image courtesy psychoshadowmaker / dreamstime
Homicides make headlines, and understandably, they being the most sinister of human transgressions. But consider this: According to the National Institute of Mental Health, there were almost twice as many suicides in the United States in 2020 (45,979) as there were homicides (24,576). The second number should horrify you, considering the toll of such loss. But then what do we make of that first — considerably larger — number?
The coronavirus pandemic will forever be associated with 2020, even as the initial agent that caused it (Covid-19) is attached to the previous year. But the effects of the pandemic — the damage of the pandemic — lingers. And it’s dealt a worldwide blow to mental health. While it’s difficult to clinically connect the pandemic to particular forms of mental illness, there’s a tragic result when cases of depression spike: suicide.
“People who are single, the pandemic really hurt them more,” says Dr. Dan Boyd, medical director at Lakeside Behavioral Health System. “Families were stuck with themselves, but at least they had each other. Singles really got depressed because going to work was a social event. I had some patients [in this category] who really got depressed.”
Depression doesn’t necessarily lead to suicide, but suicide attempts can almost universally be connected to a form of depression or another measurable imbalance in mental health. “I see suicide as a human behavior,” explains Boyd, “and like so many other behaviors, there are a million reasons people do it. What we see in our work: depression, bipolar, schizophrenia, alcohol and drug troubles are the big factors.”
“So much depends on what’s the underlying force. Somebody who’s schizophrenic might hear voices that tell them that if they don’t jump off a bridge, their family will be killed. They’re doing something that, in their mind, is loving, caring, and gracious.” In other words, what appears to be an internal decision and act to those of us who read or hear about a suicide could well be considered externally influenced by the victim. Suicide is a directive.” — Dr. Dan Boyd
As a young physician, Boyd was drawn to these troubles in patients. A 14-year-old girl who had overdosed convinced him that psychiatry was his calling. He arrived at Lakeside in 1996 and has been director of its neuroscience center since 2011. “My interest,” he says, “is more in people’s stories than their labs.”
image courtesy psychoshadowmaker / dreamstime
Butler Vin Cole wants to be part of the healing, both for people, like them, who have attempted suicide, but especially for those who find themselves trapped in the darkness, contemplating the end of life as being a solution. A palliative care chaplain at the Memphis VA Medical Center, the 36-year-old asked to be identified by their real name, not a pseudonym. Their story is one of survival and, ultimately, hope.
“I’ve suffered depression since I was 12 years old. I’ve had seven or eight episodes since then. My first episode started at age 12 when my basketball coach committed suicide. Since then, I’ve lost four people close to me to suicide. Another mentor of mine, the Memphis musician John Kilzer, was my seminary professor, and he committed suicide in 2019. That was the same year my mom died, and I began to have complications in my marriage. My spouse struggled with depression, too. It was all on top of each other. I resorted to isolating. I was drinking, and on the highest antidepressant I could possibly take. On top of that, I was working in a hospital with mentally ill veterans.
“Grief can be a death, but it can also be a loss. A loss of family. As an LGBT person, we had our challenges in my family. It all hit at once. I was doing everything I could to survive each day. Seeing a great therapist regularly. One day I went to work, and I couldn’t function. Couldn’t even write an email. I had no energy, no motivation. The essence of who I was had just dissolved. I was desperate, and having tons of suicidal ideation.
“I went inpatient at Lakeside for the first time. I felt like a walking zombie and just wanted to die. I wasn’t going to make it. All the death and dying, the trauma. It was a lot.”
Thoughts and acts of suicide have demographic distinctions. “White people are much more likely to kill themselves than Black people,” says Boyd. “Men are much more likely to kill themselves than women. [According to Boyd, women are twice as likely as men to attempt suicide, but men are twice as likely to succeed. Men tend to use more violent means such as firearms.] Past attempts are a huge risk factor for completed suicide. Serious medical issues — people on dialysis, for example — are high risk.”
Most perplexing to those who study suicide is the root of such severe depression, the beginning of a darkness none of us wants to experience. And it’s challenging to identify such a point on a human being’s timeline.
“So much depends on what’s the underlying force,” says Boyd. “Somebody who’s schizophrenic might hear voices that tell them that if they don’t jump off a bridge, their family will be killed. They’re doing something that, in their mind, is loving, caring, and gracious.” In other words, what appears to be an internal decision and act to those of us who read or hear about a suicide could well be considered externally influenced by the victim. Suicide is a directive.
“That voice is so real,” emphasizes Boyd. “I’ve had patients way smarter than me who have hallucinations. Intellectually, when they’re doing well, they understand it’s not a real voice. But when they experience it, it’s overwhelming. It’s too powerful.”
Boyd notes schizophrenia has genetic predispositions, and such a condition places a person at higher risk of suicide than the general population, even before a first attempt, or consideration of an attempt. Another underlying cause of suicide is substance abuse, the deadliest substance being also the easiest to acquire. “Alcohol can get you depressed and uninhibited,” says Boyd, “so it’s a double whammy. You’re more likely to dance on a tabletop or shoot yourself. A really toxic combination is alcohol, gunpowder, and testosterone. A drunk male with a gun is a disaster.”
What about cases of suicide where there were no indications or predispositions toward a person harming himself? People can spend their lives lifting others, who then choose to end their own life. The most famous recent example may be actor/comedian Robin Williams. “Our field isn’t good at explaining that,” says Boyd, “because we never see those people. There’s no record. They never became part of our world. People can be severely, clinically depressed and just don’t show it. They’re good actors. It’s a great skill set, because you can’t show your depression on the job.” Poor energy, poor appetite, and a lack of enthusiasm are traits Boyd suggests should lead a person to ask for help.
“I look at therapy like paying rent: it’s not an option. You go, not just when you’re feeling bad, but when you’re feeling good. It has to be part of your budget. There are so many options out there, which says to me that we’re doing better with mental health.” — Butler Vin Cole
“I had made plans, options for how to be done with myself,” says Cole. “I did have a suicide attempt [in 2019] that I didn’t report to anyone until recently, when I told my psychologist. I took a bunch of pills — a combination of muscle-relaxers and painkillers — and had a hallucination that lasted 45 minutes. I was testing the waters, took probably half the [lethal] amount. I wanted to see how it would make me feel. I did report the hallucination, but I attributed it to new medications, because I was so ashamed. It scared me so bad, I didn’t want to tell anybody. And I knew I needed help. I called my former spouse, and they drove me to another good friend’s house. I relaxed, came down from it, and was able to go to sleep.”
Once the underlying cause of suicidal thoughts is identified, treatment can begin. More than 20 drugs can play a role in helping individuals emerge from personal darkness. Lithium has measurably reduced the likelihood of suicide in bipolar cases. Likewise, Clozaril in cases of schizophrenia. “Clozaril has an interesting history,” explains Boyd. “It was invented in the 1950s but didn’t get to our country until 1991. It can cause blood counts to drop, so there was liability risk. It’s a strict protocol, and a balance of risk. It has a lot of side effects, like a drop in white blood cell count. But it’s the most effective drug in the world of schizophrenia.”
Antidepressants require four to six weeks, typically, to take effect for a patient. In cases where a person is at dire risk of suicide, electroconvulsive therapy (ECT) is a primary option. Boyd calls it “the sledgehammer” of treatment for potential suicide. It involves a brief (one minute) electrical stimulation of the brain while a patient is under anesthesia (usually ten minutes). A standard schedule would call for six to 12 treatments (two or three per week).
An alternative to ECT is transcranial magnetic stimulation (TMS), a procedure that uses magnets to stimulate the brain’s nerve cells. (Boyd says a combination of ECT’s efficacy with TMS’s tolerability would be the ideal approach, and it may be coming with a recent trial procedure overseen by Stanford University professor Nolan Williams: Stanford Accelerated Intelligent Neuromodulation Therapy, or SAINT.) “We use ECT if a patient hasn’t responded to other treatments,” notes Boyd. “Or if they are really suicidal, and we just can’t wait. It’s up to them; their choice.”
“I had heard bad things about Lakeside,” notes Cole, “but my experience there was amazing. One of the patients — he was a first responder — asked me if I’d considered ECT. He said it had saved his life numerous times. The first time you do it is the hardest. Your muscles tense up in a way they probably never have. Everything’s sore that first time. But for the most part, it’s a very doable procedure. I’ve had three rounds of treatment, and I might wake up with a headache, or feel tired. The ECT staff made you feel welcomed, like you weren’t a freak. Mental health has that stigma. They treated me like a human being, with respect. They genuinely cared.
“After four or five treatments, my friends could tell it was working. ‘Butler, you look like you’ve got life back in you.’ People have this image from One Flew Over the Cuckoo’s Nest, and that’s not what it is at all. Feeling better, that made me want to do more things to help myself. I’ll go for a walk today. I’ll go on a hike with some friends. It was still a struggle, but I could tell I was improving.
“When mental-health struggles are at their darkest, and you start to come out of it, it’s the most amazing thing ever. You want to get where you might have a couple of rough days over a two-week period, instead of every day. I’ve had another episode since the one in 2019, but it was nowhere near as bad.
[Butler’s former spouse lost her battle with depression and took her own life in 2021, and Butler’s father died earlier this year.]
“I have major depressive disorder, and I’m perfectly fine being transparent about it. I don’t have a lot of anxiety, but I get overwhelmed, and when I get overwhelmed, I shut down. I’ve had a lot of loss since 2019. Going through the anniversaries and holidays … . It’s actually a big part of why I’m doing this interview. I’m choosing to honor [my ex-spouse], to no longer hide my mental health, or hide who I am as an LGBT minister.”
Relapse, sadly, is common with most mental illnesses, which requires a form of monitoring, starting with the patients themselves. “A lot of our illnesses are chronic episodic,” says Boyd. “Some people have one bad depressive episode and never have one again. That’s great. But the chance for recurrence is around 50 percent. Once people have had three episodes, the likelihood for another is around 90 percent, at which point they’ll need treatment — with whatever antidepressant worked — for life. One drug is often enough to keep them [stable].”
Can a person be considered “cured” of suicidal instincts? “Most people with these episodic illnesses get out of the suicidal part,” says Boyd. “The suicidal thoughts will go away. Most of our patients are not chronically suicidal. The suicidal thoughts are a subset of really bad depression.”
Boyd doesn’t hesitate when asked about the first step for an individual with suicide entering their daily thoughts. “A lot of people feel comfortable with their family doctor,” he says. “That’s a good place to start. If they have a therapist, great. But find somebody. [Lakeside is open 24 hours a day, seven days a week.] Get started somewhere.” A new call line — 988 — offers support and resources in both English and Spanish for those suffering mental distress.
“I have to be intentional about sleep, exercise, staying connected with people,” says Cole. “It takes a lot of energy and planning to manage my mental health. I’m a grief counselor. I’m around people who help others with mental health, so you pick up some coping skills. We share what we see on a regular basis. There was so much I hadn’t processed. I’ve gained some tools for managing trauma since my inpatient time at Lakeside. I kept in touch with some of the other patients, and that’s been a gift, being able to text them, to talk and vent with each other. With other healthcare professionals, we can vent without having to filter. It’s the same thing with veterans, with police officers, with divorced people. Finding that niche, it’s important.
“We check on each other on a regular basis, and we have to be intentional about it. Also athletes, those who play soccer with me, or go mountain biking with me … people who don’t do what I do at work. Just being able to talk about normal life stuff.
“I don’t have any profound answers, except those things that we all hear. Spend time in nature. Sleep hygiene. Eat healthy. Eat something bad for you one day a week, instead of every day. When I’m in a depression episode, I go to sugar, and sugar just makes my depression worse. I’ll eat it maybe once a week now. I might have a drink once a week, but even then, I’m real careful about when, where, and how I’m doing it. Alcohol wrecks your sleep.
“And I look at therapy like paying rent: it’s not an option. You go, not just when you’re feeling bad, but when you’re feeling good. It has to be part of your budget. There are so many options out there, which says to me that we’re doing better with mental health.”
Need Help? It’s just a phone call away:
Suicide and Crisis Lifeline — 988
Memphis Crisis Center — 901.274.7477
Lakeside — 901.377.4733
Mental Health Resources — 901.682.6136
