Blood Test for Suicide - Are We Humble Enough for Such a Tool?

People are afraid to even say the word suicide, none the less ask a suffering person if they've thought about it. And now they have a blood test for it? 

Is our world ready?

Well, John's Hopkins psychiatric researchers are developing one.

The researchers have discovered a mutation in the SKA2 gene that predicts suicidal thoughts and behaviors. To grossly simplify what this means (for a more complete explanation, see this Science Daily article: Blood Test for Suicide). The gene SKA2 works in the prefrontal cortex, the part of the brain in charge of decision making and impulse control, keep cortisol - the stress hormone - from flooding this important part of the brain. When the mutation is present, there is too little SKA2 and the cortisol is able to flood the prefrontal cortex, keeping the brain from suppressing negative thoughts and dangerous impulses.

In a recent trial, low levels of SKA2 predicted with 96% accuracy whether a participant had attempted suicide or not. Levels of SKA2 were highly related - 80% - to thoughts and attempts of suicide in earlier trials.

An assistant professor at John's Hopkins, Dr. Zachary Kaminsky, summarized it well, "We have found a gene that we think could be really important for consistently identifying a range of behaviors from suicidal thoughts to attempts to completions."

The Science Daily article indicates the use for such a test would span from tests of military personnel to emergency room visits. The military could test for the genetic mutation to see if a individual is vulnerable and have them monitored after deployment. Emergency room personnel could use the test to help assess risk of suicide in making decisions about hospitalization.

Sounds great, right?

It is easy to make the assumption here that one suicide prevention is solely predicting "a range of behaviors from suicidal thoughts to attempts to completions," but this is the farthest from the truth. 

Suicidality is not a constant state. Just because a test can predict with 96% accuracy whether a person has attempted suicide in the past does not mean they will attempt the day the test was taken. 

Suicidal thoughts do not equal suicide attempts. Most people in their lives think about suicide at least once in their lives. Only 38,000 people in the United States die by suicide in 2010 according to the Center for Disease Control. The Los Angeles Suicide Prevention Center, one of the National Suicide Prevention Lifeline centers, gets 70,000 callers from suicidal individuals or their loved ones every year. Only about 5% of those callers would fall under the category of high risk, and even fewer require a visit to the emergency room or hospitalization.

Further, hospitalizations are not always therapeutic for a suicidal individual. A prominent psychiatric stigma researcher, David Roe, warned of the pervasive "culture of 'doctor/judge/lawyer always knows best'’’ when all too often the patients' experience of hospitalization is not taken into consideration or simply not well understood (Roe & Ronen, 2003, p. 322).

The article goes one to describe the experiences participants shared in his study:
            "Describing the impact his hospitalization had on him, Ron said 'It shook my foundation, made me uncertain about everything.' On the most basic level, leaving the familiar environment in which one lives, the routine and activities in which one is engaged, and becoming a patient in a hospital with its novel set of rules and expectations can be quite traumatic. Furthermore, hospitalization bears a powerful statement about one’s limited competence and capacity for independence. In addition, the experience can threaten one’s self-concept by promoting negative appraisals of self" (Roe & Ronen, 2003, p. 322-3).

So can we blame people for not wanting to be hospitalized?

It is important to keep in mind that a blood test is not the only way to find out about suicidal thoughts and behaviors. When working for two years on a suicide prevention hotline I could get this information on a phone call or even an online chat. Just. By. Asking.

Is this because I'm special in some way? While I have had a lot of training and experience, the act of asking a person if they are suicidal can be done by anyone. And in my experience people will generally answer with more detail than one would expect.

What a blood test provides is hard evidence - it takes out the guesswork. It's a number on a paper. Researchers like this. People who offer research grants like this. Insurance companies like this. This is a test that satisfies the powers that be. (Which, frankly, we need. Funding for this kind of research is vital and if this helps get it, more power to you.)

What a blood test does not do is treat suicidal thoughts, behaviors, or attempts. But asking about them can. 

Talking to a person about suicide can help them relieve stress, show them desperately needed support, and actually helps to reduce risk in and of itself. No blood test can do that.

The only time asking about suicide does not give the same information as a blood test is when the individual decides to lie. Definitely good information, but it is vital to know why a person would lie about suicidal thoughts or behaviors. 

The most common reason a person won't admit to them is when they believe that admitting to them would result in a police officer at their front door - to involuntarily commit them, as it were. (Though this very rarely happens.) It can also lead to prejudice or discrimination.

In fact, some job, government, and school applications require that applicants report any involuntary commitments. (It is notable that this question usually is asked in the criminal record section of applications.) Involuntary commitments can therefore lead to blatant discrimination.

So is a suicide blood test useless? By no means. But we must always keep in mind that the reason for it is to benefit the patient. We have to be humble enough to know what a blood test can do and what it can't do. We have to keep in mind that even experts may not know what is best for a patient and that bureaucratic decision can result in traumatic experiences. 

A suicide blood test must be used with humility. And I'm not certain we have that yet. 



Based on the article in Science Daily:
http://www.sciencedaily.com/releases/2014/07/140730043402

Cited:
Roe, D & Ronen, Y, (2003). Hospitalization as experienced by the psychiatric patient: A therapeutic jurisprudence perspective. International Journal of Law and Psychiatry, 26: 317–332.

CDC Fact Sheet on Suicide: http://www.cdc.gov/violenceprevention/pdf/suicide_datasheet-a.pdf

A little about my research...

You would rather kill yourself than seek mental health treatment?

Taking calls on the Suicide Prevention Hotline I asked myself this question dozens of times. What's going on here?

Stigma. Stigma against mental illness and psychological help-seeking. 

And I'm going to fight it. 

The stigma of mental illness is one of the most powerful and pervasive stigmas that exists today (Bathje & Pryor, 2011). I once stood at a bus station when a man with schizophrenia hobbled up. People backed away in open fear and disgust. Against what other group of people do you see such blatant discrimination?

The same stigma that literally keeps people from seeking treatment that could drastically improve or, in some cases save lives. 

I will be going to Israel this summer to work with working mental illness stigma researchers and advocates. My research is focusing in on the way this stigma shows up in religious communities - an area that has had exceptionally little research. The researchers in Israel have already made progress in this and other areas of mental health stigma. I will be able to work with them to learn what they know and to collaborate in future research to uncover and combat this stigma.   

My long term goal is to apply my research to systematically combat stigma in communities and help them understand what they can do to help, instead of hurt, those with mental illness.


To check out what's going on with my trip to Israel, check out my new blog: www.lilysisrael.blogspot.com

Who cares about mental illness? Well, maybe we should...

Are our attitudes so important they should keep individuals from getting the help they desperately need?

Right now, negative attitudes about mental illness, stigma, are doing just that. According to a recent survey by the American Psychiatric Association, one in three Americans believe that a major cause of mental illness is emotional or personal weakness is a major cause. Let’s be honest, why would we treat weakness? 

Well, let’s look at the impact mental illness. According to the 2009 National Survey of Drug Use and Mental Health (NSDUH), one in five adult Americans suffered from a diagnosable mental illness. With that in mind, consider that one in two prison or jail inmates have one. In fact, largest psychiatric hospital in the United States is Twin Towers Correctional Facility - the Los Angeles County jail. Deaths from suicide, which are inextricably linked to mental illness, are twice as common as those from homicide. In fact, while the percentage of deaths from homicide, traffic accidents, coronary disease, and cancer have all decreased in past decades, suicide has not. But let’s consider those who may not be committing crimes or attempting suicide. What is the leading cause of disability in the US and Canada? Not back pain, not diabetes, not heart disease, it’s mental illness.

We still talking about emotional or personal weakness here?

And yet that very attitude, that mental illness is just weakness, perpetuates all these problems. The NSDUH also found that whose functioning was seriously impacted by mental illness, less than sixty percent received mental health treatment. It is staggering how many people needlessly suffer from mental illness when there is effective treatment.

This is my research - addressing mental health stigma through intervention. In fact, you are taking part in it right now. This is an intervention. The stigma has been named, its effect described, the assumption challenged. My next step is to measure the impact of my intervention.

So here’s the question, what are you going to do next? 

Sources:

APA Survey/NAMI

https://www.nami.org/Template.cfm?Section=top_story&template=/contentmanagement/contentdisplay.cfm&ContentID=33805&title=Public+Still+Lacks+Mental+Health+Knowledge

Suicide/NIMH

http://www.nimh.nih.gov/about/director/2014/a-new-research-agenda-for-suicide-prevention.shtml

Serious Mental Illness/NIMH

http://www.nimh.nih.gov/statistics/SMI_AASR.shtml

http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml

MH Prevalence Rates/SAMHSA - National Survey on Drug Use and Health 2009

http://www.oas.samhsa.gov/NSDUH/2k9NSDUH/MH/tabs/TOC.htm

http://www.oas.samhsa.gov/NSDUH/2k9NSDUH/MH/tabs/Sect1peMHtabs.htm#Tab1.1A

Bureau of Justice Statistics

www.bjs.gov/content/pub/pdf/mhppji.pdf‎

LA County Jails & Mental Illness

http://www.lasdhq.org/divisions/correctional/mh/

Efficacy of Stigma Interventions

http://bjp.rcpsych.org/content/182/4/342.full

Bet My Suffering is Worse than Yours...Or is it?

It's striking how many people don't feel like they aren't allowed to be hurting.

I take 3-6 crisis calls and chats every week at the Suicide Prevention Center in Los Angeles, CA and every week, sometimes multiple times a week, individuals tell me that they don't want to burden me with their problems - even when it's literally my job to listen when I'm on the lines. I hear friends tell me the same thing over and over.

How often I hear people tell me that other people have been through worse - they don't want to complain.

What they mean is they don't feel like they have the right to complain. They don't have the right to feel as if they are suffering.

We see images of emaciated children in Africa and we think, "What right to I have to call anything I experience suffering when I have clothes on my back and some extra belly fat?"

We see images of Jews in concentration camps and we think, "What right to I have to call this suffering if I haven't experienced that level of persecution?"

It's as if suffering were some kind of competition.

As one person who called the Suicide Prevention Center eloquently put it this way, "If someone is happier than I am, does that mean I'm not happy?"

So often people tell a person in very real suffering that their suffering is nothing. That they shouldn't complain. Sometimes even that they are going through nothing compared with themselves. Too often when we try to share the difficulties we are going through who isn't weary of that one person who's just waiting to one up us.

But this kind of thinking simply doesn't make sense.

So what happens when we act like suffering is a competition? Then only one person can win. Only one person - or group of people in the case of the Holocaust - are allowed to win. The rest of the world isn't allowed to suffer.

We belittle the pain of the person trusting us with something very personal and fragile. By belittling their pain instead of trying to understand it, we push them further away, putting them in even more pain.

It can be difficult to understand why a child who has gone through abuse most of their life names the death of their dog is their most traumatic moment, certainly. But when one stops to consider that if their parents, their siblings, their aunts and uncles are there to be safe and welcoming form of love, then a dog becomes the only source of love they can depend on.

Take that away and what do they have?

My suffering will never look like yours and will most certainly never look like that of Elie Wiesel, the author who wrote a memoir about being a victim of the Holocaust.  And if we expect it to then we will miss the truly most important thing about another human being - what hurt them the most deeply.

Suffering is not and will never be a competition. If it were, then even Elie Wiesel could never win. Because even he could never be truly understood.

Snapshot of Mental Illness: Naïveté

Naïveté

Naïveté. Entrapment of cathartic desire
concealed beneath folds of misapprehension.
Naïveté beckons with demonic undertones
to desire the horrific. Naïveté envies
through silent anger victims of rape
and vicitms of burns and lacerations paid
by their fathers' violent anger. 
A wise, a saner voice asks 

why empathy extends only to victims of drunk 
and violent fathers, or perhaps a Munchausen mother
by proxy, poisoning her son's oatmeal. No pity

I ask, for pity may smother more. No. 
Neither squirming nor shock at my story. No. No more. 
Not your first uncomfortable visit to the world
of residual "emotional dysfunction" from 
an unprotected childhood. No more do I want to be
your token freak, your one-uppance in tales of mistfortune. 
Like a ghost of story. No. 

I beg your silence, your ears.
And perhaps if you too can sit in pieces
of broken innocence, I beg but your companionship,
your arms around my chest, my chin 
allowed on your shoulder despite
the tears soiling your shirt.

But instead I find naïveté painted
as reality. 

Naïveté: (to) consider the reactions of the sane 
to the insane as naïveté.

No empathy. Only fear, repulsion that makes pain 
keen. 

Then worse. The verdict. 
The two sentence answers to lifelong battles
fought in the demon dark corners 
of a haunted mind. I don't interrupt anymore.
Just see naïveté.

Naïveté: (to) consider the reactions of the insane 
to the sane as naïveté.

Until the "h" word broke through the stupor. 
Hospitialization.  
Wait, me? Yes. Then, oh, temptation of escape. 
Wanting nothing more than a pillow, sinking into covers
staring at a wall. With others. Like me.
So perhaps this is, as they say, a sever mental illness. No more. 
No more no more no more. Naïveté.

Unpacking the Insanity Plea: Looking at Suspected Murderer James Holmes' Not Guilty by Reason of Insanity Plea

http://www.nytimes.com/2013/06/05/us/suspect-in-colorado-movie-killings-enters-insanity-plea.html?_r=0


Not guilty by reason of insanity means you don't have to be punished for your crimes - right?

Definitely not.

Before we get to the issue of punishment though, let's make sure we have a firm grasp of what the Not Guilty by Reason of Insanity plea (NGRI) is.

The NGRI is a unique plea not only because it references mental illness, but because it is saying something seeming paradoxical - the individual has committed a guilty act without having a guilty mind.

What? We watch law and order and time and time again it's about proving that it was Joe that killed Mary. So if there's no question there, then what are they talking about? What's this "guilty mind" nonsense?

Well, lets talk about insanity. Insanity, despite the way we throw it around everyday, actually has a stringent legal definition. It is a "mental illness of such a severe nature that a person cannot distinguish fantasy from reality, cannot conduct her/his affairs due to psychosis, or is subject to uncontrollable impulsive behavior. Insanity is distinguished from low intelligence or mental deficiency due to age or injury." (http://legal-dictionary.thefreedictionary.com/insanity)

The crux of this definition is the severity of the mental illness. Even if a person is in the midst of a psychotic break it is extremely unusual for them to be so completely impaired that they they think they are holding a banana when they are actually holding a gun. Another example of a severe mental illness is if the individual was so out of touch with reality - so utterly in the throws of a delusion, for example, that they honestly believe that if they don't kill their son then he will be tortured in hell for all of eternity. So they kill their son.

The NGRI, then, is not a trial whose goal is to determine whether the individual committed a crime, rather it will be based on "the issue of the defendant's insanity (or sanity) at the time the crime was committed." (http://legal-dictionary.thefreedictionary.com/insanity)

 So let's skip to the end, let's say that an individual actually goes through a trial, and the verdict is Not Guilty by Reason of Insanity. (Which less than 10% of individuals who attempt this plea succeed in doing). Does the individual go free?

By no means. The individual goes to a state mental hospital until they can prove that they are no longer a threat to society due to their mental illness.

This means that the individual may actually spend more time locked away from society than they would have in jail.

A infamous example of this is John Hinckley, Jr. - the man that attempted to kill then-President Ronald Regan in order to win the love of teen actress Jodie Foster. His conviction was not guilty by reason of insanity.

He is still in St. Elizabeth's Hospital in Washington, DC. He has been there more than thirty years.

The Blessing of Mental Illness

I have come to realize that the exertion of wrestling with the monster called Mental Illness has enabled me to lead others toward life.

In the New Testament of the Bible, there is a story of a man born blind. Jesus' disciples asked him, "Who sinned, this man or his parents, that he was born blind?”
  
"Neither this man nor his parents sinned,” said Jesus, “but this happened so that the works of God might be displayed in him."

 I heard this story and for most of my life never understood it.

To a certain extent the disconnect is cultural. Our society sees a man or woman who is blind and we chalk it up to genetics. Blindness has nothing to do with this or that person's sin. The concept is completely foreign. (I will come back to this in a moment.)

But there is a far deeper level here as well that, frankly, repulsed me: why would God make a person suffer so that he might gain fame? Why would God give someone cancer or lupus or tuberculosis or leprosy so that He can heal them and amaze any onlookers? Isn't there a way to amaze without inflicting so much pain?

To consider the problem from a less spiritual point of view, we can return to this cultural assumption that illness or disability is caused by some sin. We may not think this true about a slipped disk or autism but this is the standard assumption, otherwise called the stigma, about mental illness.

Why does that person have major depression? Because they made terrible life choices or they are weak or their parents mistreated them when they were children. Because they didn't pray enough or try hard enough. Not because they have a illness that needs treatment just as much as diabetes.

The similarity is striking to me in particular because I have been in treatment for chronic major depression for six years and have likely had it for most of my life. In addition I was a psychology major focusing in on mental illness and have worked in clinical psychology research labs and as a mental health paraprofessional on a suicide prevention hotline.

And still I think I have this mental illness because I am doing something wrong. Because I've sinned. Because I'm weaker than other people. In many ways I believe the stigma.

And there was definitely a part of me that saw the story of the blind man and wanted to revolt against the vanity in it.

But recently I've come to understand this story from a different point of view.

I may still have some part of me that believes the stigma but I've also broken loose of its most restraining bonds. It was not without tears of shame and self-loathing that I went to therapy the first time. How worthless I felt going to a psychotherapist - I have to pay someone to talk with me.

But I went. And I over the years I came to realize that the problem I had wasn't normal. I was reading C.S. Lewis' description of his grief after his wife passed away and I shut the book thinking - what's the big deal, this is what my life looks like at least a couple months out of the year. I didn't think much of it until a good friend, who also struggles with depression, described to me her grief after her father passed away. She said that it was as though she was going through another depressive episode, only there was a reason for it.

And I realized. The depth of despair and suffering in the midst of severe depression is comparable to the grief after the death of a loved one. Only there's no understandable cause.

This is what it means when people call Major Depressive Disorder an illness.  And an illness should be treated by a healthcare practitioner.

So what does all this have to do with the concept "that the works of God might be displayed in him?" 

I, a woman who has nearly drowned in the cesspool of depression, became a suicide prevention counselor on the National Suicide Prevention Hotline. I've come to realize that because I somehow dragged myself out I've been able to guide others how to escape. 

I've literally saved lives because I, too, have suffered.