Don't Be Angry With David


Why does a person kill themself?  Was he/she just selfish and uncaring about those left behind?  What about his children?  How could he leave them with these scars and questions for the rest of their lives?  Shouldn't we be angry with him for leaving us all behind?  How could he do this to me?  It didn't have to end this way.  He should have gotten help.  He should have tried harder.  He should have not been so thoughtless about all the people he loved.  He should have thought about us instead of just himself.  What could possibly make an otherwise loving, caring, considerate and compassionate person, a thoughtful father and a good friend, do such a thing?  If it were me, I would never have done this to all of these people.  Why does a person kill themself?


Albert Camus starts his philosophical treatise, The Myth of Sisyphus, with the statement, "There is really only one truly philosophical question and that is if one should or should not kill themselves"  He concludes that suicide is not a valid existential choice although he points out that there is no reason not to kill yourself either.  Did David exercise his existential right to determine his own fate and free will by killing himself?   I think not.  The existential choice of self destruction is presumably made with a clear mind.  It is a choice, something that has been thought out in detail and decided upon.


I believe that it is a human being's right to commit suicide.  I believe in free will and autonomy.  I am a physician but I do not believe in euthanasia.  I am undecided about the ethics of physician assisted suicide.  Still, I believe that a person must be free to end their life when they want to, when they need to.  I feel that this is essential as it is a person's right to put an end to intractable and terminal pain and suffering. I believe that a doctor's role is simply to relieve suffering.   I think we would all agree that a cancer patient, having exhausted all tolerable therapy and who is suffering in pain should be allowed to die and maybe even  assisted in this regards.  There is no hope for this person.  The patient realizes that he is going to die and there is no hope.  This person makes a rational choice to stop living in order to avert horrible pain.  The alternative may be relying on modern medicine to prolong the process, fighting against the ultimate enemy, death.  I have seen many instances when death is not the enemy but a friend and savior.  I believe, in this instance, it is a person's absolute right to commit suicide.  I also believe the same truism exists for any terminally ill person who rationally makes the same choice.  This choice can only be reasonable when one is not consumed by depression.  Most hopelessly ill people have reached the stage of acceptance by this point.  Most of us would respect this decision and understand.  We generally would not be angered by it.


So, what about David?  Certainly he was suffering.  Was his suicide justified in my opinion?   I do not believe that David's situation resembles either of the two scenarios mentioned.   If David had made an existential choice to end his life then I believe we should all be very angry with him, as his rational action could only be described as thoughtless and selfish.   Likewise, David was not terminally ill and his suicide was NOT a choice that he made or even rationally planned.   He was suffering from major depression, which is neither terminal or hopeless although it feels like it is when you have it.  This is a real illness with a high mortality rate.  David was bipolar (manic-depressive).  


Many people simply don't understand mental illness.  They think that it is not a real problem.  They have never experienced true depression and cannot conceive of why one can't simply snap out of it and be happy.  Psychiatric disease is not considered a "valid" illness for most people.  It is simply not taken seriously and most people feel that it is a cop-out.  There is an unavoidable stigma in mental illness.   Mental illness is not a "real", respectable disease.  Indeed, it is all in their heads.  There is no real pain and suffering like someone dying of cancer.  The disease is the person's own fault, not like someone with colon cancer.  Likewise, a suicidal death is their own doing, their own failing and as such a disgrace.  "It's merely selfish, foolish, cowardly and a waste of a life."   Consider that the prevalence of bipolar is 1.2 - 4.3 % of the population (3.3 - 7 Million US adults) and the lifetime suicide attempt rate is 30% and 1 in 5 are lethal.  The prevalence of colon cancer is .005% or 150,000 people.  There is a 60% five year survival for colon cancer in the  US.   Mental illness is a real disease with a high mortality rate.


I would like to explain the spectrum of mood disorders a little better.  In my mind, the best way to understand what happens is to realize that manic depression is just an accentuation of the normal process that each of us goes through on a day to day basis.  We all fluctuate around what absolute normal is, if it really exists.  Some days we feel a bit high and some days we might feel a bit low. 




 Normal Up-----------------Normal Up


Normal Down-----------------Normal Down


Suicidal<==>Major Depression------------------Major Depression<==>Suicidal


Normal people cycle tightly around normal, up and down in a sine wave fashion.  People with unipolar depression cycle below normal.  People with dysthymia spend their entire lives below normal and major depression basically includes suicidal thoughts or ideation.  On the other hand, hypomania (mild mania) is a really powerful place to be with boundless happiness, energy and creativity.  On the down side, it is shadowed by features such as aggravation, anger and irritability or dysphoria.  This is much worse than normal happiness or anger.  One may feel over confident, have no need for sleep, have racing thoughts with difficulty focusing, fast speech with increased talkativeness (force of speech) and practice risky behaviors such as hypersexuality, spending sprees, impulsiveness and poor business ventures.  Mania is typically a delusional and somewhat psychotic state.  One may have delusions of grandeur and believe they are Jesus or God.  There are also often hallucinations.   If you ever taken speed or acid, you might have an idea of what this is about.  Manic-depressive people can be quite impulsive and completed suicide is an incredibly impulsive act.


Hypomania is the feeling that many people with bipolar crave.  This is what David thought was his normal or high energy state.  I have never known anyone with bipolar to never crash.  This can be the complete spectrum down to depression and major depression.   This cycle may occur on a daily basis (rapid cycling), weekly or monthly.  A doctor may only see the person at one extreme or the other, such as mania where schizophrenia might be suspected or major depression where unipolar depression might be diagnosed.  This leads to a delay in diagnosis.  Most family members and friends see the real person though.  In addition, antidepressants, such as Prozac, can cause mania as a side effect.  So can stimulant drugs such as cocaine and speed.  A lyric from a song that I wrote describes this, "manic moments, morose in misery, like a seed the sound Marie."


Bipolar is a very common disease and some of the most creative people in human history have suffered with it, such as Mozart and Van Gogh.  "Manic depression drove the creative engines of some of the greatest artists and writers and musicians in history, as well as fed the destructive appetites of history's worst tyrants."   Here is a more complete list.   Many of these people remained undiagnosed and untreated (when treatment was available) for many years.  Self medication with illegal drugs is very common and substance abuse is often highly associated with mood disorders.  No wonder being a heroin addict seems to be a prerequisite for being a great musician.   It is said that the creativity of mania is flavored by the experience of angst and the blues of depression.  The medications used to treat mania such a Lithium are called mood stabilizers.  The problem with them is that they decrease a person's creativity and this leads to noncompliance.   David stopped his medications, but he was never placed on a mood stabilizer.  He was only treated with drugs like Prozac.


Let me present an analogy.  The myth of Sisyphus is that this Greek man was punished by the gods.  He had to push a large boulder to the top of a mountain and when finished, release it to roll back down, only then to push it back up and this for eternity.  Camus viewed this as a metaphor of the absurdity of normal life, the existential dilemma.   He concluded though that Sisyphus was happy.  You might consider this to be the normal fluctuation that people experience around normal.   Imagine if you will that major depression is akin to falling into an abyss and grabbing hold of some rocks on the way down.  If you lose your grip, you will fall into the abyss and die (suicide).  Otherwise, you must use all of your strength to climb out of this hole in order to scale Everest again.  Coming out of major depression is like having to crawl out of the abyss and then when one feels totally awful and weak.  This is a terrible chore, something that one does not want to ever re-experience.  Everything seems completely hopeless and dismal.  One feels entirely helpless.  All is despair.  There is no pleasure at all. This is the complete  opposite of hedonism and depression is anhedonia.  It is reversible, but believe me, you never want to be there in the first place.  Imagine falling into depression repeatedly.   The suffering seems immeasurable.  Sometimes it is intolerable and suicide follows, losing your grip.


Suicide is an impulsive act.  The choice to pull the trigger occurs in an impulsive instant.  Bipolar people are often quite impulsive.  If you can get past that impulsive moment, rationality may reappear and life will go on.  This is why when a person has a plan of just how they will kill themselves, they are at great risk.   If they have the means at hand, the result may be dismal and lethal.   David had an extensive gun collection which he refused to relinquish.   When I talked to him the week before he departed on the phone, he mentioned that he felt unsafe being alone.  When I asked him about guns at home, he skirted the question.  He told his sister Suzie, who wanted to remove the weapons, that he had no ammunition.   Obviously he purchased bullets.