rarely, if ever, available…

Posted on Friday 15 August 2014

But our discussions of mental illness rarely focus on this inconvenient truth: these illnesses are currently just as fatal as the “big killers.” We must continue to invest in research to develop new and more effective treatments for people with depression and other mental illnesses. The goal must be a future in which no lives are lost as a result of suicide.

“It’s very important that we stop seeing these illnesses as false and stop blaming patients and see them for what they are — which are medical conditions, genetic conditions, brain disorders that require appropriate diagnosis, treatment, care, and support,”
APA President Paul Summergrad, M.D., on NBC Nightly News

I sincerely doubt that there will come a time when some pill will come along that will quickly whisk away the kind of profound depression that Robin Williams was apparently suffering. He was no stranger to feel better pills, and chose not to take them – to his credit.  There were a myriad of risk factors we know about: waning celebrity; financial problems; a cancelled tv series; the diagnosis of Parkinson’s Disease [which can be associated with Depression over and above as a stressor]. He was sleeping 18 hours a day and had no appetite. In his last picture, his weight loss is obvious.

I don’t want to pile on with after the fact analysis. There’s plenty enough of that coming from everywhere. But there is one thing that needs saying. A mainstay of treatment for patients with this kind of profound depression is hospitalization. And one of the reasons is protection from suicide. This is the kind of depressive illness that got lost in the 1980 DSM-III Revision that lumped it in with the more usual depressive illnesses – once called neurotic depression. Independent of one’s theories about the etiology or nosological preferences, impulsive suicide is a constant risk in such severe depressions, so protective hospitalization is a big part of any rational treatment plan – or at least it was. Managed Care and the psychopharmacological revolution have essentially eliminated the kind of mental hospitalization such patients need. It’s a paradox that with all the modern talk about depression, this kind of depression with delusional hopelessness and unbearable pain has gotten lost in the shuffle.

In June, Robin Williams checked in to the Hazelden Rehabilitation facility. not because of a relapse, but for a "tune up" of his sobriety. Maybe people do that, but I’ve never heard of such a thing. My guess is that he was looking for help in the only way he knew how, but that’s not what he needed. This kind of Depression is uncommon, but in a modern world, the "diagnosis, treatment, care, and support"  that Dr. Summergrad mentions are rarely, if ever, available for these particular patients…

"…the pain of severe depression is quite unimaginable to those who have not suffered it, and it kills in many instances because its anguish can no longer be borne. The prevention of many suicides will continue to be hindered until there is a general awareness of the nature of this pain. Through the healing process of time — and through medical intervention or hospitalization in many cases — most people survive depression, which may be its only blessing; but to the tragic legion who are compelled to destroy themselves there should be no more reproof attached than to the victims of terminal cancer."
    August 15, 2014 | 10:37 AM

    Mickey, I am going to avoid commenting on Robin Williams but instead, focus on general suicide issues.

    If psychiatry and the mental health profession was truly interested in listening to the perspectives of suicide survivors instead of talking over them, maybe things would improve. Many of them have constantly said that inpatient hospitalization was not helpful and only made them feel more suicidal. It was only when they found supportive peer counseling that they began to improve.

    One poster from the MIA board, Steve McCrea whom I believe works in mental health advocacy has said that when he worked suicidal hotlines, simply acknowledging that their suicidal ideation was an understandable reaction to their life circumstances did wonders in making people feel better. Listening to patients seems to have disappeared among many of your colleagues and instead let’s just drug people to the gills which will do wonders for their depression by making them non functional. NOT!

    No, this is an anti drug message. Even as opposed as I am to them generally, I realize they have their place.

    What I am opposed to are people who are understandably despondent being put routinely on antipsychotics when they are hospitalized who don’t have a history of delusions.

    Anyway, I know I am rambling but I will leave you with this message. The same old, same old practice of medicalizing suicidal ideation is not helpful. But unfortunately, no one seems to care.

    August 15, 2014 | 10:44 AM

    I more or less agree with your points, save one. A patient with this particular kind of depression left alone is always a suicide risk. Delusional hopelessness is not a casually chosen term.

    I sincerely doubt that there will come a time when some pill will come along that will quickly whisk away the kind of profound depression that Robin Williams was apparently suffering. He was no stranger to feel better pills, and chose not to take them – to his credit.

    August 15, 2014 | 1:10 PM

    I love Robin Williams. I’m just glad he’s happy now. Though I’m still very sad that he was in so much pain. I hope when I die I can see him perform live at the pearly gates.

    August 15, 2014 | 1:18 PM

    Aside from Robin Williams, I think the idea that depression can be ever so successfully exorcised with a pill alone, allows people that should be supportive to put the person suffering at arm’s length while telling them to get a prescription. The common social expectation that someone should get better and be restored with an antidepressant can be oppressive, especially with those who are labeled as “treatment resistant”.

    I agree with you Mickey about a person’s need to get respite and to be taken care of and monitored when in the throes of hopelessness, helplessness, and dark thoughts; but hospital staff treating a person like they might blow up at any moment while pushing pills, giving weird exercises in “art therapy”, glib little group meetings teaching “coping skills” that appear to have come out of a women’s magazine, and being given the message over and over again that what you’re suffering is irrelevant— just take the drugs— doesn’t really help a person to deal with themselves because their selves are being denied.

    And for Robin Williams and other celebrities, I imagine it’s even less likely that their selves will be acknowledged and taken into account— in the eyes of most others, they’re the characters they’ve played.

    It can be the least worst option to be hospitalized, and some people truly benefit from it; but without treating the person, biological reductionism limits responses and avenues of coping.

    August 15, 2014 | 1:20 PM

    And, as you may know, I’m not opposed to medication in general, it’s just not a good substitute for empathy and humanity.

    Bernard Carroll
    August 15, 2014 | 3:38 PM

    This thread tells me we have a long way to go in achieving a general understanding of malignant mood disorders. To reverse the expression of an earlier commenter, the same old, same old practice of demedicalizing malignant suicidal ideation is not helpful. Neither is it helpful to suggest that empathy and humanity are the most needed interventions. Malignant mood disorders – what Dr. Mickey calls showstoppers – place the patient in a different clinical ballpark from those with existential issues who can be talked down through a suicide hotline call.

    August 15, 2014 | 3:39 PM

    In Robin Williams’ case, I don’t quite understand why he didn’t get into a psych hospital. Were his financial problems that bad? If you have $40,000/week cash available, you can go to the places that don’t take insurance, e.g., McLean’s Pavilion or the Retreat at Shepard Pratt. The Pavilion–despite being luxurious–is still a locked unit.

    August 15, 2014 | 4:24 PM

    A few points here that I hope are at least pondered:

    1. MIA is just selling in repeated posts of late that psychiatry should not exist, and that people should not only have the right to commit suicide, but that it is wrong to intervene. That , folks, is as insincere and dangerous an agenda I have read from the abolitionist rhetoric up to now.

    2. It is now Friday, and I have yet to read Robin Williams was on any psychiatric meds, so this speculation has to be called on it, simply speculation, so the gospel talk of “yet another victim of SSRIs/psych meds/inappropriate medicating” has to shut up until facts are stated.

    3. The outing of yet another APA president who is only selling the “Biology is the only intervention” message is now clear, per the quote above:

    “It’s very important that we stop seeing these illnesses as false and stop blaming patients and see them for what they are — which are medical conditions, genetic conditions, brain disorders that require appropriate diagnosis, treatment, care, and support,”
    APA President Paul Summergrad, M.D., on NBC Nightly News

    Man, people in the hierarchy of the APA won’t change, give me a break to think otherwise!

    August 15, 2014 | 8:11 PM

    I agree with Dr. Carroll. Love and empathy are no match for melancholic depression. They might help, but only when combined with ECT. But organized (aka academic) Psychiatry is to blame for the misperception that love is enough– hell they dumbed down depression to encompass all forms of sadness, a lot of which does respond to support, empathy, and insight. The field reaps what they sow. And so do, unfortunately, our sickest patients.

    James O'Brien, M.D.
    August 15, 2014 | 8:58 PM

    I’ve made this point elsewhere, but I’ll repeat it: I agree with Anna Freud that humor is a mature defense mechanism…against anxiety, but not in malignant mood disorders when it is expressed not as a defense, but often as a symptomatic compulsion.

    August 15, 2014 | 8:58 PM

    Do we know that he was suffering from melancholic depression? As I said, I have no problem with medication, but the fact that he was diagnosed recently with Parkingson’s is surely relevant. I don’t doubt that he may have benefited from hospitalization and treatment but I don’t assume that he would have not committed suicide had he been hospitalized. I don’t get why everyone has him diagnosed, and still think that the treatment should include acknowledging a person’s situation. Do people who aren’t melancholic commit suicide? Does having committed suicide prove that a person had a mood disorder?

    August 15, 2014 | 9:44 PM


    Of course we don’t know for sure. At least I don’t. But the descriptions of his state of mind, his weight loss, his sleep disturbance, his anxious depression certainly point in that direction. I was making my point because nowhere in all the commentaries did I see anyone mention protective hospitalization and it needed to be said.

    Patients with this kind of profound depressive illness are the ones where the term “mood disorder” is accurate. Their depressed mood drives their thought. I’m a psychoanalyst/psychotherapist who’ll talk until the sun comes up, but with these patients in the midst of their despair, they are so driven by how they feel that you can’t make a dent in their hopelessness and self loathing. And as soon as you leave the room, they return to that state Styron is describing. That’s why they need protection.

    But in response to your specific question, I don’t know he had Melancholia – it’s a speculation – something that certainly needed to be thought about. And you’re right, suicide is not limited to Melancholia, though, as Styron says, that’s a place where it’s always on the table – throughout the illness and even during the time when they’re improving. Likewise, of course his situation matters and we don’t know if he was on meds for PD which also matters. My point is only about the very real danger of suicide in severe depressions of the type he likely had.

    August 16, 2014 | 1:14 PM

    “but with these patients in the midst of their despair, they are so driven by how they feel that you can’t make a dent in their hopelessness and self loathing.”

    I had a dear well educated intelligent friend commit suicide last year and I knew she was in black despair. I listened to her describe her despair and tried to help. After talking with a friend who was a therapist she told me suicide seemed to be from continuing stress of events. Not one single event but one after another. My friend had stressful events happening on top of feeling lonely and she felt they was no answer. Robin Williams had several depressing events happen to him and for him the weight of them became too much.

    Bernard Carroll
    August 16, 2014 | 3:48 PM

    Here is a new commentary from Kay Jamison, who knows whereof she speaks:

    August 16, 2014 | 5:28 PM

    I should have also said, Dr. Nardo, that longer hospitalization should be an option for people who need it, though I have no idea of the likelihood of them getting helpful treatment and have good reason to think the odds aren’t great. I’m guessing that they’re just as likely to be given a whole slew of drugs that make them feel worse or be given too much ECT. In other words, they’re likely not to be treated for melancholia, but Major Depressive Disorder and to be labeled “treatment resistant”. Arguably, such things might happen and may be a result of a rushed effort because it’s difficult for people to get longer stays when necessary. The structures of our medical/mental health care system cannot be separated from the kind and quality of care— our for-profit health care system and insurance policies operate on the short term, as you know all too well.

    Psychiatrists don’t have a good record for predicting suicide, nor is melancholia acknowledged in the mainstream. Since suicidologists are just now listening to people who have attempted suicide in order to try to gain a genuine understanding of it, I kind of want to see more openness about suicide, rather than the popular assumption that the person was suffering from “depression” and antidepressants would have prevented it. The public perception of “depression” and medication is simply too broad and doesn’t account for other medical illnesses that just appear to be depression. And most people never heard of melancholia, nor have they been exposed to critical psychiatry.

    It would be great if this could all be sorted out and it became widely understood that some people need longer hospitalization, along with more specific clinical research to separate melancholia from Major Depressive Disorder. I think you and Dr. Carrol would know melancholia when you saw it, and would be more likely than most to treat it successfully— if you and the sufferer were given enough time and you were allowed to use your judgment instead of being pressured or forced to use an algorithm generated for a general category. I don’t trust most to be so knowledgeable and discerning.

    There is some correlation between SSRIs and asphyxiation near the floor (I think)
    — as opposed to hanging from a height. It’s a common method that may be attributed to the effects that earned SSRIs the black box warning as is stabbing oneself to death.

    Any way we look at it, a person has to be in a very dark place to want to take their life, and should not be alone.

    August 16, 2014 | 9:32 PM

    I agree with wiley, surely his physical illness was relevant. Parkinson’s would have taken away a great degree of his expressiveness. He was young for it, and those cases progress faster.

    I can only imagine what this would have meant to the performer Robin Williams.

    I’m always uncomfortable with the post-suicide psychoanalysis, which tends towards each pundit using the case as an example of his or her favorite pathology. Each suicide is an individual act. It should be honored as a individual act, not a projection about the effectiveness of this or that remedy.

    Each suicide is a mystery. Only the person knows the exact reasons.

    Robin Williams met a sorrow he felt he could never overcome. We will never know what it was. It might well have been the specter of advancing Parkinson’s.

    As a person who’s lost much faith in medicine, particularly psychiatry, for excellent reasons, I can understand why Williams might have looked at his options and chosen the one he did.

    It’s sad those who loved him have lost him so soon, but that was his choice and it should be respected.

    James O'Brien, M.D.
    August 18, 2014 | 2:54 PM

    I’ve read recently that he was making plans for the future on the day he suicided and there was no obvious indicator of impending suicide. I’m not sure hospitalization would ultimately make a difference or even be theoretically possible. I don’t think any one of us would have insisted on a 72 hour hold given the information we had in advance. If he had been in the hospital he’s eventually going to leave as he did with Hazelden.

    I agree that this is already being overly Monday Morning QBd….sometimes horrible things happen and there’s nothing you can do…

    August 18, 2014 | 3:01 PM

    True enough. There are always surprises, or people who refuse treatment, etc. My point is that not even having hospitalization available for profoundly depressed people is a real hinderance – a hole in the system…

    Bernard Carroll
    August 18, 2014 | 5:38 PM

    On the matter of suicides that come as a surprise, the interpretations one generally hears seem like just-so stories, at least for patients experiencing malignant mood disorders. It isn’t that they make a reasoned decision to kill themselves. It isn’t that they act in an existentially noble manner. It isn’t even that they want to kill themselves. My sense of it is that their executive inhibitory mechanisms lose control over what has become a prepotent aversive internal stimulus. It is in part loss of cognitive flexibility (which would be compounded by Parkinson’s disease) and in part increased mood lability in the severe depression. The patient with malignant melancholia doesn’t “choose” to kill himself any more than the patient with crippling obsessive-compulsive disorder chooses to be paralyzed by doubt and rituals. So I agree with Dr. Mickey that when the warning signs of a malignant mood disorder are present a protective inpatient milieu can be essential.

    James O'Brien, M.D.
    August 18, 2014 | 6:24 PM

    But practically speaking, isn’t that hospitalization based on actuarial data, rather than clinical acuity and mental status? We do understand the Orwellian implications and practical limitations of that idea, don’t we? This is a country where if you tell a judge a day after you swallowed a bottle of lye that you are no longer suicidal, they let you go. (Which I find absurd). I mean we simply can’t really hospitalize someone on the demographic items of the SADPERSONS scale…

    August 18, 2014 | 7:16 PM

    A woman who was in the ward where I was committed, attempted suicide in front of her young child. She told the doctors that her husband was talking about leaving her and she did it to stop him. She knew she was going to be let out the next day, and she was.

    Can’t hold people for being manipulative, I guess.

    August 18, 2014 | 8:45 PM

    Well even IF Parkinson’s reduced his “cognitive flexibility” and compromised his “executive inhibitory mechanisms” and he had a “major mood disorder” this doesn’t explain fully the suicidal act. Not by a mile. The fact remains that 99% of PD patients with a major mood disorder don’t kill themselves.

    August 18, 2014 | 10:17 PM

    Umm, the SADPERSONS scale seems to be fairly predictive, let’s apply it to Mr Williams as example for the readers, eh?

    Male, over 60, hx of depression if not bipolar (and if coming off mania increases the intensity of the depression, (prior attempts unknown), h/o at least past sub abuse, rationality could be question if he was hopeless and not redirectable, seems like social supports might have been lacking in intensity at least (and where was the wife not checking on him before leaving the house?), plan seems perhaps spontaneous but he did also cut himself a bit prior (?), married but divorced twice prior and as alluded to earlier here was the marriage sound?, and the recent diagnosis of Parkinsons.

    Soooo, at least positive for what, about 6 of them more directly, and 2 others with strong question as positive, I think the scale seems to rate as reliable there was a risk factor.

    Ironic it is Monday a week later discussing this.

    Bernard Carroll
    August 18, 2014 | 10:18 PM

    Tom, I said that when it happens that is how I think it happens. It’s the proximate mechanism, if you will. I agree with you that getting to that point is a multi-determined process.

    James O'Brien, M.D.
    August 19, 2014 | 1:15 AM

    Joel, I agree it is predictive, but that would have been true the rest of his life…you can’t expect him to agree to lifetime hospitalization…and I don’t think he had ERSON on that list….I don’t know about P….no evidence of ethanol currently….but if he has every item on the list chronically…what do you do even if the resources are available? I think day treatment of some for is the most realistic option if he has all but currently no plan….

    It’s no surprise he suicided, but it was obviously a surprise that he did it a week ago…

    August 19, 2014 | 7:31 PM

    Dr. Carroll: Thanks for your clarification. And your point about proximate mechanisms is instructive. I would only add that it would be premature for us to toss aside the writings of Shakespeare, Chekhov, and Sophocles as we attempt to understand the proximate mechanisms that lead to suicide.

    August 21, 2014 | 5:37 PM

    A correspondent has pointed out to me that psychiatric drugs can induce Parkinsonian symptoms and, indeed, it’s not uncommon http://www.ncbi.nlm.nih.gov/pubmed/17044803

    Here’s a scenario that seems as likely as any other: Robin Williams developed iatrogenic Parkinsonism from a psychiatric drug cocktail. Drugs for Parkinson’s added to this cocktail didn’t seem to help. The side effects of the drug combination get worse and worse.

    He decides his situation is hopeless and kills himself.

    A misapplied psychiatric drug cocktail leads to a misdiagnosis of Parkinson’s, which does not respond to drugs for Parkinson’s.

    Far-fetched? Heck no. Even elite medical treatment cannot protect a person from this type of medical error. You can run into the blindness of arrogance, a lack of common sense, and unquestioning faith in the drugs at any level of clinical care.

    I see people whose extremely obvious severe drug reactions are misdiagnosed by physicians every day.

    Then there’s the possibility the Parkinson’s drugs weren’t working, his symptoms were getting progressively worse and interfering with his ability to express himself — to be Robin Williams. Having been around the treatment block more than a few times, he decided he didn’t want to live with that quality of life.

    (I had a friend who died recently from Parkinson’s complicated by ALS. The drugs didn’t work. The ALS was identified far, far into the progression of her disease. She was 57.)

    As for the suddenness of his suicide: Given what I’ve learned, if I seriously intended to kill myself, I would never, ever discuss it with anyone in the mental health field or other medical professional. I would pretend to be thinking of the future, and do it in a way that wouldn’t leave a mess.

    Bernard Carroll
    August 22, 2014 | 4:45 PM

    I think we could turn Alto’s words on her: they show “the blindness of arrogance, a lack of common sense, and unquestioning faith” in her own tendentious narrative. Turnabout is fair play. Her comment is professionally presumptuous and it is disrespectful of its subject, Robin Williams. May he rest in peace without the Altos of this world piling on for their own agendas.

    August 23, 2014 | 1:38 PM

    Dr Carroll, don’t waste your energy and time to consider a reply to some commenters here, just go to Madinamerica.com and read some of the threads there, and you will see what you are dealing with.

    These are people who not only advocate for suicide, but also advocate for the punishment of anyone who dares interfere with a person’s efforts to commit suicide. I think it is a twisted, perverse way at population control, but, I have been known to be wrong on occasion.

    Oh, and I would bet a day’s pay that all these people who are so hell bent on allowing suicide, would be the first to file lawsuits against those who were deemed accountable for not providing care if someone these “suicide advocates” lost to a suicide.

    The site above should really be renamed “Mad (that psychiatry exists) In America”. But, that would advocate for transparency, and the aliases and anonymous commenters alone at sites like that would scream for heads if transparency was honestly expected at blogs there…

    Bernard Carroll
    August 23, 2014 | 2:17 PM

    Yes, I am aware of the MIA site, Dr. Hassman, but I try not to go there – haven’t been there in months, as a matter of fact. Too many one-song concerts.

    August 23, 2014 | 4:23 PM

    I beg your pardon, Dr. Carroll, as long as we’re speculating on very, very little evidence, is not every potential scenario equally as respectful or disrespectful of the deceased?

    Why would medical error be out of the question?

    If you read David Foster Wallace’s biography carefully, you will see he was suffering from 1.5 years of Nardil withdrawal syndrome when he killed himself. He was convinced the drugs he was being prescribed were harming him; that’s common in prolonged post-discontinuation syndrome, which is almost invariably misdiagnosed.

    Could not medical misdiagnosis and mistreatment have played a role in his despair?

    Does positing every possible scenario dishonor anyone who has suicided? Or are we permitted only to assume serious mental disorder? (I find that assumption offensive.) If medical error were involved in a death, would it not make the world safer for the living if it were brought to light?

    August 23, 2014 | 10:08 PM

    Even I will bite on that one, Altostrata. 1.5 years of withdrawal?

    Per your definition, if someone was EVER on a medication and then had a negative outcome, even decades later, you will blame it on the psychotropic.

    Nice try!

    Oh, and now almost 3 weeks later and still no mention Robin Williams was on any psychotropics at or just before the time of his death.

    But, in Alto world, does that matter?

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