White Coat Underground

When Major Nidal Malik Hasan opened fire on his comrades at Ft Reed, he gave no indication of his motives, other than a generic shout of “God is great!” Generally we think of terrorist acts as involving a conspiracy rather than the actions of an individual, but the difference is unlikely to matter to the dead. Understanding Hasan’s motives may, however, help prevent future murders. If this was a terrorist conspiracy, hopefully the government will display more competence than has been apparent. But if his actions were more closely related to those of a disgruntled teenage loner with a gun, psychologists may have more to say than law enforcement.

Of course, no lack of facts will stop armchair psychologists from painting the murders with the brush or their own pet theories. Since the Huffington Post has never been shy about printing pseudoscientific conjecture, that’s were we find the latest dung heap of pseudo-psychology.

In Shooting Spree: A Response to Constant Humiliation?, Thomas Scheff argues that a feedback loop of humiliation may have been behind Nidal’s murder spree. That, and anti-depressants. He cites no evidence for his wild speculations but does give this interesting and unverified pseudo-fact:

Medications may be involved to cut down on self control. It appears that many of the rampages shooters in the last twenty years have been on antidepressants, especially the SSRIs. I will take this issue up later.

Really? If this is so, might it be that these disturbed people actually sought help for their problems, but that the help was insufficient? Could there be any simpler explanations than, “the prozac made me do it?”

So I went over to PubMed to see what kind of credibility this guy’s speculations might have. He is published, but most of his contain observations and speculations rather than data. The observations are interesting, if unsophisticated, but are not enough to form conclusions about human thought and behavior. An example of his methods:

During 5 months in 1965 I observed nearly all intake interviews of male patients in a mental hospital near London. Most of them were over age 60, and all but one were diagnosed as depressed. However, there was usually a temporary lifting of depression in those interviews in which the psychiatrists asked the patients about their activities during World War II. At the time I didn’t understand the significance of these episodes. I now offer an interpretation in the light of current studies of shame and the social bond: Recounting memories of belonging to a community temporarily resolved shame and depression.

Scheff has some mildly interesting ideas, but I don’t see how his baseless speculations will be of any use in understanding or preventing future mass murders.

Comments

#1 Rosiecee
December 4, 2009

I wonder if Hasasn was on or withdrawing from antidepressants? He could have been self-prescribing.

The Physicians Desk Reference states that SSRI antidepressants and all antidepressants can cause mania, psychosis, abnormal thinking, paranoia, hostility, etc. These side effects can also appear during withdrawal. Also, these adverse reactions are not listed as Rare but are listed as either Frequent or Infrequent.

Go to http://www.SSRIstories.com where there are over 3,400 cases, with the full media article available, involving bizarre murders, suicides, school shootings/incidents [51 of these] and murder-suicides – all of which involve SSRI antidepressants like Prozac, Zoloft, Paxil, etc, . The media article usually tells which SSRI antidepressant the perpetrator was taking or had been using.
#2 MonkeyPox
December 4, 2009

Yes, I’m fairly certain that most violent crime is due to SSRI use and SSRI withdrawal. I heard that the 911 guys were all wacked on prozac.
#3 leigh
December 4, 2009

correlation, causation, what’s the difference?
/snark
#4 daedalus2u
December 4, 2009

One of the comments there:

”To me, it starts with child abuse and bullying. No healthy person does either or allows anyone to do it to him without a big fight.”

Spoken as someone who has never been a victim of child abuse or bullying. Blaming the victim for being a victim. Blaming a child for being a victim of child abuse? But what do you expect, it is a reader of the Huffington Post.

Rosiecee, all effective treatments for depression cause an acute increase in suicidality when the treatment starts working, including talk therapy. The only exception might be ECT.

Depression has at least 2 components, feeling so terrible that you wish you were dead and having no energy or motivation to do anything, including kill yourself. Depending on which part of depression resolves first, it is extremely dangerous for someone to feel so terrible they want to kill themselves when the medication gives them the energy to do so.

When SSRIs are introduced, the death rate from suicide goes down. Depression is a very serious disease, it is the 11th leading cause of death (2005) 32,637, 1.3% of deaths.
#5 History Punk
December 4, 2009

I lack a peer-review study to back this up, but from my observation and personal experience, making shit up is a lot easier than actually going out and doing the work. In an environment where people know better and give a shit, you get caught. In a place like Huffington Post where nobody knows better and, even better, most fail to realize they don’t know anything and swagger about with a sense of unearned education, it’s a like having a license to print money.
#6 jane
December 4, 2009

daedalus2u claims:

“Depression is a very serious disease, it is the 11th leading cause of death (2005) 32,637, 1.3% of deaths.”

I wondered where this suspiciously exact statistic came from. Apparently it is a distortion of suicide statistics. According to an online anti-suicide organization, the total number of suicides in 2005 was 32637. CDC’s official number is slightly lower. You cannot equate suicide deaths with depression deaths: while most people who kill themselves may do so solely because they are mentally ill, it’s simply not true that none have other, more comprehensible and even reasonable motives. On the other hand, if the correlation of depression with higher rates of other chronic illnesses, like heart disease, reflects causation *in that direction*, which has not to my knowledge been proven, then the actual number of deaths associated with depression might be much higher.
#7 katydid13
December 4, 2009

I have to say this whole investigation kind of alarms me. Honestly, I care less about what we know about who Hasan emailed in the middle east, and more about the fact there seems to have been a fair amount of direct evidence Hasan was not publically acting like he was not acting ways that wwould let him effectively treat the patients he was supposed to treat.

I realize that the military is short mental health professionals, but there are rumors that some people had concerns about his clinical judgement for years. That he was transfered out of Walter Reed to somewhere he could do less damage. It seems like there are some questions about why he was still a practicing Army doctor.
#8 The Ridger
December 4, 2009

Because the military cares a lot more about billets being filled than who they’re filled with. (And that’s even worse now, when we’re fighting two wars with a broken army.) Plus the usual treatment for mental health problems is some form of “suck it up and do your job”.

And yes, I was in the army for 10 years.
#9 katydid13
December 4, 2009

The Ridger, from everything I’ve heard you are right, but I think that should be the subject of bigger public outrage.
#10 Robert
December 4, 2009

It sounds like a case of a guy who never had a girlfriend hoping to nail 72 virgins in heaven. If not that, then something else equally useless in helping us understand his motivations.

He became a shrink because he fainted while observing childbirth during his residency and he needed a medical field where he would never again see blood. Sounds like a perfect guy for the army in wartime.
#11 daedalus2u
December 4, 2009

Jane, the number is from the CDC.

Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data for 2005. National vital statistics reports; vol 56 no 10. Hyattsville, MD: National Center for Health Statistics. 2008.

Table B on page 5 and if the number is off by 10%? (a gigantic amount), it still beats out #12 cirrhosis.

That number is just the deaths. The number of people going through life depressed is a lot higher.

I presume you have never experienced depression. If you had ever experienced depression, you will know that suicide from depression is actually quite “comprehensible and even reasonable.” Since you haven’t, you will have to take the word of those who have. I hope you never do experience it.
#12 Dianne
December 4, 2009

That number is just the deaths.

Actually, that’s just the number of overt suicides. It doesn’t count the people who are too depressed to get medical care and die of curable diseases (to give a slightly altered example: a patient who presented a year after being diagnosed with colon cancer because she fell into a deep depression just after diagnosis and didn’t get follow up until the depression remitted a bit-at which point the cancer had gone to her liver.) Nor does it count the people who self-medicate with EtOH or other dangerous substances. Or those who starve because they’re too depressed to eat (yep, it can happen.) So the stat daedalus gave is almost certainly an undercount of deaths, even if a certain percentage of suicides occur in people who are not depressed (and who but a suicide bomber kills themselves when not depressed-they may have some other co-morbid mental illness, but I can’t imagine many cheerful psychotics-for example-kill themselves.)
#13 DuWayne
December 5, 2009

First, I would like to address the claim that suicide = depression. To clarify upfront, I do think that depression is a pretty nasty beast and have little doubt that it is a huge contributor to death. I just have to take exception to the notion that suicide stems solely from clinical depression.

While in a sense people who commit suicide due to extenuating circumstances in their lives are depressed, situational depression is not always the same as clinical depression. It can be, but quite often it is just not the same. And a great many suicides are not the result of what can even really be classified as situational depression, clinical or not. There are a great many suicides (successful or not) that are the result of someone believing that there is a significant practical value to committing suicide. A great example of this are parents, usually fathers, who believing they have completely failed their families (through loss of job and/or serious financial failures) decide they are more valuable to their families dead than alive. Sadly, this is not even necessarily a mistaken belief.

And we haven’t even addressed people who choose to end their life proactively, rather than suffering to the bitter end of a terminal illness, or suffering a significant loss of quality of life. While these folks are not a huge percentage of the annual suicide rate, they are there and often enough they aren’t really depressed. Indeed for a lot of them, the decision to take control of their situation actually ends depressing episodes, because they no longer feel powerless in the face of an illness that is killing them slowly and with a great deal of suffering.

Claiming that suicide is all about depression, is like saying that addiction is all about a single neurochemical imbalance or always about neurochemical imbalances, or saying that all depression is based on feelings of inadequacy. It isn’t that simple and it isn’t even always an inherently negative choice. In particular, taking control over one’s end of life, is quite often a very positive choice – even when an individual chooses not to carry out their plans. In Oregon, a fairly large percentage of people who opt for getting the suicide script choose not to use it. It is more about having control than actually ending one’s life.

For my own part, as a reasonably healthy, relatively young adult, I cannot begin to say what choices I will ultimately make when it comes to the end of my own life. But I absolutely derive a great deal of comfort from knowing that the choice is my own, that I have control. I appreciate that I have the option of ending my suffering, or even my decline into a deteriorating quality of life. That has nothing to do with depression and everything to do with my desire for control of my life.

As far as the larger discussion goes, I think a lot of people, including a lot of people who should really know better, have a lot of serious misconceptions about the nature of antidepressants and psychopharmacology in general. For that matter, a lot of people fail to grasp that being diagnosed with depression, doesn’t always mean that that is the sum of a person’s neurological issues.

First of all, there are several classes of antidepressants. Depending on the individual, the first one tried may not only not work, but cause significant negative side effects. Or they might work, but also cause serious side effects. SSRI’s are extremely problematic for me. They work, in that they help moderate my mood, but they also cause extreme discomfort in the genital region. While for some people they may cause some minor sexual dysfunction, for me they cause actual pain – not to mention they make it very difficult for me to use the toilet. Welbutrin works exceptionally well for me with no notable side effects, while for some people it causes extreme anxiety, hallucinations, heart palpitations, aggression and can even augment, instead of helping moderate depression. The same is true of SSRIs.

And those side effects aren’t always immediately apparent. People taking a particular antidepressant may actually find that it really helps initially and the descent into oppositional side effects can be so gradual that they don’t really notice until they are in incredibly bad shape – sometimes badly enough off that they are no longer thinking rationally. It is really easy for someone in that position to spiral out of control, with symptoms being compounded and new symptoms emerging.

When it comes to getting diagnosed, a known issue can easily cover up something that is less obvious. This is especially true of men, who are generally less able to interpret their feelings and emotional states than women generally are. Depression and other neurological issues are very difficult to diagnose under the best of circumstances (shy of symptoms being so very overt that there is little doubt about what is happening). Throw the general tendency men have for some degree of alexithymia and things get even more complicated. Add multiple pathologies to the mix and you can have a real mess on your hands.

I have spent a great deal of my life knowing that I am bipolar and have severe ADHD. Because of that and because they were unmedicated, it was really easy for me to fail entirely to note that I am also clinically depressed. Hindsight makes it rather obvious, as I look over my general behavioral tendencies. Tendencies that when I have observed them in others, I easily recognized them as symptoms of depression. Yet I was entirely unable to recognize them in myself, because I already considered much of my behavior in the light of bipolar and my attention deficit issues.

This is not an uncommon phenom, whether one is a layperson observing themself, or a professional diagnosing someone else. Shy of going through an exhaustive diagnostic criteria, it is actually quite easy to miss something in the mix. And while I appreciate physicians who are often quite capable of tentative diagnosis, they are not usually licensed psychologists, qualified to provide such an exhaustive diagnosis. They basically have to rely on trial and error (which with psychopharma is always the case anyways) to determine how medications are working with a patient and possibly consider that something else may be going on that requires a change in the diagnosis.

One of the biggest problems with psychopharmacology is follow up. After initially starting a medication, the patient should have a follow up within about three weeks – no sooner than two (with the caveat that they should come in a great deal sooner if there are immediate adverse reactions). When I first went on meds, I saw my doctor four times in less then three months and went through changes in medications several times over the first six months, until we found the right combination. And I have had regular followups ever since, my most recent being the first that didn’t schedule the next. I have been on the meds I am on now for a little more than six months, with the only change being a gradual increase in my dose of welbutrin. And even now, when I call in for refills, the nurse asks a few questions about how I am managing, to make sure that nothing is creeping up on me.

The thing is, if patients don’t follow up properly, things can creep up. Adverse reactions can manifest slowly over time and very bad things can happen. That Nidal was a psychologist himself is not terribly relevant, because unfortunately psychologist does not inherently = an fairly strong understanding of the nature of psychopharmacology. That gap is slowly being closed, but it there are a lot of psychologists with very minimal understanding of the subject.
#14 The Blind Watchmaker
December 6, 2009

Funny how people blame antidepressants for psychological breakdowns.

I usually don’t hear people blaming antihypertensives for strokes, or insulin for Diabetic Ketoacidosis, or crutches for ankle injuries.

Cum hoc,ergo propter hoc.
#15 jane
December 7, 2009

daedalus2u, I noted that the death toll from depression may be much higher than you claimed, which should suit your cultural purposes here, and Dianne provided an additional explanation of why that is the case. But it simply IS NOT VALID to claim that all suicides are due to depression.

I find from the CDC web site that 3060 people age 75 and older killed themselves in 2005. It is not common to develop endogenous depression at that age. I suspect that many of these elderly people had incurable health problems; they were either terminally ill or facing a one-way downhill slide to a nursing home bed, either way with a terrible loss of comfort and dignity and with the real possibility that their surviving spouse could be rendered bankrupt and homeless. If YOU would not choose to kill yourself under those circumstances, that does not entitle you to presume that anyone who does is mentally ill.

In fact, your ad hominem remarks to me are entirely out of line. You do not know anything about me, and your insinuation that only a person who has been depressed has the right to an opinion on related subjects – and that opinion had better be the same as yours – is the same sort of argument that you would sneeringly reject if it was offered by, say, an autism activist.
#16 jane
December 7, 2009

Blind Watchmaker, that’s a great way to absolve pharmaceutical companies of responsibility for neurological side effects. Hey, they were bonkers anyway; whatever happens to them, it must be their own innate weakness to blame. We have previously seen that a popular treatment for cardiovascular problems actually increased the death rate from heart disease, and right now they are advertising on TV an asthma medication that admits it increases the asthma death rate. Is it so hard to believe that a drug intended to significantly alter brain chemistry and behavior could have a downside for some people? The best available scientific evidence says that these drugs do harm some users. Are “skeptics” supposed to think like climate denialists, who consider science “sound” only when it shows no negatives whatsoever for business as usual?
#17 Calli Arcale
December 7, 2009

The Ridger:

Because the military cares a lot more about billets being filled than who they’re filled with.

Ain’t that the truth. My father-in-law had a friend when he was serving in Kuwait. The guy was born in the mideast (naturalized US citizen and huge patriot), was fluent in Arabic, knew local customs, and really wanted to work as a translator. Very motivated and talented individual. So the military, in its infinite wisdom, and having an acute need for Arabic translators, scheduled his next deployment for South Korea.

The problem is, it’s a massive bureaucracy, and massive bureaucracies tend to be a bit brainless at times.

jane:

We have previously seen that a popular treatment for cardiovascular problems actually increased the death rate from heart disease, and right now they are advertising on TV an asthma medication that admits it increases the asthma death rate.

I would guess you’re talking about Advair. That’s actually a very interesting example to pick.

As an asthmatic, I can speak to the nuance that folks aren’t aware of with LABA drugs. (Advair is a combination steroid and LABA.) LABA stands for long-acting beta agonist. A very popular one is salmeterol. It’s better tolerated than albuterol (the classic “rescue inhaler” beta agonist) and lasts much longer (hence the name). It is not a bad drug, in and of itself, and it does not, in and of itself, make asthma worse.

So why do asthma deaths go up if people take these LABA drugs? Because beta agonists of all kinds do not treat asthma itself. They just provide temporary symptomatic relief. The underlying inflammation is still present. Salmeterol does such a good job of relieving the symptoms that it can fool an asthmatic into thinking they don’t have to take anything more. They lose their best measure of the condition of their lungs. For this reason, asthma experts warn never to take salmeterol for an extended period unless you are also taking a steroid to treat the actual inflammation. Advair was, I believe, the first drug containing both salmeterol and a steroid, thus satisfying this requirement, though they still are required to caution users not to take it for extended periods unless their doctors says to do so, and only to use it if other controller medications aren’t providing adequate relief. (Note: albuterol and salmeterol are *not* controller medications.)

So salmeterol really doesn’t increase asthma deaths, in and of itself. The danger comes when people take it and think they’re actually getting better. Like taking urinary pain relief pills (phenazopyridine) and thinking you’re okay instead of going to the doctor and getting a urinalysis done. Those pain pills are awesome, providing complete symptom relief in many cases, but they don’t treat infections at all. I know this from experience; I’m leery of taking the stuff for an extended period, because it makes it hard to tell if an infection is responding to treatment or not.
#18 Calli Arcale
December 7, 2009

Curse me and my itchy “Post” finger! I have a bit more to say.

Given the reason why salmeterol is associated with an increased rate of asthma death, I would not be at all surprised if the same sort of thing is at play with antidepressants. Anecdotally, I found from my clinical depression that medication alone did not cure me — but it did help. Medication plus therapy worked. I strongly suspect that antidepressants don’t increase suicide by making people more depressed. Rather, I suspect they can give people enough clarity of mind to carry out something they’ve been thinking about for a while. Hopefully, for most people, that’s getting counseling and making up with friends and family and so forth, but for some, that’s going to be removing themselves from existence. I mean, we’re talking about clinically depressed people here. Their minds have been treading some very dark waters lately. Suddenly clarity of vision might not always be the best thing. So I think the best thing to do is always couple medication and therapy. It’s not a time when they should be left alone.
#19 DuWayne
December 7, 2009

Calli Arcale –

There is actually a lot of evidence that the potential side effects of a lot of antidepressants can be adverse to what the antidepressant is trying to do. While I can imagine that some people might just be getting the clarity to follow through on plans, it is also very likely that some of them are just having a very adverse reaction. Not all psychopharmaceuticals work the same for everyone. While it is important to recognize the positive effects of antidepressants and other psychopharma (I am able to functionally go to school because I am on several), it is also important to recognize the potential dangers and act accordingly.

These problems can be dealt with, with basic followthrough on the part of both patients and their doctors. But not all doctors deal with these drugs in a reasonable fashion and not all patients deal with them reasonably. Such as people deciding that because it isn’t working properly, or is causing adverse symptoms, they should just quit taking it cold. Or people not really paying attention – not talking to the doctor. Sometimes these effects creep up. And with many people and many of these drugs, not tapering off can be exceedingly dangerous.

And unfortunately, sometimes cognitive therapy isn’t an option. Indeed quite often it isn’t. It is expensive and insurance rarely covers it – or if it is covered, there are very sharp limits to the sessions covered. I am not arguing that combining drugs with cognitive therapy isn’t the ideal, just that it isn’t always an option. It is quite possible to manage the drugs without it – it just takes some effort on the part of everyone involved.
#20 daedalus2u
December 7, 2009

jane, You presume to know my “cultural purposes” for posting here? Who is projecting? Who is sneeringly rejecting an opinion?

I only reject the opinions of people who have demonstrated they do not understand what they are talking about. When autism advocates don’t know what they are talking about I reject their opinions too.

It is interesting that you mention that in the 75 and older age group there were 3060 suicides. In that same age group there were a total of 1,389,834 deaths, making the percentage of deaths due to suicide in that age group 0.22%. The suicide rate in the entire group is 1.3%, about 6 times higher, suggesting ill health may not be the main driver for suicide. If we look at the 0-74 age group, there were 1058183 deaths, of which 29577 were suicide, for a rate of 2.8%, more than 12 times the rate in the 75+ group and more than twice the rate in the whole age group. The 75+ group pulls the total rate down by a lot.

In your comment, you seemed hell-bent on minimizing and dismissing deaths from suicide due to depression by attributing suicide deaths to something else saying:

“You cannot equate suicide deaths with depression deaths: while most people who kill themselves may do so solely because they are mentally ill, it’s simply not true that none have other, more comprehensible and even reasonable motives.”

Suicide from depression is completely “comprehensible and even reasonable” to anyone who understands depression. Since you write as if you don’t understand that, my (quite reasonable I think) presumption is that you don’t understand depression. If you don’t understand depression, either you have never experienced it, or have have experienced it and then blocked your understanding with denial or are being disingenuous with your writing to advance some other agenda, for example if you are a Scientologist who are well known for their cult-like anti-anti-depressant agenda.

No reputable mental health practitioner minimizes the adverse effects of antidepressants or any other psychopharmacological drug. No one gives big pharma a “pass” or absolves them of all responsibility.

If you don’t understand how suicide could be a “comprehensible and even reasonable” choice by someone simply by virtue of being depressed, then you do not understand depression. It is ok to not understand everything, but one needs to appreciate the limits of one’s knowledge and not go too far outside those limits. Being depressed is in some ways like being in love, unless you have actually experienced it for yourself it can be very hard to understand how it feels and how it changes one’s priorities.

My purpose in posting here is to encourage people who are depressed to present themselves for effective treatment, and not to stigmatize people with depression by calling them “mentally ill”, and to not demonize antidepressants by falsely claiming antidepressants cause people to kill themselves. Every effective treatment for depression (except perhaps ECT) has a period of increased suicidality. This is well known and is not in dispute. Denying the effectiveness of antidepressants and so frightening people into not using them is to deny depressed individuals an effective treatment modality.
#21 jane
December 7, 2009

Sorry, daedalus2u, your response to me continues to be only an ad hominem argument. I “don’t understand” … either I haven’t had the disease or maybe I am “in denial” or “disingenuous” [i.e., a liar] because of “cult-like” beliefs … therefore, I am wrong and you are right on an issue of fact. Sorry, no dice. I am not out to pick on people with emotional problems, so if you said that your message reflected how a sufferer PERCEIVED this issue, I would agree that I could not put myself in your shoes. But you present yourself as being smarter and more rational than us average commoners (and you admitted that you do have a purpose, or “agenda”), so I’m going to hold you to the standards of logical argument.

To wit: you write well enough that I presumed you’d understand the use of words like “comprehensible” and “reasonable” as used by average people. When a young, otherwise healthy person commits suicide due to depression, indeed it might seem reasonable to him, but not to the rest of us. OTOH, if someone commits suicide because he is facing a miserable and expensive death from Alzheimer’s or ALS or pancreatic cancer, this seems reasonable enough to me. Neither you nor the pharma industry has the right to redefine that person’s tragic situation as depression.

You suggest that because suicide is rarer in the old [if you think about it logically, this is probably because they are more religious and less often depressed], ill health “may not be the main driver” for suicide. Well, I never said or implied that it was. I only said that it was for some people, probably most of them elderly. Your claim was that ALL those who commit suicide are victims of depression; to disprove that, I only have to argue convincingly that at least one is not.

Now, I said earlier that possibly MORE people died indirectly from depression than you claimed – which implies that even people who are not suicidal might benefit from treatment to reduce their risks of heart disease, etc. (Perhaps they might benefit from exercise, which both relieves depression and directly reduces CV risks.) Nor did I in any way suggest that people should not get pharma treatment if that’s what will help them. If you suggest again that my challenging your mistaken interpretation of a statistic means I might be a Scientologist, you are just plain lying … oh, sorry, I meant to say “being disingenuous to advance some other agenda,” please forgive my rudeness.
#22 DuWayne
December 7, 2009

It is interesting that you mention that in the 75 and older age group there were 3060 suicides. In that same age group there were a total of 1,389,834 deaths, making the percentage of deaths due to suicide in that age group 0.22%. The suicide rate in the entire group is 1.3%, about 6 times higher, suggesting ill health may not be the main driver for suicide.

daedalus2u, this is ignoring a great many other factors involved in the choice an elderly person’s decision to end their life. I am sorry, but there is no way you can take those bare statistics and conclude that ill health may not be the main drive for suicide. You are also ignoring the dramatic social shift in the last fifty years, away from the idea that suffering to the bitter end is somehow noble and suicide is bad.

The bottom line is that people in that age group are suffering a dramatic decline in their health and mobility – a dramatic decline in fact, in their quality of life. And there is considerably less pressure on people to fight it out. Indeed, there is some evidence to suggest that those figures are actually on the low side. That a fair percentage of suicides are filed as natural deaths, because they are assisted suicides.

Please understand that I am not agreeing with Jane. I accept that a large percentage of suicides are in fact due to depression and other mental illnesses. (When it is due to certain other disorders, labeling it depression is not appropriate – even if one could say that they were depressed in a sense. In those cases, where the symptom of a depressive state is brought about by a specific neurological issue, it is considered the result of that disorder.) I just think that you do a disservice to people who have chosen to take control of their lives and the end of their lives, when you claim that suicide = depression and mental illness. That is definitely not the case and we should not pretend that it is. Doing so does nothing to help people who are depressed and harms people who are trying to fight for their right to take control of the end with dignity.

Jane -

You should really look up the definition of ad hominem. It does not mean what you seem to think it means. I don’t always agree with daedalus2u – I don’t entirely here in fact. But he generally provides well thought, rational responses to people and unlike a great many people around these parts, he does not engage in personal attacks. Where you are seeing that is beyond me.

I “don’t understand” … either I haven’t had the disease or maybe I am “in denial” or “disingenuous” [i.e., a liar] because of “cult-like” beliefs … therefore, I am wrong and you are right on an issue of fact. Sorry, no dice.

Then please, explain it to us. If you actually understand (and claiming you don’t understand is not an insult, fact is that most people don’t understand), then explain how depression works.

To wit: you write well enough that I presumed you’d understand the use of words like “comprehensible” and “reasonable” as used by average people. When a young, otherwise healthy person commits suicide due to depression, indeed it might seem reasonable to him, but not to the rest of us.

Umm, when a young person who is healthy commits suicide due to depression, it is quite understandable to a whole hell of a lot of us actually. It is understandable to people who work with people who are depressed, it makes sense to people who have bothered to take the time and learn something about depression and it makes sense to people who suffer depression. It really is completely comprehensible to a whole hell of a lot of people, because we actually do understand depression.

And when it comes to personal insults, claiming you do know something about depression and deigning to tell people who are suffering or who have suffered clinical depression that when others who suffer the same commit suicide, it is incomprehensible is extremely fucking insulting. Unless you have been depressed enough that you were sitting there wishing you were motivated enough to actually do it – unless you have sat there working out the best way to go about it, that will be the least harmful to the people you care about – or unless you have loved dearly or worked with clients who are suffering exactly that…Do us a favor and just shut the fuck up about it. Consider simply listening to people who actually know what they’re talking about. It might prevent you from making a condescending, ignorant jackass of yourself in the future.
#23 daedalus2u
December 7, 2009

No jane, my argument is not ad hominem, sorry you can’t understand that. Rejecting your argument when you are arguing from personal incredulity (i.e. suicide from depression is not “comprehensible and even reasonable”) is not ad hominem.

Understanding a person’s motivation can only be done from that persons perspective; we have to put ourselves in the position of the person we are trying to understand. I appreciate that you do not understand the motivations of depressed people. You have said so. I take you at your word. I understand that because you don’t understand you need to impute “mental illness”, and “emotional problems”, and all matter of psychopathology separate and distinct from “depression” on people who kill themselves. I understand that you don’t want to understand people with depression.

I am telling you that imputation of irrationallity is not necessary. A completely rational person could want to kill themselves simply because they are depressed, just to end the pain of depression. The pain of depression is not an “owie” pain, it is much more fundamental than that. If you wanted to understand the motivations of people who are depressed and commit suicide, you would be listening and asking questions, not being hyper-critical of insignignificant minutia.

Your comment 16 reads like an anti-antidepressant diatribe, painting big pharma as monsters and criminals, saying “Hey, they were bonkers anyway; whatever happens to them, it must be their own innate weakness to blame.”

You also say “The best available scientific evidence says that these drugs do harm some users. Are “skeptics” supposed to think like climate denialists, who consider science “sound” only when it shows no negatives whatsoever for business as usual?” No, real skeptics weight the evidence positive and negative and give it appropriate weight. All drugs have side effects. All treatments involving drugs must balance the adverse side effects against the therapeutic effects. That balance can only be made by the individual taking the drug. It is only pseudoskeptics who demand zero-harm and zero-risk medical interventions.

The self-perceived quality of life of people who are depressed is lower than the self-perceived quality of life of people with pancreatic cancer or Alzheimer’s. That is why people who are depressed kill themselves at rates that are too high. In the 75+ age group there were 67,045 deaths from Alzheimer’s and only 3,060 suicides. Looks like more than 95% would rather die from Alzheimer’s than from suicide.

So what is your agenda in posting here, other than to hyper-correct my assertion that the number of suicides from depression, 32,637 in 2005 is too high? So what number do you think would be ok?

DuWayne, I don’t dispute that many elderly people may do things that hasten their death because of ill health and those deaths may not be counted among the self-inflicted deaths. I don’t attach a stigma to people who die of depression, even when it is from their own hand. I know that depression is due to physiology, and is treatable, and more people would be accepting of treatment except for the misguided and harmful stigma attached to any type of “mental” illness.

The physiology of depression can be invoked by many diseases, there is vascular depression, depression associated with heart failure, kidney failure, liver failure and other things. People feeling terrible at the end of their lives probably is actual depression. I think it should be treated even if it accelerates death, but that is just my perspective. I think the final common pathway is the same (ATP depletion), antidepressants don’t treat that final common pathway very well because it is too difficult and they don’t have the right treatments (hint it involves nitric oxide).
#24 jane
December 7, 2009

DuWayne, as far as I know you and I largely agree, so I’m genuinely sorry if you were extremely fucking insulted. While I don’t wish to give personal information to a Netful of strangers with the personal malevolence of some so-called “skeptics” who, e.g., accuse questioners of being Scientologist plants, I will say that I have a close relative with emotional issues including long-term (non-suicidal) depression, and a childhood friend with “everything to live for” committed suicide due to manic depression. I didn’t think, when I heard of it, that the act was “reasonable.” It was shocking, because s/he had a loving family, successful career, seemingly good health. If s/he had been rendered quadriplegic or was headed to prison for life, I would have called that “reasonable.” There was absolutely no insult intended by the use of that word. To me, a “reasonable” suicide would be one that others should not try to prevent, whereas if a depressed person told you they were suicidal but had not at least tried drugs etc., you would loudly encourage them to do that instead of killing themselves. If either DuWayne or daedalus2u think this term is an insult to people with depression, I apologize for my ignorance and ask them to suggest a more appropriate way to express this distinction.

I am not, though, ignorant of what an ad hominem argument is, and daedalus2u’s previous messages did include an insinuation that my factual argument could be disregarded because I’m ignorant and/or a bad person. The most recent message by the same poster, though including personal vitriol, does not qualify. Instead, he describes my correction of his factual error as “hyper-critical of insignignificant [sic] minutia.” Sorry, there are plenty of blogs where people can go for comfy emotional support. This is supposed to be a SCIENCE blog, and if you don’t get your facts right, you can expect to be called on it. You slander me twice, and irrationally, in saying I have an agenda to lower the number of suicides attributable by depression: if I did, why would I have been the first to raise the point that more premature deaths may be attributable to depression than were included in your count? As for what the real number is, I do not know and neither do you. If you wanted to use suicide deaths as a rough proxy for purposes of discussion (assuming the deduction of an unknown number of suicides with other motives, and the addition of an unknown number of extra heart attacks, etc.), I could accept that. But you’d better round off the figure a bit.

I do not dispute the scientific studies that show antidepressants help many people with depression (or those that show the same for exercise and dietary supplements, for that matter). But it is increasingly clear not just that SSRIs can inspire some suicidal and violent behavior, but that they can wreck the libido, flatten the affect so you can feel less love for others, or give you weeks of “brain zaps” if you try to get off them. None of these things happen to all users by any means, and it doesn’t mean nobody should use them. It’s likewise a fact that statins wreck some people’s livers or kidneys, but if you have severe hypercholesterolemia, that’s a risk you’ll probably be happy to take. daedalus2u’s little lecture about the need for patients to balance risks and benefits sounds odd coupled with an aggressive attack on a message that really only commented that the risks of antidepressants are real. Patients cannot weight risks versus benefits accurately if everyone conspires to pooh-pooh the risks (as if, for example, we were to just pretend that rhabdomyolysis must be caused by high cholesterol, so don’t try to blame the statins).
#25 daedalus2u
December 7, 2009

jane, I really am not attacking you and am really not making an ad hominem attack. You just repeated that you do not understand how a smart, young person with “everything to live for” can rationally decide that the most important thing for them to do today is kill themselves because they are depressed. That is exactly my point. That is exactly DuWayne’s point. That non-depressed people do not understand why rational depressed people can make a rational choice and kill themselves is a reason why those non-depressed people do not take action to stop depressed people from killing themselves. Depressed people who want to kill themselves can be completely rational and can pass any test of rationality. The myth that only someone who is irrational will kill themselves is just that, a myth, a very dangerous myth. It is not dangerous to people who are not depressed, it is dangerous to people who are depressed.

I will try to better qualify how I am saying you are wrong; I am saying you are correct when you say you do not understand how someone with depression and “everything to live for” could rationally decide to kill themselves. Where you are wrong is saying that someone who is rational cannot rationally decide to kill themselves if they have “everything to live for”. I understand why you think that, you are simply wrong.

I now don’t think you were being “insulting”, simply uninformed and dismissive of people who are more knowledgeable than you. I did think you were being insulting at first and with a definite anti-antidepressant agenda. I tend to come down very hard on such people because of the pernicious anti-antidepressant sentiments that are out there, fanned in large part by Scientologists (which is why I mentioned Scientology). People with untreated depression can be very vulnerable, and untreated depression is life threatening. Scientologists seek such people out to exploit them.

Depression is a very serious and life threatening disorder and needs effective treatment. Anything that inhibits people from getting appropriate treatment is (to me) unconscionable. I think it is unconscionable to PalMD too, I would much rather hurt the feelings of someone who is not depressed than impede someone who is depressed from getting appropriate treatment. If I have hurt your feelings, I apologize. My intent is not to hurt your feelings, but to counter the dangerous misinformation you are spreading.

I have been on antidepressants for over 25 years. They have saved my life. Yes, they do have side effects. No, the side effects are not worse than being depressed. It is extremely patronizing for someone who has never been depressed to assert that the side effects of antidepressants are unacceptable. Many (if not most) people who do so, are doing so because they are dismissing the seriousness of depression. That was the context of my bringing up the 32,637 number. That is a big number; it is 20,000 more than the number that died from HIV. If you do not understand the seriousness of depression (as you say you do not because you do not understand how a depressed person could rationally decide death was better than continued life), then you are unable to make a judgment as to how to balance the benefit of a therapeutic effect with adverse side effects. It is ok that you don’t understand how to do that. Don’t imagine that you do and inject yourself into discussions of that balance and pooh-pooh the risks of untreated depression, thinking that a little exercise, or a few supplements might be enough. Depression is a serious life-threatening disease; it needs to be treated seriously by serious medical professionals.

Of my citation of 32,637 deaths, you said: “Apparently it is a distortion of suicide statistics.” It is not a distortion, it is the number from the CDC report. I didn’t round it, so it appears to give a false sense of precision. I don’t know exactly how the CDC compiles those numbers, but I bet that some official in some office could attach a name and a death certificate to each one of those deaths. Did everyone one of those individuals have a DSM IV diagnosis of depression by a licensed mental health practioner? Almost certainly not. The purpose of a differential diagnosis is for differential treatment, not to have something to put on a death certificate. Depression is not something that can be diagnosed postmortem, it takes an interview. You call my equating of suicide deaths with depression deaths a “distortion”? I threw it out because it was a big number. I used the precise number because I happened to have it because I have the paper I cited it from.

You are right, we don’t know how many of those people were depressed and how many killed themselves for other reasons. To me it doesn’t much matter. People are extremely ready to deny depression in friends, aquaintences, loved ones, even in themselves, they see it as “weakness”. It can even be a way to mitigate the depression. That is unfortunate, it is very sad that people are unable to get the help they need because they will be perceived as being “weak” and make themselves a target for bullies and other perpetrators. Another thing I find very sad is when I drive around New England and see old cemetaries where there are graves outside the cemetary wall. That was the custom, to bury people who had killed themselves not in the cemetary because suicide was against God’s law and such people couldn’t be buried on hallowed ground.

I am very sorry that your friend killed him/herself. I have never lost a friend to depression. Not putting my friends and family through that has been one of the things that has kept me alive at times, before I had antidepressants that worked. Knowing that there but for the grace of God go I, is one of the reasons I have a short fuse regarding depression and its treatment.

The context of the comment was in a post about distortions on HuffPo regarding how to deal with bullying and depression by the military.

http://www.nytimes.com/2009/12/07/us/07therapists.html

How they are approaching it is unconscionable. It is not effective treatment, it is nonsense, it is abuse instead of treatment.
#26 jane
December 8, 2009

daedalus2u, your above message is filled with statements of “you say…” (or “assert,” or “repeated”) followed by statements which I did not in fact say (and do not believe). Clearly, this subject is so sensitive for you that you aren’t able to discuss it unemotionally, so it’s best if we drop it. I will just suggest that next time you are getting ready to mock or berate someone who has gotten upset because you deliberately or accidentally challenged an opinion he’s deeply attached to, you recall the emotions you felt here that inspired you to speak as you have, and consider that your target’s emotions are no less valid and meaningful than yours.
#27 DuWayne
December 8, 2009

…and a childhood friend with “everything to live for” committed suicide due to manic depression. I didn’t think, when I heard of it, that the act was “reasonable.” It was shocking, because s/he had a loving family, successful career, seemingly good health.

I am sorry Jane, losing someone you care about to suicide really sucks. I have been there too.

But I want to point out the erroneous assumptions you are making here, because they are important. I am bipolar and while it is type II, which is probably not what your friend had (bipolar = manic depression), I have some inkling of what she was dealing with.

First and absolutely most important thing to understand – she was not in seemingly perfect health. She had serious neurological issues, a problem that is still really hard to treat and if she had been diagnosed with manic depression, it happened at a time when the treatments were even shittier. She was probably bounced around on her meds, getting switched from this one to that, onto something else – every time throwing her head into a major fucking shitstorm, while she got off teh old and used to the new. On top of that, as it came closer to time for another drug change, she was losing emotional stability. Trust me when I say that losing emotional stability is really shit – cycling, is really shit.

She was not anywhere near perfect health. The problem is, she had lived with it for so long, most people probably didn’t notice. But I can bet you her family did and I can bet you they have absolutely no desire to talk about it.

The reason we call it reasonable, is because we have either been there personally or been there with people we love. For me it is both. It is reasonable, because for a lot of people with neurological issues – in my case, bipolar, ADHD and unipolar depression – we get to teh point where hate how our minds make us feel. For me it was when I was a small child and I finally realized that the people around me were just smiling and nodding at my ideas, because they had no idea what the fuck I was talking about. I am really smart and I was then. I wanted to die when I was about seven or eight, because very few people in my life could actually comprehend what the hell I was thinking – our head librarian being one of the few. I ended up creating an entire world in my head and decided to live there. I also decided after a while that I didn’t want to die persay, but I would certainly do nothing to stop it. Then I became a young adult and discovered sex, drugs, hitchhiking and music.

Not terribly long ago, having failed at a small business, I seriously considered how much more valuable the social security my children would be entitled to if I were dead, than if I were not. Why? Because I was tired of coming so very close, so very often, only to fail yet again, because my head is so very fucked up. I hadn’t been on meds since childhood and wasn’t sure how the fuck I could actually get on them – there weren’t any healthcare options available to me and I lost my family’s apartment.

It made perfect sense to me at the time. The only thing that held me back was the idea that my children’s mother is not in the best mental health either. And because my kids have enough going against them – they need me to take care of them. But I could have done it. Could have done it and it would have been an entirely rational decision, if not the most intelligent.

Living in the head of someone with neurological issues is not easy. Often times it is unbearable – takes every bit of will to get to the next fucking breath, the selfloathing is so very intense. You have no idea how very rational and reasonable suicide can be, until you have sat for hours, clutching at your head, wishing you could rip your fucking broken brain right out of your head (that would be a loved one, not me – though I have had very similar experiences). You have no idea how reasonable suicide might be, until you have knocked yourself unconscious, beating your head bloody against a wall, hoping it will slow your mind down just for a little while, just so you can fucking sleep.

Death is entirely rational, when you are suffering through ever fucking breath. The major difference between us and people with terminal injuries or illnesses, is that sometimes what we have is treatable and you can’t actually see that we have it.
#28 DuWayne
December 8, 2009

Just to make myself clear, I wasn’t trying to be malicious Jane. I noticed that came off as rather harsh, which was not my intention. You honestly seem to want to understand and I wanted to explain.

I sincerely apologize if that was too much.
#29 jane
December 9, 2009

Accepted. I can understand that the subject is an emotional one for you, given those experiences. And I certainly also understand that such pain is real, and is a real illness; that’s why I said my old friend had been in “seemingly perfect” health. S/he had not made his/her struggles public, and almost nobody had any suspicion of what s/he was going through.
#30 GSeattle
December 12, 2009

It comes across like: “Nevermind the fact that he’s a Professor Emeritus, a contributor forwarded an opinion/theory in the Huffington Post and we don’t like the Huffington Post so lets ignore that as a possibility and focus on anything except”. It is putting one’s head in the sand.

Would prefer to hear: “A lot of people are concerned about the possibility that SSRIs/antidepressants might have been a major contributing factor (as they are proven to be so often before) so lets do the research, gather facts and find out”.