuse, there probably isn’t much the doctor can do. Some patients simply reach the point of not being interested in self-motivation any longer. That seems to be the key.

  • Mary

    Thank you for your honest and straightforward thoughts on this subject. I do understand and agree with what you say,I made my 1st attempt at 13 yrs of age, before knowing the methods of delay as you have shown, contacting therapist etc. I had already discovered that step helped me to stop, temporararily, however after trying for so long I find I can not live with the chronic nature of this and look forward to the day I can get over the hump so to speak, and either complete the action, or find a solution. The chronic nature of this is one of the overriding factors for me. I don’t see an end to the thoughts, and have been on Lithium without success in the past, in fact no drugs so far have had the desired effect. I find myself hoping that I gain the strength to complete the action and end the misery for everyone, family and doctors included. After too many years, it is too much to bear. But your paper is indeed good,I hope and pray that many will find a way to resolve the issues with your words as a starting point for them.

  • Lisa

    When I told my therapist of 3+ years that I still thought of suicide every day (and for as long as I can remember), she replied that for some people it never goes away. I felt relief, then extreme frustration. Weekly therapy, highest dosage of current anti-depressant, meds for anxiety, learned coping strategies, stress management, etc., and I still have to carry this burden the rest of my life? Difficult doesn’t begin to describe this struggle. It is utterly exhausting. It does feel like a separate entity, working against me.