I wrote this in 2016. I’m not sure if it holds true anymore…in fact, I’m almost certain it doesn’t.
This is form before I was an Interventional Brain Medicine identified doctor.
I was still considering myself a psychiatrist and therapist with limited tools including white-knuckling it and therapy that works but takes a while. I was a LOTR fan, even then. Enjoy this very early dispatch from the vaults for what it is: a time capsule. I did light editing to make the it suck less.
The Way Back Machine
When taking care of suicidal patients, as physicians, we are entrusted with, to quote Frodo Baggins:
“A terrible burden.”
This human before us may die. We have an obligation. Yet unlike critical care medicine, we can't grab hold of a person's physiology, nor push their broken head and heart back together with a whole team of technologists and healers.
There is no extracorporeal membrane oxygenation to infuse hope for depression like that machine does oxygen for cardiopulmonary failure. There is no ventilator to carefully pop open alveoli, the tiny air sacs in the lungs. There is no dialysis to become kidneys for a person. Not even blood transfusions to replace the blood lost through their accidents. The closest we come is the support we can offer acting like IV fluids...carefully supporting another human's hope like normal saline does blood pressure. Not a trivial intervention! Live saving! But not always enough.
Brief sponsorship-of-my-own-event break: remember to get your tickets for Rapid- acting mental health treatment 2024!
Jan 7, 2024, 6-9pm!
We sit. We talk. We are armed with words and medications that have almost no data in suicidal patients. There are no already suicidal subjects allowed into most antidepressant trials. We have 2 Randomized trials1 for suicidal patients, and only one showed a difference. And that medicine is drastically underused.2
We have the ability to make your life worse by locking you up to try to prevent you from doing it. And yet people complete suicide in hospitals.3
Regularly. In terms of modifying your long-term risk of suicide completion, after discharge is the highest risk time. I'm not convinced they help.
Life is the treatment for wanting to die. We can intervene for depression, psychosis, OCD...slowly. Weeks...more. Waiting to feel better. Hoping it will work. I fear it won't.
We have a phone. Many doctors don't pick that up. Certainly not at night. Not on a weekend.
I do. I pick it up more than I should perhaps, for my family and friends. It still didn't stop everyone from completing suicide. Hundreds of phone calls later, when the time came...it was silent.4
Suicide is like the master ring from J.R.R. Tolkien's classic series "The Lord of the Rings." It tempts those who carry it, as it weighs them down. It is a burden, and terribly so. The burden promises to make you invisible when you feel the need most. You won't have to face the things you fear should you only slip into it. It seems so easy.
But people don't generally walk into Mordor, the heart of their worst dreams and worse still, their darkest days, because they want that escape. They know they are on a mission. Not one they chose. Others may be better equipped to take such a journey. When suicide enters your mind; finding relief is a task appointed to you by your mind, your life, your woes, your family, your loss, and your sorrow.
People come to me for fellowship on the walk. They trust me. They don't often say it with words, but their eyes, their quiet voice, and their return to my office week after week say clearly: walk with me. Don't abandon me.
Often, their friends, family, and lovers have broken their fellowship. “Everyone leaves me;” they can think. Sometimes, they are correct. Death is not a pleasure to have as a companion on a walk, not even if it's just your companion's companion. Their friends, teachers, confidants, and people who promised them never to leave may have meant it. They might have good reasons. They might have wanted to escape for themselves. Sometimes, their journey kills them, too—an alluring ending for someone carrying something so heavy. Did I mention that outside of a very small circle of people in the lives of most, no one can know?
What might they think?
It's heavy, and it's secret.
But— not to me. Someone has got to travel with them. That person is me. Sam Gamgee was a brave and stalwart soul. But he only walked to Mount Doom once and was successful. In hour-long increments, I make that walk with many. Every day. And sometimes the people I'm walking with don't want to be carried. They just get pulled to the ground slip away, and with the knowledge of my failure in the face of the struggle they faced, I start at the beginning with the next hero, aware of how long the journey will be, and how dark the night.
—Owen, circa 2016
That lament was written before all the rapid acting treatments I am so excited about. I also have become a better writer by a bit.
This is old, remember? Out of date.
I’m referring to clozapine in the intersept trial.
A point I have beaten to death
This is now a matter of public record and litigation even after OPMC clearance, which has led to the defamation case, as a plaintiff, that is also public record.