I remember clearly a conversation I once had with a doctor I was seeing to treat my Attention Deficit Disorder. We often talked to each other as friends and equals, rather than as patient does to doctor. He brought up the question of suicide during anti-depressant therapy and asked me if I knew why patients with depression treated with antidepressants often find that it’s shortly after improving they feel most suicidal.
In psychiatry its common knowledge that a patient with long-standing depression is most dangerous to him or herself the first few weeks after responding well to therapy. And intuitively this does seem puzzling. If you have suffered so long with such severe mental pain and lived in this perpetual fog of self-doubt and pessimism why would you want to kill yourself when you’re finally free from it? You would think that living with that pain must be harder than living without it? And isn’t it the goal of every depressed person to treat and eventually (hopefully) beat their depression? To live a happy life where they can actually enjoy and engage things, rather than merely spectate through fogged glass?
I never had a good enough answer to this question. The conventional reply most give is something like ‘well the realization that this is how good life can be weighed too heavily on them, and eventually the fear of dipping back and losing themselves again becomes too much to handle’. Perhaps for some this is true, but as a rule I’ve found that concerning most people, the simplest answer is often the right one. With that in mind, why is it that after appearing to improve, depressed patients are at the greatest risk for suicidal ideation?
In thinking of this problem, I thought about my own life. I suffer from chronic pain. I attempt, often in vain, to treat my pain. I also live without any real emotional support; I come from a broken home, with parents indifferent and apathetic and siblings fighting fate, too busy and unavailable to help. So I’m alone. When you live with chronic pain, the consequence of that pain isn’t just the physical feeling of pain; it’s so much more than that. It’s feeling tired and out of the loop, and feeling physically worn out. It’s feeling weak, and separate, and broken, and afraid and hopeless and unhappy. It’s living with the stigma of not being like your peers and not being able to live the life you imagine for yourself; not having a full-time job, or a girlfriend or wife—or at least having those things with great difficulty and perhaps maintaining them with no great success. It’s a status as well as an experience; one which we are given, and which we in turn give ourselves. When you suffer on a daily basis, and you don’t have anyone to turn to, life screeches to a halt. So I know all too well what its like to live life spectating through fogged glass. And while my days are filled with many hardships, I also know what its like to experience joy and moments of pure, unaltered bliss. I know what its like to feel love, to feel connection and security. I know what it’s like to make a group of friends laugh, to get a good grade and to create something out of nothing. My days are filled with things that constantly remind me of the hard side to life, and yet I can on occasion comfort that swelled nihilism with the memory of something good—and feel hopeful that again I may experience that feeling. The hardest part about being sick isn’t just being sick—and that’s hard enough as it is. It’s the ups and the downs. And more specifically, its the refractory period between the ups and the downs; the time spent in the middle, waiting in anticipation for the inevitable fall. While its true that most of us will never experience sadness and happiness in pure simultaneity, we do experience moments in our days of joy and of sadness. Yet much like the consequences of chronic pain, the experience of sadness or joy doesn’t happen in a vacuum; it affects us. It’s not feeling sad that drives me to think of suicide, it’s the aggregate of the effects of sadness that does. It’s the realization and also the fear that I’m going to have to feel this way for the rest of my life; that there will always be this constant battle. It’s the feeling of failure I experience on a daily basis. And it’s most importantly just the raw emotional pain.
Tonight I took my pain medication, but as I was in quite a lot of pain, I took twice what I normally take. I was aware of the potential consequences of what I was doing, and as I take a very low dose, and have taken much, much higher doses in the past, I felt quite assured that things would go fine. A little while later, after a few cups of tea to ward of any drowsiness, I sat down and continued from where I left off in The Two Towers. After an hour of reading I got up and asked my brother for a copy of a book I have been meaning to read. I came back, sat down on the couch beside my dog, and noticed how great I felt. I was leaning with most of my weight on my shoulder, which usually really hurts, but I didn’t feel any pain. I felt normal. A short while later though my shoulder did begin to hurt. The chapter I was reading at the time was The Passage Of The Marshes. The chapter deals with themes of burden, endurance, decay, hopelessness, mental fatigue and oppression. And I came upon, and underlined a passage I’d like to share “For a while they stood there, like men on the edge of sleep where nightmare lurks, holding it off, though they knew that they can only come to morning through the shadows. The light broadened and hardened. The gasping pits and poisonous mounds grew hideously clear. The sun was up, walking among clouds and long flags of smoke, but even the sunlight was defiled.” And as I read this I thought about my shoulder. And a memory came fresh to my mind; a memory of pain. It was like experiencing some acute trauma all over again. Then I thought about my day today. Today I didn’t take any pain medication. And today I was more active than I have been in a very long time. I did things today which should have caused me agony. And I couldn’t figure out why. It’s not as though I had less responsibility today. Today was one of the hardest days I’ve had in a long time; fewer times have I felt more helpless and alone. Yet here I sat, reading comfortably in my beautiful apartment, with a belly full of warm tea, doped up on pain meds, in relative comfort, beside my best friend, feeling weaker than I had all day; feeling as weak as I have felt in my weakest moments.
Our bodies while tough and durable, are very sensitive. We can differentiate between many different tactile sensations; a soft or firm touch, a pin prick, and even the feeling of specific textures. First experiences are something unique. Good first experiences like the first time you taste something wonderful, the first time you hear a fantastic song, or a first kiss are almost magical. That’s because it’s so much more than just a drink, or a tune; it’s a whole, full-bodied experience, ripe with anticipation, illusion, expectation and often blissful ignorance. Going to the dentist for the first time, or the doctor, or receiving a vaccination share similar content, and yet we perceive them as so much worse. The dentist isn’t inherently bad, nor is the doctor. And neither is a first kiss, or a taste inherently good; in fact, they can quite often be quite painful firsts. The reason this huge dichotomy exists between bad and good experiences is found in the nature of anticipation. When something good is about to happen, we feel excitement. When something bad is about to happen, we feel fear. And we all know which of the two is a more compelling, powerful force.
Pain has something constantly reinforcing it. And the things associated with pain are so much more powerful than those that are associated with pleasure. Pleasure has no force like fear; pleasure has excitement and anticipation, but neither rival in intensity the experience of fear.
Some depressed patients during therapy experience an emotional flatline; they cannot experience intensity one way or the other. I have experienced anhedonia, and it definitely drove me to thoughts of suicide; so I get that. But that’s probably not the real problem here. I think that many break free from the depression only to realize that a bigger obstacle faces them; living life in recovery without any emotional support. They are alone, and have to find some way to acquire a network of support; a daunting task for anyone. But that’s still not a comprehensive enough answer, because there are a great number of people with depression who have a great support system, and a secure environment to call home. The hardest part about my condition is the ups and the downs. Not just in the level of pain, or loneliness, or depression. But in the amount of information, tools and answers, that is lost along the way. It’s such that when I’m on the top, I’m there by chance; rarely by my own doing. Some medication is working, or a perhaps a friend popped by or I’ve had a good nights rest. The fall from those high points wears you down. The people at most risk of suicide aren’t just those who respond well to therapy, but quite often those who are responding well to therapy again. You just don’t want to suffer that pain anymore. It’s not really cognitive, existential, or moral. It’s just a desire to go out savouring the best your life has to offer.