Tragic death on camera in Miami

The death by overdose of a 19 year old Abraham Bigg on camera watched by thousands of people on the internet is tragic. Commentary about this has focused either that it was online and people actually encouraged him to carry through with his act (sic) or that "internet causes suicide". Just to put this in context there are over 30,000 suicides in the USA every year - so what was different about this death? People have very different views about people who want to die. Historically the view that people who want to "self murder" are bad people who should be condemned has been prominent. This is clearly what a lot of people watching this thought. More recently thinking of suicide as a medical probleem has generated several useful ways of thinking about suicide prevention including effectively treating mental illness. What hasn't been emphasised is that Mr. Bigg had a bipolar disorder the adequate treatment of which represents an important opportunity for suicide prevention. This however is not a sexy headline - especially when compared with internet causes suicide. The other thing to note here is that clearly Mr. Bigg was ambivalent about death - otherwise he wouldn't have killed himself in a way which also offered the chance of someone saving him. Mr. Bigg's exposure by web cam to a potentially vast audience was both an expression of anger and hope. It is a truism that if someone is talking to you about suicide they are ambiivalent and at least part of them wants to live.

South Korea tackles record suicide rate

South Korea has the highest suicide rate in the 30 OECD countries (24.7/100,000) followed by Hungary (21/100,000) and Japan (19.5) – this compares with New Zealand on 11.9/100,000 (OECD Health report 2008; figures from 2005). Now it seems the South Korean government is doing something about it. According to The Korea Times the government is coming up with a strategy that involves “that focuses on strengthening the social and economic safety net for those in the low-income bracket and the aged…. seeking to establish more screen doors at subway stations to prevent people from committing suicide by jumping in front of trains…regulating purchases of poison pesticides … and Web sites encouraging suicide are also considered a major target.” Curiously no mention at all of the role of mental health services or primary care in suicide prevention. The strategy will be announced on world suicide day on September 10th – hope they’ve looked at the ways other countries are doing it.

Drugs and suicide?

A sign of things to come. The FDA in the USA is now considering the case of various drugs prescribed for “physical illness” in causing an increase in suicides. The two drugs reported to be in the spotlight are Singulair (Montelukast sodium) an asthma medication and Neurontin Gabapentin). The report describes two people who committed suicide whilst on these drugs – and that really is the difficulty. Providing any evidence for a connection between the prescription of these drugs and suicide is going to be hard to do as suicide is such a relatively rare outcome – even in people taking antidepressants it is a rare outcome and hard to prove a connection. One solution proposed is to set up a monitoring system for all new drugs to look at suicidal thoughts – however thinking about suicide is a wobbly old construct which is quite complex and doesn’t usually lead to any actions. It certainly is not the same as thinking about death (something it is often confused with in teenagers). However at least this shows that yet again thinking about physical and mental problems as separate is not a particularly helpful thing to do.

Cancer and depression

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Depression in people with cancer is not "normal"

A recent study reported widely (although not referenced) has shown that feeling significantly depressed occurred in 8% of a sample of 2900 people with cancer in the UK compared to 2.6% in the general population. The study was done by the Psychological Medicine Research group at the University of Edinburgh. It builds on ten years of major work in this area including their recent Lancet RCT which used problem solving therapy (amongst other interventions) in depressed people (Strong, V., Waters, R., Hibberd, C., Murray, G. D., Wall, L., McHugh, G. L., Walker, A., & Sharpe, M. 2008,"Management of depression for people with cancer (SMaRT oncology 1): a randomised trial",The Lancet - Vol. 372, Issue 9632, 5 July 2008, Pages 40-48).

The fact that depression is common in people with cancer is not on the face of it that surprising. When bad things happen to people they grieve for what they have lost - which includes going through a period of depression. Maybe what is more surprising is that 92% of people reported not feeling significantly depressed. In liaison psychiatry one of the major day to day issues is the problem of other health professions not recognising significant depression because it is "understandable" or normal. One take home message from this study is that even when bad things happen most people do not get depressed and feeling that they would be better off dead is not a normal and "understandable" reaction.

Awful care in the Emergency Room

A terrible story from the US about the death of a 49 year old woman with "psychiatric problems" who had been waiting for a bed for over 24 hours in an Emergency Room of a New York hospital. She collapsed from a pulmonary embolism and lay on the floor for nearly an hour whilst other patients and hospital staff looked on without doing anything (sic). What makes this news is that it was captured on tape that has been broadcast around the world. While some commentators have written about what an awful thing it is to have to wait, sometime for days, for a hospital bed to become available that somehow misses the point. (Although it is interesting how the financial incentives in the US encourage hospitals to keep well insured patients as in-patients and the poor or uninsured in emergency departments). What is striking to me is the complete lack of professionalism and care of any of the staff involved. Staff just looked at the woman and walked away! The lack of professionalism is reinforced by the fact that after the event the notes were altered by staff, (what were they thinking of and how stupid when the tape showed they were lying...) to make it appear as though the woman had been consistently observed and the collapse was responded to promptly. So far seven people including the head of psychiatry have been sacked. Interestingly the media reponse to this has been to portray the woman not as "someone to blame" or as "someone not worthy of attention" but as someone who lived a rich life who was unfortunate to have suffered a mental illness - a refreshing change. Be interesting to know how the media got hold of the tape and if the story would have made news without these pictures.