March 28, 2008 -- When the most famous author in the world said that she not only had a depression in her 20s, but that she felt suicidal during it — and further, that she was not ashamed — she struck a heroic blow against the evil power of stigma that surrounds mental illness.
"What's to be ashamed of? I went through a really rough time, and I am quite proud that I got out of that," J.K. Rowling, author of the Harry Potter series, was reported as saying in the Sunday Times of London this week.
Indeed, shame is one of the greatest enemies when confronting suicidal thoughts, because it diminishes the likelihood that people will reach out for help when they desperately need to.
Suicidal thoughts often emerge from depression, an illness that descends on someone like Rowling's Dementors descend on characters in the Harry Potter books, bringing a cold, dark, deadening, hopeless feeling.
While the suicidal thoughts sometimes understandably relate to life circumstances, at other times they may be wholly irrational, springing up without warning. William Styron, another novelist, described this phenomenon in a memoir of his own illness called Darkness Visible:
"Many of the artifacts of my house had become potential devices for my own destruction: the attic rafters (and an outside maple or two) a means to hang myself, the garage a place to inhale carbon monoxide, the bathtub a vessel to receive the flow from my opened arteries. The kitchen knives in their drawers had but one purpose for me…"
A Witch's Brew
Suicide is responsible for just over one percent of deaths in the United States, with the impact particularly pronounced in young people, for whom it is the third leading cause of death. A greater proportion of our population, about four to five percent, report having made a suicide attempt. And more still, about 13 percent, have thought seriously about suicide.
The overwhelming risk factor is clearly depression (and its cousin, bipolar disorder). One study from a Swedish community found that the risk of suicide in people with severe depression was 79-fold higher than in those without it. A U.S. twin study showed a 23-fold increase in attempted suicide for people with depression.
Another key risk factor is drug and alcohol use. Many who die by suicide are found to have been intoxicated at the time of death. The combination of depression and intoxication can be a volatile and lethal brew.
Genetics also plays a role in suicidal risk. Family studies show that relatives of people who die by suicide have a five-fold increased rate of suicidal behavior themselves. Research in twins has shown that suicidal behavior is more common among identical than among fraternal twins of someone who died by suicide. Adoption studies have found an increased rate of suicide in the biological relatives of adoptees who died by suicide.
Dr. Virginia Willour, a geneticist at Johns Hopkins, is currently searching for genes that predispose people to attempt suicide. With funding from the National Institute of Mental Health, she is following up a lead that suggests the presence of such a gene on a portion of chromosome 2.
One hypothesis about a suicide gene is that it might predispose to impulsiveness and/or aggressiveness. Several studies have found that a person's suicidal behavior is related to increased impulsive aggression in their relatives. This trait might represent a third risk factor in addition to depression (and/or bipolar disorder) and alcohol/drug use.
Stressful life events have also been shown to increase risk for suicidal thinking or attempt in some studies. Childhood abuse and early parental loss are among the greatest stressors. In some cases, stressful events probably interact with the other risk factors to precipitate suicide attempts.
For people who are feeling suicidal, the first step is to do what J. K. Rowling did: Tell someone. She called her general practitioner. The doctor (or therapist) then needs to determine the nature of the problem and the extent of the danger. In some cases hospitalization is clearly the right thing to ensure the patient is safe. Often, however, the situation can be managed, as it was for Rowling, in the outpatient setting.
Providers need to be clear with a patient that suicide is wrong, and that theirs is a life worth living. Providers need to make clear how devastating suicide would be to the people who care about the patient. And they need to emphasize that no matter how bad the patient feels, she has to battle to make the right choice, to not give in to suicidal urges.
"It is our choices that determine who we are," Professor Dumbledore tells Harry Potter.
Providers need also to mobilize the help of family and friends who care about the patient. I had a patient who was living alone and became intensely suicidal. He had not told anyone about his dangerous state of mind. We called his sister, who decided to take two months off from work and drive 1,000 miles to stay with him until he felt better. He did eventually, and she was able to return home.
The other key is to treat the underlying conditions, such as depression or bipolar disorder. One patient felt suicidal every day for 30 years, from the time she was a teenager. Then, a week or two after a psychiatrist prescribed lamotrigine, those thoughts vanished, never to return.
Kudos to J.K. Rowling for talking openly about her experiences. This is heartening to stigma busters everywhere, such as the American Foundation for Suicide Prevention (AFSP), for which I serve on the Scientific Review Board. AFSP sponsors Out of the Darkness Community Walks to raise awareness, as well as money for suicide prevention research. Help AFSP drive away the Dementors!
If only we could wave a magic wand.
Dr. James Potash is an associate professor of psychiatry and co-director of the Mood Disorders Program at the Johns Hopkins School of Medicine in Baltimore. If you have questions or comments, please e-mail at firstname.lastname@example.org. To participate in our genetic and clinical studies, call 877-MOODS-JH.