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I interviewed people less than 24 hours after they attempted suicide.

Questions of patients after they attempt suicide

For two years I worked on an NIH funded study at a major metropolitan general hospital before starting my PhD in psychology.

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What happens to someone after they attempt suicide? Are they forced to stay in a facility until they're deemed 'stable'?

It depends, actually. Many people make attempts that are not serious - especially as many attempts are very impulsive. A lot of people, for instance, drink heavily, periodically sink further into a depression, and decide to attempt impulsively. If the attempts are not that serious and the person displays a will to live, commitment to outpatient treatment etc., the person is not forced into an inpatient treatment. In fact, people are more rarely forced into an inpatient treatment against their will. If the person is not in contact with reality however, and has psychotic features (e.g. they are hearing voices, think the TV is speaking to them), they are more likely to be forced into treatment. If they also display distress at the suicide attempt failing, continued wish to die, no support system, access to lethal means (e.g. a gun), and intent to re-attempt, they may also be mandated to stay. I should mention though, that my experience was in Boston and the same may not be true for the rest of the country/world.

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Do you believe it's ever the correct move to commit suicide?

Interesting question. I don't believe it is my right to tell anyone whether or not it is moral to take their lives. Especially if people are in unbearable emotional or physical pain, they should have the choice in continuing to live or dying. After all, none of us ever had a choice in being born in the first place. Some of the stories I have heard from the people in the psychiatric emergency room are simply horrifying. From hearing not only about the traumatic events people have experienced but their long-term every day repercussions, I can begin to understand why someone may chose to no longer live.

Ironically, as a therapist, I find having this stance is very beneficial. Understanding the client in this way without pretending to know what is moral fosters trust and strengths the relationship. While the type of therapy I practice with people who are suicidal is certainly focused on keeping people alive with research validated techniques and methods, we have to respect a person's right to chose.

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Were there specific reasons why they attempted suicide, or did they have a mental illness?

Rarely do people without a serious mental illness attempt to take their own lives. If my memory of statistics serves me well, about 90% of people who attempt suicide are diagnosed with a mental illness.

I interviewed about 60 people who attempted suicide w/in the past 24 hours and all had a mental illness.

One person, though, had a major depressive episode that was triggered after a specific incident. While the patient had a history of depression, he was not currently experiencing depression before the incident.

In short, it is exceedingly rare to have a suicide attempt or completion without mental illness being present; however, some specific events can trigger an attempt, especially among people with mental illness.

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After a suicide attempt, do people tend to recover from depression, or are they still miserable?

Depression may lift to some degree if the person has a lot social support after an attempt; however, this is not necessarily a good thing. After an attempt, getting the social support (that is usually much needed but never given) all of a sudden can actually reinforce suicidal behavior. Ideally, it is best to be there for the person, but gushing about how happy you are they are alive, you love them, and you couldn't live without them - especially if the person never hears loving things like this - could be trouble.

Concerning your question specifically though, I haven't really seen a marked increase in depression after an attempt, per se. Actually, many people reattempt once they get out of the hospital.

On the other hand, many people may start a course of antidepressants after a suicide attempt, and after about 6 weeks, the depression may start to lift a bit. They may also get solid researched treatments like Cognitive Behavioral Therapy, which has been shown to markedly help anxiety and depression.

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How long did each interview last?

The first interview was about an hour (then I followed up once or twice for less time).

I started off by asking participants basic questions and then would move into more personal territory.

After that, I administered what is called the Implicit Associations Test (IAT) - those of you who read Malcolm Gladwells' book, Blink, might be familiar with it. It is a reaction time test that measures how strongly you associate various stimuli presented on a computer screen. It is most famous for detecting racial biases. Check it out here:
http://en.wikipedia.org/wiki/Implicit_Association_Test

For our purposes, we used the IAT to examine associations between words like "suicide" and "good" versus "bad." Roughly speaking, the more quickly people responded to "suicide" when it was paired with "good," the more likely they were to attempt suicide in the future.

In short, the computer test helps better predict who might attempt suicide once released from the hospital, which is unfortunately very difficult to do at the present moment. In fact, suicide rates are highest just after being released from the hospital.

If you're interested, results of the study were recently published in a paper I co-authored:
http://pss.sagepub.com/content/21/4/511

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How do you talk someone out of suicide? It must be hard!

I'm not necessarily in the business of talking people out of suicide, per se. I deal more with longterm treatment, but many therapists do get calls of people on the brink of an attempt.

There is a FANTASTIC treatment called Dialectical Behavior Therapy (DBT) that has successfully treated people who have attempted suicide. There is a good crisis management protocol built into it.

The treatment involves contracting people for safety for various amounts of time. For example, I might as a client to contract not to attempt suicide for just two months to give the treatment a chance. After all, the treatment won't work if you're dead.

Some clinicians have also come up with clever contingency plans. For instance, if you kill yourself, all your money will legally be donated to the Republican party. Also, while I realize that making suicide illegal may not make sense, the idea that if you kill yourself, your insurance money will not go to your family is also a more general - albeit clever - contingency plan.

Another more simple thing to do with people who are about to attempt is revisit reasons for living.

In general though, DBT involves teaching people to meditate and become more mindful of their thoughts, urges, and emotions. It incorporates some training in reasoning ability.

The treatment is structured in part like a class that teaches various skills in a group setting along with individual treatment.

Again, it is absolutely fabulous. There was an article about the inventor, Marsha Linehan, in the NYT this week:
http://www.nytimes.com/2011/06/23/health/23lives.html?_r=1

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Is there usually a "last straw" that puts people over the edge, or is it more gradual?

In my experience / opinion, there is no real last straw, per se. The vast majority of people who attempt suicide have a serious mental illness like borderline personality disorder or major depression. While it is true that suicide attempts are often preceded by a trigger, that immediate trigger is almost always nestled in a long history of a real struggle with regulating emotions, depression, anxiety, and/or addiction.

It should be noted though, I have obviously only had the experience of interviewing people who have survived suicide attempts - albeit, some very serious attempts with little chance of survival. Interestingly though, people who are most likely to die by suicide often have many previous suicide attempts in their past.

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What stops people from successfully committing suicide?

Sometimes alcohol, actually. Many attempts are committed under the influence of alcohol or drugs, and as such, one may not have the clarity of mind to carry out an attempt with a high intent to die.

While intoxication can prevent someone from carrying out an attempt to completion, many may not have a 100% will to die. Many people are apathetic and take pill, for instance, not caring if they wake up or not. In fact, I would say that the vast majority of people I interviewed were apathetic about their attempt to some extent.

Also, some people may choose to abort their attempt, call a loved one, 911, or take themselves to a hospital. Perhaps a will to live prevents people from carrying out an attempt as well.

Other times, people intervene with an attempt, to the dismay of the person making the attempt. Other times the person who is attempting might feel relief or apathy if another person thwarts their attempt.

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How do they feel afterwards?

Only two people explicitly said they were upset that their attempt failed.

Of those two people, I am pretty certain that one meant it. The other seemed to have been attempting to garner social support rather than being 100% truly upset to be alive.

While the vast majority were certainly not thrilled to survive, they also did not report deeply wishing their attempt succeeded.

I only remember two people particularly happy to be alive (and one was in the middle of a manic episode.)

Most people feel pretty low, unfortunately.

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Of people who attempt suicide, what's the average number of total attempts?

This is actually a trickier question that it might seem.

Without taking into account the various ages of people in the study etc., I would say that of the people who I interviewed who made an attempt, they typically attempted 2 or maybe even 3 times beforehand (I was also interviewing people who hadn't just attempted).

But the best way to answer this question might be to look at a group of people who made attempts that have already died - both from suicide and not from suicide - and see how many total attempts they had while they were alive. I'm sure studies have looked at this, but can't recall the numbers off the top of my head (lol). I'll look it up & edit this post when I find the time.

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What were the primary ways people attempted suicide?

I saw a lot of different things, but probably the most common was pills. While I didn't see any attempts at hanging or sitting in garage with the car on, I saw several people who cut themselves - some tried on their arms while another person made a cut at the neck. I also met someone who walked into traffic and others who jumped off bridges.

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What were some of the common patterns you noticed?

Interesting question. Since I interviewed almost 100 people for that study and remember practically every person very individually, there are so much rich qualitative and quantitative data to sift through. I'm sure we're going to be publishing results from this study for a while.

What the main data analyses showed though, was a 6 fold increase in the likelihood of making a suicide attempt after being released from the hospital if they scored in a certain range on a computer test we designed. This test- called the Implicit Associations Test - measures reaction time in milliseconds (so the test results cannot be deliberately manipulated) between words like "suicide" and positive adjectives like "good." It can be inferred that a relatively quicker response (in milliseconds) to "suicide" being paired with "good" versus "bad" indicates the participant's brain processes this association more quickly because that pathway is a road well traveled in the brain.

I wrote a little bit more about this in the post about how long each interview was.

If you have any questions about this or my explanations are unclear, please let me know!

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Are you allowed to talk about this?

yes - as long as I don't give away any identifying information.

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Are you published?

In fact, I am. I listed a bunch of published work along with some other thoughts on my blog:
http://taradeliberto.blogspot.com