Saturday, January 1, 2000

Q&A Kay Redfield Jamison: Suicide

Originally appeared in the Boston Book Review. Date Approximate.

Kay Redfield Jamison, a Professor of Psychiatry at Johns Hopkins Medical school, is known for her two studies of bipolar disorder, "An Unquiet Mind: A Memoir of Moods and Madness" (1995), and "Touched With Fire: Manic-Depressive Illness and the Artistic Temperament"(1993). Her new book, "Night Falls Fast: Understanding Suicide", is an examination of suicide among the young.

The science is of the first water; it is fast-paced, and it is laying down, pixel by pixel, gene by gene, the dendritic mosaic of the brain. Psychologists are deciphering the motivations for suicide and piecing together the final straws -- the circumstances of life -- that so dangerously ignite the brains vulnerabilities. And throughout the world, from Scandinavia to Australia, public health officials are mapping a strategy to cut the death rate of suicide. Still the, effort seems unhurried. Every seventeen minutes in America, someone commits suicide.
     "Night Falls Fast: Understanding Suicide"

HB: Is there more suicide among young people than in the past?
KRJ: Yes. The rate has quadrupled since the 1950s among younger people. It's begun to level out here, though, it's still increasing in most countries.

What's been wonderful though is having David Satcher as Surgeon General. He comes from The Center For Disease Control, knows the numbers, and says, look, this is a big problem, this is where I'm going to invest a lot of my time. He's also been looking at the increasing number of suicides among African American kids. With his help, we're trying to launch a program about depression in D.C. to try and do something about the suicide rate. It's just in the planning stages now, but there's a lot of enthusiasm for it.

HB: You write: "In 1996, 60 percent of the suicides in this country were carried out with guns; indeed, the number of suicides by firearm exceeded the number of firearm homicides." More people killed themselves with guns than killed other people? That's an astonishing statistic.

KRJ: Yet it is the case. A few years ago Time Magazine did something very revealing; they showed pictures of people who killed others and people who killed themselves over the course of a week in the United States. That made the relation easier to see.

HB: So gun control is a form of suicide prevention, too, isn't it?

KRJ: Studies show a third to a half of the people who commit suicide with a gun bought it within the previous month. It's not as if they bought it to protect their home. And there's the problem of having the gun in the house with adolescents. If you have a very impulsive adolescent who gets severely depressed, a gun is an easy, highly lethal means of committing suicide.

HB: Your focus, in "Night Falls Fast", is on suicide as a function of psychopathology rather than of existential choice, is it not?

KRJ: First of all, I think a great deal has already been written about the existential view of suicide. Secondly, I think the scientific and clinical evidence world-wide is pretty overwhelming; so many studies show the very powerful link between pathology and suicide that they can't be ignored. And I was interested in presenting the advances psychology and medicine have made in the understanding of suicide.

HB: You write about brain imaging as a way, potentially, of literally looking at schizophrenia and other disorders. What are the current diagnostic uses of brain scans with regard to suicide?

KRJ: At the moment, the diagnostic uses are pretty limited, partly because brain scans are expensive and partly because the science is still developing so rapidly. Brain scans are research tools. Their potential is in the diagnosis and in understanding of what's actually going on inside the brain of people with very severe mood swings. Ultimately, scientists want to understand why and where, to can pinpoint the areas of the brain involved and get some sense of what is going on that might have suicide as one of its effects.

HB: It's a theme of "Night Falls Fast" and your earlier work that some of the things that are most destructive about us are linked to some of the things that are most creative. If that's so, how do you separate the destructive, and potentially suicidal, from the creative?

KRJ: It's pretty easy in some ways. I don't want to romanticize suicide or mental illness. I've been there, I've treated it, I've watched too many people die from it. I believe there are certain aspects of temperament and behavior that in their milder forms may be advantageous and in their extreme forms are extremely dangerous and cost people their lives.

A lot of my patients are writers and artists, and my experience in treating them is that they work out pretty creative solutions to their treatments; they may take certain risks with their treatments that others might not. But depression, for example, can be paralyzing. It is a completely non-creative state, and extremely demoralizing. If your identity is as a writer and you cannot write and you cannot think and you cannot feel, there's nothing to be said for it. I don't know of any writers who are not very eager to give up that pathological state. That's pretty straightforward.

You get more discussion about the mild manic states, the high energy states where people feel the rush. But again, most people, by the time they have been hospitalized often enough, and have had relationships and work destroyed, are not interested in maintaining those states, either.

HB: Are there some patients who say, leave me alone, I'll take my chances?

KRJ: Yes, but most don't.

HB: You had your own bout with suicidal impulses.

KRJ: You could say that. I attempted suicide and nearly died from it.

HB: How does your own experience motivate your research?

KRJ: My experience makes me more impatient. I raise money, work with support groups and some of my research is driven by those interests. I don't think you should ever generalize too much from your own experience; people are hugely different. But you play the cards you've got, and one of the cards I've got is a very strong personal desire to make a difference.

HB: In your view, we're now, for the first time, able to talk about mood disorders without romanticizing or demonizing them; we can even make an effort to keep them to within with safe limits.

KRJ: There's a tendency for people to say that if you find the genes and tamper with them, you're going to make people into an homogenous mass. But those kinds of issues have to be raised now, before the results come in from genetics. We need to be thinking in advance about what we would do with information about the genetic basis of mood disorders.

HB: You point out ways that bipolar disorder, depression and even schizophrenia might be adaptive. For example, you say depression might help maintain social hierarchy, that manic states can lead to innovation, and that schizophrenia might promote acute sensitivity to danger.

KRJ: You want to have blood pressure but you don't want to have high blood pressure. You want to have thyroid functioning but you don't want to have low thyroid functioning or high thyroid functioning.

HB: So the goal is to moderate the extremes.

KRJ: And to give people choices. People tend to polarize the situation as if it's a case of treatment versus no treatment, and if you have treatment then you're pulverizing people's will. In reality, it's a bad clinician that allows that to happen. Mostly you want to give options to people who are ill. People can always do what they want to do. What's horrifying from a public health point of view is how many people are unaware of what the options are -- unaware of what a horrible problem suicide is and how many young people are killed by suicide every year.

You were talking about existential approaches. I love literature and philosophy; it's always more interesting to go that route because it's highly individualized. But the fact of the matter it doesn't save lives.

HB: The main point of the book, is it not, is to peel away the denial surrounding suicide?

KRJ: Right. Why is it people care so little? I have a great deal of respect for AIDS activists, for example, because I think they've been unbelievably effective at making society deal with a group that has suffered unbelievably. That has not happened with suicide, maybe because of the stigma attached to it.

HB: We're used to treating viruses and mental illness differently.

KRJ: Exactly, but we're very naive about this. I don't think there's much question that in twenty years we're going to know about the viruses that are effecting the brain.

HB: So mental disorders are material in origin rather than, say, spiritual.

KRJ: The brain is complex enough without having to call in all these extra layers. In the meantime people are dying. The philosophical level is important but what's really important to the family of a suicide is that they've lost someone.

HB: As you see it, our culture's ban on suicide gets translated into denial. People are ashamed of it, can't admit it, and, as you point out, often pretend to themselves that a friend or member of the family did not die by suicide, even when the truth is obvious.

KRJ: Suicide is genuinely threatening. None of us want to think much about the possibility of dying, much less about the possibility of doing it to ourselves.

HB: You talk about suicide epidemics, dating back to the rash of suicides after Goethe's "The Sufferings of Young Werther." And you talk about national styles of suicide. So there's one reason for fear of suicide; it can be catching.

KRJ: Right. That's why one approach in the schools today is to focus, say, on the dangers of drinking while depressed and the way that effects impulsiveness, rather than on suicide per se, which risks romanticizing it.

HB: Isn't the culture right now undergoing a major reevaluation of suicide, as in the movement in favor of a right to die among the terminally ill?

KRJ: I address that in "Night Falls Fast" mostly by saying it's way beyond the bounds of the book. One of the things I was struck by -- and I've been studying suicide for 20 years -- is how vast the literature is. And one of the most contested and socially most important issues exactly pertains to the right to die. It is a very different issue from what it means to kill yourself when you're young. So I didn't even want to write a paragraph about it, that would have seemed presumptuous.

But it's a very important movement and asks lots of questions people are going to have to answer. I think it's very clear we don't give people who are dying the kind of psychological care they need. A lot of people choose to die because they're depressed or because they're lonely or because they're made to feel by society like they are expendable. You buy a great deal of time and happiness for people if you treat them aggressively. On the other hand, people have the right to do whatever they choose with their own lives.

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