Nassir Ghaemi M.D., M.P.H.

Mood Swings

A suicide

Why did he kill himself?

Posted Sep 26, 2008

A few months ago, one of my former patients - I want to say one of my friends - committed suicide.

His mother informed me by email. (Email these days seems to be the messenger not only of mundane matters, but of existential crises). I had treated him for about three years, but then he and I had both moved away, he to Utah, I to Georgia, and we lost touch. He saw a new psychiatrist there, and continued the medications I had prescribed for him, low doses of a mood stabilizer for the bipolar disorder I had diagnosed. He had experienced psychotic mania once, flying to Germany with the belief that he heard voices from God.

He had experienced severe depressions too, as had a number of persons in his family. I knew the family well, personally; they were friends with my mother's family. So they came to me not as patients, but as friends.

I liked him so much; he was about my age. We had similar backgrounds ethnically and socially. We might as well have been cousins, but we were doctor and patient. Maybe I liked him too much. Maybe I should have pushed him to take more of the medications, like I do with strangers. But he was so familiar. His smile, in retrospect, may have seduced me into not seeing his suffering.

He killed himself, and we never talked about suicide. He never brought it up; I never brought it up. We never knew; or, more correctly, I never knew, because in his suicide note, he said he had been thinking about it for a decade.

He bought a gun in Wyoming; you only have to say if you have been involuntarily committed for psychiatric treatment in these vaunted background checks, it turns out. He had been voluntarily, not involuntarily, treated; he checked "No." They gave him a gun.

He bought some tape, and covered up his mouth and nose. Somewhere on the internet, he had studied how to kill himself most effectively. How many lives has the internet taken?

He went to his aunt's house in Seattle. He went in the woods while she was shopping. He left her a note, and one for his family. I read them both.

At first it seemed so rational: "I have had enough joy in life," he wrote. "Forty years is enough; why should I ask for more?" Philosophical suicide, I thought; a modern Marcus Aurelius? His mother said that he had not seemed depressed when they had visited from Florida a few months before. Maybe he was not sick, I thought; maybe it was rational.

Then I saw his picture in the gun application; he had bloated up, the handsome face now looked old and angry. He had aged from 30 to 60, without any years in between. What happened?

His family came to see me, his mother and father and sister. His sister was clear: "He was not the same that last time we visited," she said, 3 months before his death. "He was withdrawn, cold, preoccupied." Eating too much, uninterested in things, unable to concentrate. He had severe clinical depression after all.

I went to the wake. I brought my 5 year old son, forced by babysitting constraints. I had not expected too much talking, but one after another, his friends talked about what he had meant in their lives. There were pre-planned speakers, and then they opened it up if anyone wanted to say a few words. His sister had kindly commented about how much help I had been when he had been seeing me. I felt more like a failure; all doctors take the death of their patients seriously, a friend of mine told me. But I still felt responsible.

A family friend, a professor of economics, stood up and praised the family, and talked about how inexplicable his suicide was. I thought I had to say something.

I took my son to the front of the room, and talked about my former patient's depression, and his bipolar disorder, and how this illness killed people, like any other illness. I talked about how he took life very seriously, perhaps too seriously, and that he was probably severely depressed when he took his life. I did not want to diminish his death, I said; his life was not defined by his illness, or by his death; but his death was defined by his illness, I thought.

He was not just an illness, though; he was a man. And any man has more in common with me, and with you, than not. We are all much more human than otherwise, the psychiatrist Harry Stack Sullivan used to say. Which led me to recall the verses of Auden, who spoke thus in eulogy at a friend's suicide:

We are lived by powers we pretend to understand:
They arrange our loves; it is they who direct at the end
The enemy bullet, the sickness, or even our hand.

It is their to-morrow hangs over the earth of the living
And all that we wish for our friends: but existence is believing
We know for whom we mourn and who is grieving.

A while later, I came across a discussion of suicide in the psychiatrist Victor Frankl's book, The Doctor and the Soul. Frankl, who survived the Holocaust, talks about how life has meaning for any person who is loved by anyone. "Life is meaningful to every human being, under any circumstances," he wrote. Suddenly I realized the fallacy of my patient's utilitarian calculus about suicide; his life had much more to give him; more importantly he had much more to give life. The grief of his father and his mother and his sister was testimony to that fact.

Why had I not penetrated that smile?

He could not  think of any reason to live.  But Frankl thought of reasons even in a concentration camp. 

Sometimes it seems to me that even a good glass of wine is enough reason to live. Or maybe a burgundy sunset. Or a child's smile.

About the Author

Nassir Ghaemi, M.D., M.P.H.,

is Professor of Psychiatry at Tufts University School of Medicine, and Director of the Mood Disorders Program at Tufts Medical Center in Boston.

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