American researchers are gradually coming to the conclusion that it is necessary to get rid of suicidal thoughts not with pills, but with psychotherapy. But first, these thoughts need to be identified …
For reasons that always elude, many of us seek to self-destruct. Recently, people have died from suicide more often than from murder and war combined. Despite the advances made by science, medicine and psychiatry in the 20th century (sequencing of the human genome, lobotomy, the emergence of antidepressants, rethinking how mental hospitals work), nothing has been able to reduce the suicide rate in the general population.
In the United States, it has remained relatively stable since 1942. Around the world, about a million people kill themselves every year. In the past year, more American soldiers on active duty committed suicide than were killed in action, and the suicide rate in this category has been on the rise since 2004. Recently, the Centers for Disease Control and Prevention (CDC) announced that the suicide rate among middle-aged Americans has risen by nearly 30% since 1999. In response, Thomas Frieden, director of the CDC, advised TV viewers to communicate more, heal their psyche, exercise and drink alcohol only in moderation.
In essence, he recommended staying away from demographic groups with high suicide rates. The problem, however, is that they include not only people with mental illness (such as mood disorders), but also uncommunicative loners and drug users, but also older white men, young Indians, residents of the Southwestern United States, adults who were abused as children, and people who have weapons at hand.
But most representatives of these groups never have suicidal thoughts, and they act even less often, and statistics are not able to explain the difference between those of them who continue to live and those who choose death. In other words, there is no way to know who will commit suicide in the next hour or in the next decade, and which risk factors will play a sinister role.
Understanding how suicidal thoughts develop, how to detect and stop them, is little better than two and a half centuries ago, when suicide became not only a philosophical but also a medical problem, and when doctors advised treating such people with a tub of cold water.
“We have never observed potential suicides the way ecologists or biologists, for example, do in their own fields,” laments 39-year-old Matthew Nock from Harvard University (USA), one of the most original and influential researchers of the phenomenon of suicide in the world. …
How to study suicidal mood in general? It's like trying to see a shadow - as soon as you shine a flashlight on it, it disappears. Developing suicidal thoughts in a laboratory setting is simply unethical. We have to use two frustratingly inaccurate methods: to investigate the life of someone who did kill himself in an attempt to find hints of his thinking, or to interview those who tried to commit suicide, but could not or were saved.
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Of course, the memories of the latter may be inaccurate, moreover, they often regret their thoughts and now think in a completely different way. Nevertheless, on the basis of the information received, hypotheses are created about how thoughts of suicide arise and how they develop over time.
Most researchers stop there, but Mr. Nock decided to go further. “It's easy to come up with an explanation, but you also have to test it,” he says. It is considered a common place that stress pushes to suicide: economic turmoil, exhausting caring for elderly parents and insolvent children, and then there is almost free access to dangerous drugs. Mr. Nock points out that suicide rates are also rising among soldiers who do not serve in hot spots, that the number of suicides among 45-64-year-olds is increasing and decreasing in a cyclical manner for about 20 years. How can this be explained?
Maybe some other approach is needed? Three years ago, Mr. Nock and his colleagues proposed the first objective, in their opinion, criterion that can predict the likelihood that a psychiatrist's patient will commit suicide better than the attending physician. This hypothesis is now being tested in hundreds of patients. If confirmed, psychiatrists, school nurses, and others will be able to assess the risk of suicide with the same degree of accuracy as a cardiologist predicts the likelihood of developing cardiovascular disease based on measurements of blood pressure and cholesterol combined with body weight.
It seems impossible because the thought process is incredibly complex. Man himself does not know very well what he wants. A suicide attempt can be impulsive - and then what to look for in retrospect, where to look for hints of a future suicide? Teenagers can exaggerate the topic of death as much as they want, but why does someone decide to take the last step (suddenly for themselves), while for others it still remains what it was - a romantic fantasy?
Here is one typical example. Melissa, 18, is a resident of Southern California. The girl had a developed imagination from an early age - she was "friends" with six fictional princesses. One of them was “kidnapped” all the time, and Melissa had to save her companion. Over time, she - a thin, pale, quiet and awkward - found herself a black sheep among her peers, they began to laugh at her, scoff at her. She began to drink and smoke marijuana, refused food, fought with her parents, her favorite pastime was writing the text of a farewell letter, but the girl never seriously considered suicide.
Melissa thought she was too cowardly for that. Nevertheless, one day she confessed to her parents that she was suicidal and asked to be sent to the hospital. She was kept there for five days, after which she was discharged with a recommendation to take some pills. Dad, a neuroscientist, and mom, a biochemist, found this drug too powerful and refused to give it to their daughter. They were afraid to leave her alone even for a few minutes and sent her to new treatment for drug addiction and mental disorders.
But Melissa felt that there she was only punished for the behavior, but they were not helped in any way to change this behavior, claiming that she resisted treatment. According to her, they agreed to release her only if she wrote an essay on the topic "Why do I manipulate other people by alternating passive and aggressive behavior in order to demonstrate my sexuality to boys." Such an attitude towards her inner state offended her (she herself believed that she was behaving completely differently and not at all for this reason), but in the end she told the educators what they wanted to hear - just to break free.
She was then prescribed medication for depression and anxiety and went through several outpatient programs that helped her. Melissa moved to another school in the junior grade, where she was already competitive, began to actively participate in public life: she played in school plays, collected money for poor Indian children. I entered college the first time. That summer, the mother of one of the girls, with whom Melissa was in a mental hospital, said: “What are you doing here? Everything is fine with you! For her, it was an unexpected compliment, because until now she had only thought about death.
Parents worried that she would miss classes due to the need for treatment from time to time, but Melissa gave up the medicine and stopped taking the pills, despite the dangers of abrupt interruptions. She was already 18, and she herself decided what to do with her life. She decorated the dorm room to her taste, found friends, started drinking and taking drugs again, and her academic performance declined.
A failure in a relationship with one young man led to unpleasant gossip all over the campus, she felt like no one needed anyone, as if the world would be better if she disappeared from it. On the evening after Halloween, she wrote a farewell letter, and when the neighbor and the other girls, who were doing their homework together, left the room to buy ice cream, Melissa took those anti-anxiety pills that she had once refused, all at once.
She woke up in intensive care. The doctor, cutting his clothes, bared the inscription on his hands: "Do not reanimate!" The girl did not remember how she wrote it.
Subsequently, Melissa could not explain how that evening was different from many others, when she felt exactly the same unhappy and hurt. “Somehow it all collapsed at once,” she said, not even trying to be original. “I just felt that I had completely ruined my life, and I saw no other way out.”
The earliest mention of suicide in literature can be considered, perhaps, "A Conversation Tired of Life with Your Soul", created more than 4 thousand years ago in Ancient Egypt. Until the 18th century. The "suicide mystery" attracted only artists, philosophers and religious leaders, not doctors and scientists. The first theory of suicide was proposed only in 1897 by Emile Durkheim. He argued that thoughts of suicide arise in response to a person's relationship with society: as soon as an individual feels that he is not part of the whole, when a gap arises in the fabric of everyday life, the thought is born that it is better to leave.
Sigmund Freud put suicide in the same category as masochism, that is, people commit suicide when an aggressive, super-critical superego turns on. The newest psychological theories postulate a connection between suicide and severe mental pain, which is accompanied by a feeling of hopelessness, the impossibility of breaking free, when it begins to seem that you are superfluous, that you are only burdening everyone.
It is also noticed that sometimes the desire to end one's life is inherited, that is, biology also plays a role here. “There are probably hundreds or even thousands of genes, each of which slightly increases the risk of suicide,” says Jordan Smoller of Massachusetts General Hospital, USA, who has collaborated with Mr. Knock. Gustavo Turecki of McGill University in Canada and his colleagues have shown that abused children experience changes in the receptors of the brain cells that regulate the stress hormone cortisol, causing a person to overreact to stress.
In other words, all our emotions are somehow encoded in genes and the brain, and once we understand these mechanisms, we can reduce the risk of suicide with drugs. But so far the most promising direction remains Mr. Nock's tests - today they are the most effective diagnostic tool, despite all the social and biological difficulties. They can also be used to judge suicidal thinking in general.
It all started in 2003, when Mr. Knock was teaching his first year at Harvard. Five years earlier, a test for implicit associations appeared, with the help of which it was possible to find out about prejudices about race, gender, sexual preferences and age, which the respondents did not want to admit even to themselves. One of the creators of this test was Mazarin Banadzhi, also from Harvard. Mr. Nock suggested that he change the test tasks in such a way as to check a person's attitude to life and death. After several experiments, one of the versions seemed quite decent to scientists, and it was offered to visitors to the Massachusetts Hospital. 157 people waiting in the emergency room were happy to be distracted. They hunched over gratefully in their plastic chairs and sat up on the couches.
Before the patient's gaze was a laptop screen, in the upper left corner of which the inscription "Life" appeared, and in the upper right - "Death". In the center, words began to fall in random order, and it was necessary to send them to the left or right headings by pressing the appropriate key, and without hesitation, as quickly as possible. The words were the simplest: "alive", "survive", "breathing", "prosperity" … "To live" had to be associated with "life", that is, to press the "left" button, and "funeral", "lifeless", " die”,“deceased”,“suicide”- with“death”.
If the patient was wrong, a red cross appeared and the computer waited for the person to press the correct key. Then, after about a minute, the names of the rubrics changed places, and everything was repeated. After that, new rubrics appeared: “I” and “Not me”, and the words were like this: “myself”, “me”, “myself”, “mine”, “mine”, “other”, “them”, “they ", "them". And again the rubrics were reversed.
Once patients got used to the rhythm, the bias measurement began. Above the heading "I" appeared the name "Life", under the heading "Not me" - "Death". Now it was necessary to group words like "breath" and "prosperity" with the words "myself", "mine", etc., and "die" and "funeral" - with "them", "they". It was believed that the faster patients correctly sort words and the fewer mistakes they make, the more they associate themselves with life.
Then “Life” and “Death” again changed places: “myself” and “mine” now had to be sent in one direction with the words “suicide” and “deceased”. The faster the person coped this time, the more he associated himself with death.
When psychologists and psychiatrists try to assess a patient's chances of suicide, they cope no better than a blind case (50/50), because people often lie because they do not want to go to a mental hospital. Many of them, moreover, are mistaken about themselves or do not know how to express their true feelings. About 90% of young people who subsequently commit suicide visit therapists within a year, and almost 40% of adults - within a month. And doctors do not help them to open up.
And the new test exceeded all expectations. Subjects who sorted the words associated with death paired with "I" faster than with "not me" tried to commit suicide three times more often than those who found it easier to associate life with themselves.
And it became clear: there is no point in talking to people about previous suicide attempts, because this does not guarantee that they will not try to do it again. There is absolutely nothing that would give the doctor, relatives, the patient himself confidence that suicide will not happen again. Just this test.
Mr. Nock and his associates are testing their instrument in various hospitals, as well as on volunteers who are ready to come to their laboratory (invitations are posted on the Internet). Other methods are being explored. For example, they put headphones on Melissa, which transmitted a frightening sound, while electrodes under her eyes measured the speed of muscle contraction.
The sound was accompanied by a display of pictures, some of which were related to suicide (for example, a train was on its way, and a man was standing in front of it). Scientists suspect that in order to commit suicide, a teenager must first overcome the fear of death, and the less they are afraid of such images, the more likely a suicide attempt.
In the future, Mr. Nock is going to prepare a program of four or five tests devoted to various aspects of cognitive processes. The work is far from complete. The data that the researchers received thanks to Melissa and other volunteers can be interpreted only after a few months, or even years, when it becomes known whether this person fell into depression, whether he tried to commit suicide again, or everything was fine with him. Melissa and the others will be called in six months later, then again and again to talk and examine many more times.
The researchers would like to repeat the famous experiment in which 5,209 residents of the town of Framingham, Massachusetts, participated 65 years ago. Scientists monitored their habits and examined them periodically. At first, it was completely unclear how to interpret the data obtained. But over time, some people developed diseases of the cardiovascular system, while others did not, then it became clear how high blood pressure and cholesterol, smoking, obesity, lack of exercise correlate with heart disease, what coefficient should be given to these factors in a risk calculator to reduce risk and so on. As a result, a significant breakthrough in medicine was made, and the death rate from cardiovascular diseases in the United States began to decline.
Of course, in psychiatry, everything is much more complicated - there is nothing like a blood test. But it seems that Mr. Nock and his colleagues have still managed to find a way to reveal hidden thoughts of potential suicide. It is easy to deceive a doctor, but you cannot deceive yourself.
Unfortunately, these tests do not solve the main problem - how to treat those who do have suicidal thoughts. The situation is complicated by the fact that current treatments are working very poorly. Earlier this year, Mr. Knock and his Harvard colleague Ronald Kessler published an article showing that about one in eight American teenagers are contemplating suicide. Moreover, more than half of them underwent specialized treatment before or after such thoughts appeared.
After this article, a flurry of letters fell on Mr. Nock, in which psychotherapists accused him of trying to undermine the entire system - they say, you cannot make such statistics public, because then people will stop being treated. “Yes,” retorts Mr. Nock, “it is necessary to be treated, it is necessary to be treated, but one must be sure that the treatment is beneficial. We give them pills, then we tell them that suicide is bad. That's all the treatment. This does not work.
For example, there is the method of Marsha Linehan from the University of Washington (USA), the purpose of which is to change the patterns of thinking and behavior (it helped Melissa a lot), but such experimental methods are not yet available for the vast majority of patients.
The Pentagon is a great help to scientists, which in 2009 initiated the largest suicide study in history to date. Just imagine what literal army of respondents is at his disposal: they are in plain sight almost all the time, lead approximately the same lifestyle. Mr. Nock dreams of the day when the military will be obliged to take his test on a regular basis in order to detect suicidal tendencies in a timely manner.
Mr. Nock himself believes that since the association of himself with death indicates a risk of suicide, then breaking this connection would help reduce this risk. In other words, thoughts of suicide can be the result of malfunctioning memory, cognition and perception. The switchman switches tracks by sending the train on a different line. So here it also makes sense to try to switch thinking, and not to stuff people with pills.
Most importantly, the suicidal mood comes and goes. At one point, it seems to you that you are on the top floor of a skyscraper enveloped in fire, and the only way to escape is to jump out of the window. But almost all of the failed suicides Mr. Nok spoke to admit, "I'm glad I survived."
Very many are not satisfied with their life, very many want to change it. Take Melissa as an example - now she is trying to build a life that would be worth living.