Emergency Departments Should Do More for Suicide Prevention

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Every day, suicidal individuals are sent home from the emergency room with little to no follow up. I believe this to be one of the greatest threats to effective suicide prevention.

Today is World Suicide Prevention Day. I feel the need to add to this important conversation, not only because of my personal relationship with suicide but also because suicide often fails to be recognized for the serious health issue it is. The World Health Organization estimates that about 800,000 people worldwide die by suicide every year. In Canada every day 10 people die by suicide and 200 attempt suicide. In Ontario alone 1327 people died by suicide in 2014. In short, we need to talk about suicide prevention.

Discussions about suicide prevention are not complete without looking at necessary improvements to our hospital mental health systems. While hospitals, doctors and other mental health professionals work tirelessly to support their at-risk patients, there remain major flaws in the availability, accessibility and adequacy of services provided. Not the least of these problems occurs when suicidal patients are denied care in hospital emergency departments.

The Problem

Imagine for a moment that you feel there is no reason to live. You feel that you can’t stand to go on any longer and have made plans of how to kill yourself. Imagine you reluctantly make it to the hospital, perhaps of your own will or perhaps at the urging of someone who cares. With one last shred of hope, you think maybe the hospital will help you, and what do you have to lose? You wait for hours, growing more jaded as time goes on. After sitting in the hospital all night in high emotional distress receiving only cursory information from busy ER nurses, you finally see a doctor. You describe to them that you plan to kill yourself, you explain your plans, describe your hopelessness and pain. Imagine that doctor, after only spending a few minutes with you, sending you home without offering help. Imagine feeling even more worthless and hopeless, because even the system that is in place to save lives turns you away. Imagine feeling as though doctors are telling you that you are not worthy of being saved. You return home, emotions heightened, even more certain than before that your life has no value.

This happens every day. Every day people who have decided to end it all are turned away from the very systems there to protect them. While my experiences with the ER have often been positive, this has happened to me. It is one of the worst feelings imaginable, to be at the end of your rope and have your attempt to access care rejected. Few things have made me feel less worthy of living than being sent home from the emergency room when I am a threat to myself. To add insult to injury there is often no follow up even when follow up is promised. While this is certainly not the intention of the hardworking emergency department medical staff, the message I internalize from these events is loud and clear, “Your life is not important and you do not deserve to be saved.” When in the depths of a suicidal episode even the act of being assessed by a doctor for my risk of suicide feels stigmatizing. Being asked questions with the obvious motive of trying to uncover whether I am “suicidal enough” is humiliating. Shouldn’t it be enough that we are asking for help?

Suicidal patients like myself and our caregivers have been placed in the position of having to advocate for our need for care during crisis. As a suicidal person, it isn’t easy when you do not believe you should live to present yourself to the hospital and advocate for care to keep you alive. In fact, it’s one of the hardest things I have ever done. Caregivers too are placed in difficult positions, often having to advocate for care they feel is desperately needed, sometimes against the wishes of their loved one. My husband has had to advocate me, and I know it hasn’t been easy for him to simultaneously convince me to accept treatment and convince doctors of my need for treatment. I am forever grateful that he has endured that stress, it has saved my life. These self-advocacy measures should not be necessary. We shouldn’t have to convince doctors of our honesty, our intent and our need for treatment, out of fear of being sent home with no answers.

I believe the result of these interactions with hospital emergency departments can foster a distrust of mental health systems. It is dangerous, I believe, to contribute to a person’s feeling that their suicidal ideation, plans and actions will not be taken seriously. I know many people, myself included, who have at one time or another refused to go to the hospital due to the belief that they will not receive care and their time there will only make things worse. Surely, contributing to that belief is not what hospitals should be doing for suicidal individuals. Emergency departments have a key role in suicide prevention and sadly they are not always up to the task.

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Why I Think This Happens

There are, of course, many reasons why doctors might choose not to admit a suicidal patient to the hospital. A hospital admission isn’t always in the best interest of the patient. For one, there is a broad range of what qualifies as “suicidal” and not everyone who has thoughts of suicide is an immediate risk to their own safety. According to The Suicide Risk Assessment Guide by the Ontario Hospital Association (pg. 25), doctors in emergency settings should assess the risk of suicide by determining the patient’s actual level of intent to die by suicide and evaluating whether the patient is telling the truth about wanting/not wanting to die by suicide. Based on the assessment of risk of suicide, doctors determine the level of care needed and should, ideally, help connect the patient to the appropriate level of care. In Ontario we have a shortage of psychiatrists, hospitals are frequently operating over capacity, wait times for mental health services are long. I imagine that those constraints add an additional level of difficulty in pairing suicidal patients with the treatments they require. However, sending suicidal patients home without follow up care or even a safety plan is irresponsible.

Finding Solutions

Solving this issue isn’t straight forward. This is not about a few stigmatizing doctors who believe their suicidal patients are just attention-seeking (though that is sometimes the case). Often, the capacity to offer timely help to every person who needs it is simply not there. In many places, hospitals don’t have enough rooms or enough beds or enough staff or enough funding to offer immediate support to every suicidal person who comes looking for it. In an ideal world, everyone who has plans to end their life would have a place in the hospital until they are truly safe to go home. Fixing this problem isn’t as simple as admitting every patient who may be at risk to the hospital. As it stands, at least here in Ontario, that just isn’t possible.

There are ways that I believe the emergency departments can contribute to suicide prevention. Information about free community services with low wait lists should be shared. Peer support groups, for example, can be helpful in suicide prevention and often do not have waitlists. Helping the patient create a safety plan can also be beneficial. Follow up from the hospital (calls or appointments) is another way to not only check that patients are okay, but also to reassure patients that they are a priority and have not been forgotten. Doctors should make sure the patient has a mental health professional or family doctor they can follow up with soon. You would think that all of these practices would already be used consistently, but that is not the truth of my experience or the experience of many of the people I have interacted with. The result of a hospital visit due to a suicide attempt or suicidal plans should never be nothing. No suicidal patient wants to feel that they are met with apathy at the hospital. We are failing to prevent suicides by letting suicidal individuals slip through the cracks. When all else fails, compassion from the emergency department medical team can save a life. I should know, it has saved mine.


My own personal experiences with visiting the emergency department when I am suicidal have varied. At times, I am treated with compassion and a level of concern appropriate to the severity of my condition. At other times, I have been sent home without any help, care or follow up. At the worst, I have felt stigmatized and humiliated by the words and actions doctors. My experience is not unique. There are many people who are turned away from the hospital when they truly need help. If you need any evidence of that, I suggest you start looking at the mental health community on Twitter. I see stories every day of people turned away from the emergency room without help, even when they have no other supports in place.

With all that said, I am deeply grateful to the doctors, nurses and administrators at hospital emergency departments who have helped me in the past. I have had some very positive outcomes from ER visits.

Suicide prevention is something I can’t help but care about deeply. Once you have been suicidal, you understand how big the discrepancy is between the need for effective emergency care to help suicidal individuals and what is actually available. We are told to report to our nearest hospital emergency room when we are in crisis, we should be able to expect to receive real help when we do.

Take care,
Fiona

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Suicide is not selfish

This post may be triggering for some individuals. Please do not read if this may be distressing for you. If you are in crisis, you can find your local suicide hotlines here: http://www.suicide.org/international-suicide-hotlines.html. Your life matters.

Whenever a high-profile death by suicide rocks the social media news cycle, I am both deeply saddened by it and apprehensive of the comments that I know will come along with it. Comments like, “how could he do that to his kids” or “but she had a husband, didn’t she think of him at all?” or “what a selfish thing to do”. I’ve had enough of it this week, I have to say something. Repeat after me: suicide is not selfish.

Listen, I can understand how suicide can seem selfish to people who have never been suicidal. I know that the concern we all feel for the loved ones left behind by suicide can morph into anger at the person who died by suicide. If you have never been suicidal, you just can’t understand. Too often it is assumed that those who contemplate, attempt or die by suicide are not thinking of the effect their death will have on those around them. Please hear me, that is so far from the truth.

Drawing from my own experience, my suicidal ideation is usually accompanied by the feeling that I am holding my loved ones back from true happiness. In my darkest moments I cannot register how important I am to the people who love me, even if they are right in front of me telling me just how much I matter to them. In my darkest moments all I can see is how much my mental illness impacts those around me, how hard those I love struggle to take care of me, how much I am burdening them, how much better their lives would be without me.

When I am suicidal I am thinking about others almost constantly. Wouldn’t my friends be happier if they didn’t have to worry about me all the time? Wouldn’t my husband’s life be improved if I was out of the picture and he could find someone less broken to love? Wouldn’t my mom be relieved if she didn’t have to drive me to appointments anymore? Eventually the doubt is erased and the “wouldn’t they” changes to “they would”. These are highly distorted thoughts, they completely shut out that my loved ones want me to live. They are unbalanced, irrational and drastic. But these are the kinds of thoughts that claw away at me when I am suicidal. I am usually able to understand how much suicide hurts the survivors, but not when I am most suicidal. When I am most suicidal I believe that my death would be a relief and bring joy to those around me. My mental illness distorts my reality. “Yes, they would grieve”, I think to myself, “but after they got over it their lives would be better”.

One person’s experience alone can not explain suicide. It is important to note that suicidal thinking does not look the same for everyone. I provide myself as an example, but my experience does not speak for everyone. I am fortunate to have learned this through meeting tens of individuals who have been suicidal. Having listened to their stories I have gained an understanding of just how diverse the causes of suicide are and just how different each person’s thinking around suicide can be. However, one theme that is almost universal amongst the people I know who have been suicidal is concern for their families and friends.

Let’s consider for a second that someone’s suicidal thinking is not as preoccupied with others as mine tends to be. I believe that most people who die by suicide feel desperate, exhausted, at the end of their rope and that there is no hope for recovery. That still does not make suicide selfish. No one should be judged as selfish for fighting hard against a serious and sometimes fatal illness and then losing the fight. Yes, suicide is preventable. Yes, there are treatments available that work for some people. But at its core suicide as a result of mental illness is no different from any other illness that can result in death. This can be hard to grasp if your thoughts and emotions have never been overtaken by mental illness. For too long phrases like “committed suicide” or “took their own life” have programmed our collective thinking and made us believe that the person who suffered and died from suicide is somehow to blame for their death. This is why it matters that we reframe the way we talk about death by suicide. We need to use our words to convey that suicide should not be about the act itself but about the underlying distress or illness. People with mental illness do not take their own lives, suicide takes their lives from them. Suicide is more disease than act.

Saying that suicide is selfish completely ignores the experience of suicidal people. It contorts suicide into something that it is not and further confuses public understanding about suicide. I believe that the misconception that suicide is selfish stems from a real lack of understanding of what causes suicide. If you are someone who struggles to understand suicide, now is the time to do some research. You owe it to yourself and others to educate yourself about why suicide occurs. If you think suicide is selfish, you don’t understand it.

Take care,

Fiona

If you are in distress please reach out for help. If you don’t know where to turn for help, please consider contacting a distress line near you. http://www.suicide.org/international-suicide-hotlines.html

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This is My Story – #GetLoud for CMHA’s Mental Health Week

My name is Fiona and I am 25 years old. I have struggled with my mental health for as long as I can remember. Today I live with anxiety disorders and recurring episodes of major depression. This week is the Canadian Mental Health Association’s Mental Health Week and they are encouraging people to #GetLoud about what mental health really is. This is my story.

As a child I was always one of those kids who was more sensitive than anyone else. I was generally a happy kid but I could be provoked to cry or throw hissy fits much more easily than others. Probably for that reason, I was also a huge target for bullying which inhibited me from developing a positive sense of self. I was often very low and felt misunderstood when I was young. No one quite knew how to handle my big emotions. For many years it was assumed that I was intentionally attention-seeking and over dramatic. My outbursts and moodiness must have seemed like I was just being difficult. When my emotions were beyond my control I would pretend to have a cold or the flu so that I could stay home from school, a habit I kept for many years. Because my mental health problems were not seen for what they were, I went a long time before finally getting any treatment for them.

As a pre-teen I began experiencing panic attacks. However at the time I assumed they were asthma attacks because they felt startlingly similar to the asthma attacks I had when I exercised. Whether panic or asthma, I experienced shortness of breath, a sense of losing control and dizziness, but the panic attacks were far worse. One of the first times I can remember having a panic attack was at an away camp during the summer. I was so confused when my inhaler wouldn’t help me recover from what I assumed was an asthma attack. From then on I had panic attacks on an irregular basis, always assuming they were caused by my asthma until part way through high school.

In my teens I sought out romantic relationships as a means to feel better about myself. I thought that if guys could be interested in me than I must have some redeeming qualities. I had one relationship that turned toxic. The dynamic in the relationship was way off and it began to eat away at any sense of pride I had in myself. It’s hard to leave a toxic relationship, because it’s easy to tell yourself that you are getting what you deserve. When your self-esteem is low, it can feel like a blessing to have a boyfriend, even if they aren’t treating you with kindness. So I presented the relationship as a good thing to everyone I knew, I hid my suffering and the pain I was enduring. For all that anyone could tell, I was as happy as ever. But this was really the time in my life when I first knew that my mental health was not where I wanted it to be.

I first went to see a psychologist before moving away for college. A lot of changes were happening in my life and my worsening moods were apparent to my family. My mom helped me find a psychologist and set up an appointment. I met with her a couple of times and it helped me gain some understanding of what I was going through. Through various assessments she was able to tell me that it seemed I struggled with mood disorders, specifically depression and anxiety. She helped me put some of the more troubling events of my life in perspective so that I was more at peace with them.

I moved away to college when I was 18. I was looking forward to this fresh start. However, when I moved away, my ex-boyfriend moved to the same school and lived in the same residence. It felt as though my past was following me everywhere. Not long into the school year I experienced my first suicidal episode. With the encouragement from a friend from back home I approached a couple of my new friends at school about what I was going through and they brought me to the hospital. After a few hours in the Emergency Department I was sent home with an appointment to meet with a psychiatrist at the hospital a couple of weeks later. In the weeks leading up to the appointment I began to self-injure for the first time. When I went in to see the psychiatrist at the hospital I was frank about my state of mind and behaviours, and he immediately admitted me to the inpatient mental health ward.

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Being in a psych ward at 18 years old, far away from home, was terrifying. I wasn’t prepared for feeling caged up with a worn-down nursing staff, very ill patients and a frankly power-hungry and vindictive doctor. I was in the psych ward for over two weeks and I can say without a doubt that was the worst time in my life. That experience taught me to fear mental health care, which is really too bad because now years later I have interacted with several other hospitals, therapists and services and have never experienced anything even comparable to the toxicity of that psych ward. The only good thing that came from those two weeks was my first formal diagnosis which at the time was major depression, generalized anxiety disorder and insomnia.

After my stint in the hospital I moved back home with the intention of seeking mental health care before returning to school the following year. Well, it turned out that because I was hospitalized in another city, I wasn’t eligible for the outpatient psychiatric services at my local hospitals. I returned to see my psychologist but didn’t receive the kind of intensive therapy I really needed at that time. It was a desperate time, I remember feeling lost and hopeless. However about four months after moving home I started dating my now husband Tom, which was the start of a whole lot of healing. Tom helped me dispense of baggage and regain trust after negative relationship experiences. With time and effort I learned how to navigate a healthy relationship and begin to see myself in a more positive light.

I started school back up again the following year. For the past year I had been on a wait list to see a psychiatrist but only after moving away was I invited to go in for an appointment. I travelled back home to see the psychiatrist and was shocked when it was just a quick appointment to give me a diagnosis, with no follow-up plan. The whole time I was in college my mental health continued to deteriorate. My episodes of depression became more frequent and my anxiety more acute. I tried to call offices of psychiatrists and psychologists but none were taking on patients and I had no family doctor in that city to help refer me to them. Given my experience during my hospitalization I wasn’t inclined to try too hard to access services, I was petrified of receiving the same kind of treatment as I had in the past. So for the four years I was in school I didn’t receive any treatment for my mental health. I began to use maladaptive coping mechanisms as a way to get by like self-harm and an increase in overeating. Outside of my mental health my life was starting to take better shape, I was in a great relationship, had developed a really wonderful group of friends and was succeeding well in school.

After school ended I tried but failed to land on my feet in the work place. My confidence was shaken and I was at a loss about what to do in the future. Tom and I got engaged right around this time and decided to move back to our home town. Initially upon returning home I continued to look for work, but soon it became apparent that I was not well enough to work and I had to seek mental health treatment. My anxiety was starting to manifest in ways I was unfamiliar with (severe agoraphobia and social phobia) and I entered a depression that was lower than I had ever experienced. I started to struggle to see friends and family or leave the house. At my lowest I wouldn’t get out of bed, even to go to the washroom, unless Tom was home to accompany me from the bed to the bathroom. At the height of my anxiety I wasn’t able to sleep and I was having as many as 8 panic attacks in a day. I wouldn’t go downstairs because there were windows without dressings and there was a chance someone could see me, and even if not I would have to deal with light. I was so desperately low and so easily provoked to panic. In my room I didn’t have to worry about interacting with the world. If the blinds were pulled shut and I stayed quiet no one needed to know that I was home. I ignored phone calls and texts. I panicked any time I heard a knock at the door or even just someone walking by outside. It was hell.

After being followed by my family doctor for a couple of months I got an appointment to see a psychiatrist through a friend of a friend of my mom’s. I was so lucky that I got to sidestep the waiting period that would have accompanied normal referral processes, it is seriously messed up how long someone has to wait to receive necessary medical attention for mental illness (but that’s a topic for another day!). Finally after basically my whole life of struggling with my mental health, I was being followed by a competent and kind psychiatrist. It was extremely difficult at first because I carried forward such strong anxieties from past experiences with mental health professionals, but it was well worth the effort.

That was about two years ago now. The past two years have been messy, difficult and uneven. I have seen tens of psychiatrists and other mental health professionals. I have struggled with self-injury, suicide attempts and more panic attacks than I could hope to count. I have tried out a wide variety of medications. I have been hospitalized several times and visited Emergency a handful more. I have progressed in some ways and regressed in others. Getting married and watching some of my friends succeed in their personal lives has been a real highlight amongst all the messiness. Most importantly, I am working with a compassionate team of mental health professionals and I have an amazing network of supportive family and friends. Slowly but surely, we are finding solutions that work for me.

Last year during a hospitalization I decided to be open on social media with my friends about what I was going through. For years I had touted the virtues of speaking out and sharing your story, but mine was kept somewhat private. As soon as I started sharing about my anxiety, depression and experiences in mental health care I received responses from people saying it was helping them. On such a core human level, we don’t want to feel alone in our struggles. I continued to shed the facade that I was doing great and replace it with a more honest account of how I was doing, my successes and my failures. That led to me starting up this blog. It hasn’t always been easy to be so open and vulnerable. But each time I receive a message from someone thanking me for being open about my experiences with mental illness because it helps them with their own challenges, I feel a renewed energy for it.

Given that mental illness has been a part of my life from the start, I expect it probably will be until the end. But now that I have access to treatment there is a far better chance that my life will continue for many years to come. If there is one thing I wish I could shout from the rooftops, it would be for no one to ever take their mental health for granted. Don’t wait to seek mental health treatment, the longer you wait the more your issues will compound in to a bigger mess that is harder to manage. I believe as long as I continue to gain the skills and strategies I need to live with my illnesses, I will be okay. I still struggle with guilt and self-stigmatizing over my mental illness, but the more I share and am open about my experiences the more accepting I am of what I am going through.

It’s mental health week friends, time to #GetLoud.

Take care,
Fiona

The Reason

There is nothing more discouraging, to my mind, than experiencing pain without understanding its cause. A belly ache is somehow more tolerable when you know you are bloated up from PMS. A papercut stings less when you remember getting it while filling out paperwork. Similarly, a depressive low, spike in anxiety or other huge shift in mood are far easier to bear when I can tie them to a cause. A source. A reason, or set of reasons.

Unfortunately, much of my experience with mental illness and recovery is accepting that there isn’t always an identifiable reason for my plight; apart from the reliably mundane, “because you have (insert diagnosis here).” I believe a lot of people can relate. That is why, when introspection, conversation or experience uncover a reason, it feels something akin to finding a pot of gold at the end of a rainbow.

This evening, while talking with Tom, shortly after meeting with my inpatient psychiatrist, I figured it out. I realized the reason why the last two weeks have seen me return to self-harm and suicidal thoughts. I told him the reason, as though I knew it all along. (Cue references to Glinda the good witch from Wizard of Oz)

Usually, it takes me much longer to figure out what has triggered my mood shift. That is, if it isn’t readily apparent (i.e. losing a loved one, etc.). For instance, I am only just beginning to piece together why the last two years have been such a challenge for me.

But today, I’ll celebrate my victory. I understand myself a bit better and am that much closer to passing this hurdle. And I will also celebrate that it appears as though I may get to go home on Friday morning!

Take care,

Fiona