Why People Die By Suicide: Theories Through History

Margaret: [00:00:00] The highest time of risk for suicide attempts is the week to two weeks post discharge from a psychiatric hospital. 

Preston: And, and data shows that like when people are involuntarily committed, they're much less likely to seek like psychiatric treatment and other things outside of the hospital.

And welcome back to How to Be Patient, the podcast where we test your patients and ours as, oh, Morgan and I try to intelligently navigate through hard conversations. 

Margaret: That was a good opening, making it easy. 

Preston: Thank you. 

Margaret: Okay, season two. What? Let's go. 

Preston: Yeah, we, we roll with this stuff now. I 

Margaret: don't know if you know, it's I a podcast.

Do you tell people in real life that you have a podcast? 

Preston: No. I usually just say Pod I go here, record that, that for my pod. And you. But they, but like, if 

Margaret: someone doesn't know it, like you're on a first date or you like, I have a podcast, like that's the lead, that's the lead in. I try not to bring it up.

You're like, I'm famous.[00:01:00] 

So this, they already know you're this, this kind of, 

Preston: it comes up more often than I, I would like, I think, I think like I, so I try to like, go on dates with people outside of medicine and like assume they won't know, and then they'll just be like, I've seen him on before you page, I know who you are. I'm like, okay.

So like, what kind of want, like, I saw your listing video. Like, yeah, why, 

why are we open this so fast? 

So, yeah. Um, anyways, quick segue away from Preston's personal life into the topic of this episode. You sent the 

Margaret: entirety of season one. Trying to dig into my personal life. Now you don't like the un reverse, 

Preston: you see, that was a quick sidestep.

So, um, today we're, we're talking about why people die by suicide, which is something that I think a lot of people see commentary on in the public space. And it's something psychiatrists deal with all the time. But the mechanism of it, I think is often not talked about. 

Mm-hmm. 

And. The interesting thing to me [00:02:00] about like mechanisms in general is that psychiatrists in a way are kind of allergic to mechanisms, and this is the way we organize things.

But before we get into that, uh, we're gonna do today's icebreaker, which is tell me about a time that you felt like a burden. 

Margaret: Do you want, you want a real answer? Okay. Um, 

I'm like, there's so many jokes I could make here. 

Um, sometime when I felt like a burden, I think one I'm comfortable sharing is when my dad has a neurologic illness.

Um, and he was diagnosed with glioblastoma when I was like a junior in college, February 17th, to be particular. You remember those dates? Um. And when you're first going through grief or change like that, like which, you know, for the non-healthcare people are just non, not been to med school recently.

Glioblastoma is a really aggressive cancer brain cancer that usually [00:03:00] has like, I think a six month like diagnostic, like whatever. Um, so my dad is still alive nearly nine years later. But it, when someone first gets sick, you're kind of like, like people kind of rush to be with you. But I think grief that is more complicated than that and isn't like clearly punctuated by this happened and they passed away or this happened.

And how we think about how we can do things like as a family or what the future might look like changed. Like it's a, it's a moving amorphous thing that lasts a long time. And I think still having grief in different ways and having to explain it makes, was like a time where. I, I, I guess I sort of felt like a burden.

I sort of felt like this is just so heavy and dark and like I don't wanna 

Preston: over I I'm confused how you felt like a burden. Is it, is it because you were leaning on your friends or people? [00:04:00] 

Margaret: Yeah, and I think just like, you know, it was like junior and to senior year of college and it's like other people, like were we're reaching milestones and it's like, it's kind of like senior year of college.

Yeah. It's supposed to be like a happy time and then I'm like worried if my dad is gonna be alive. I see at the, by the time I graduate, like everything's, who are you burdening, 

Preston: who did you feel that you were burdening? I 

Margaret: think I just, I, no one said anything that made me think I was burdening them. It was, it was more my like own internal kind of feeling of like, this is heavy and dark and repetitive and I don't want to like ruin my friends, like the, or I don't want to bring them.

It was more than just like the content. It was like, I don't want them to bring this, like I. I don't wanna bring them this like, unsolved emotional energy that is just like dark and doesn't know if things will be good in life. Like Right. Like you feel like your life's falling apart when you go through that kind of, 

Preston: so your friends are excited and they're graduating, get funny internships, and you didn't wanna [00:05:00] like basically bring all this tragedy to them.

You, you didn't wanna impose. 

Margaret: Yeah. And I worked in ministry too. I was like a theology major and I was so, like, I was just like, what? Where not to be dark. I'm like, I'm burning the podcast right now. But like, at that time especially, I was like, where's God in this? Like 

Preston: mm-hmm. 

Margaret: Um, so that was is sometimes a time that I feel like mm-hmm.

It's felt really heavy in me and I don't want that heaviness to almost infect other people. 

Preston: That's interesting. 

So you, you felt like this deep emotional burden? Yeah. How about you? 

So mine, mine is quite different. 

Mm-hmm. 

Um, and when I was five years old and I was, uh, on one of those like bike extensions mm-hmm.

You know, that like your parents have, there's like, there's like an extra wheel with a seat on it. Oh, I do know this, that you can stick on the back of a bike. I do know [00:06:00] this. And my mom and I would go riding all the time with that. And I just remember all the time we're going up a hill and mom's like, I don't, I don't feel any pedaling back there.

Preston, we have to pedal on the hills together. And then like, I have another memory of me just like on the side of the road getting scolded while my mom's like trying to jug water. 

And, and then she'd be like, she's like, those quads are weakest me a hell of a lot easier without 50 pounds of dead weight.

I would like pedal for a little bit and then I'd get distracted by like leaves or something and then we'd like slow down and ugh, I, yeah. So I was definitely a burden. Then. Physical, A physical burden. Like she was emotion, she emotion was literally carrying the weight of me up a hill. 

Margaret: I'm laughing because my dad and I, I didn't learn to ride a bike till I was like eight, embarrassing.

Um, and we used 

to go on this like family long bike ride up in Wisconsin and my dad used to have to do [00:07:00] that. Like he would take me, I would be on the back of it. Mm-hmm. And he would similarly be like, what are you doing? And after he got sick when we went to Door County, which is this place in Wisconsin again mm-hmm.

He was like, couldn't ride a bike. And he was like, Maggie, guess who's riding on the back of the bike now? So just delightfully connected in odd ways. 

Preston: So funnily enough, my, I also wrote it on that thing with my dad Uhhuh, and one time he, uh. He was trying to make a turn around a stoplight, and the whole, um, contraption collapsed and he broke his arm.

So I remember the, 

and then the, the firetruck came and they had like, they had like stopped the entire intersection. My dad's just like sitting there with his arm broken. Like, I remember talking to a fireman and I'm, I'm just sitting, I was sitting on the sidewalk and I was like, dad, can we go home? Come on dad.

Like, talk money about your arm. So actually that 

was a burden to me at that point. And then a lady came up and said to the fireman, Hey, [00:08:00] can you change the light back to green? And that's how I learned that the fireman can control stoplights. 

Margaret: Wow. Yeah. In a way you learned about God that day too? Both. A lot of same themes.

Preston: Weirdly enough, when I'm in traffic and like I see sirens and they, they pull over and they change the light to green, I think about my dad and how he broke his arm in that intersection. All right. This has been a great icebreaker and moving 

on to the mechanism of suicide. 

Margaret: And Preston and I were both annoying as kids and couldn't ride bikes, so we should go from this 

listener.

Preston: Exactly. So, um, the, the, the burdensome part will become more relevant later as we kind of dive into some of these theories. But now, now a word on, um, causality in psychiatry, we like for some reason, refuse to use this like concept of like being secondary to hmm. Of something else. And so I guess what, um, for people that are like less inclined in medicine, when you say secondary in medicine, it means indirect cause of, or indirect response to.

So an example could be renal [00:09:00] stenosis or hardening of the renal arteries, arteries, secondary to high blood pressure. So hardening the renal arteries, indirect response of high blood pressure. So we've established that we have a primary disease mm-hmm. And it causes other secondary disease. Mm-hmm. And those secondary diseases can cause.

Third level things, which are called tertiary, but we don't need to get into all that. The point is a lot of medical science feels comfortable with this linear causality. 

Mm-hmm. 

Even though there are many other things that could cause one or another, but psychiatry doesn't do that. We're just like, it's all a soup and it happened together.

Mm-hmm. And 

you kinda like see that in our notes. So like for example, a patient will come in and they're suicidal. Mm-hmm. And it's like right after their girlfriend broke up with them. Mm-hmm. Like their girlfriend's like, I'm breaking up with you. And they're like, I'm gonna kill myself. 

Mm-hmm. 

But then when they come in and we like write up their whole assessment, like saying like they're suicidal, secondary to a breakup and direct response to a breakup is like not the language that's kind of like tolerated or [00:10:00] accepted.

It's like they were suicidal in the context of relationship difficulties and also. Maybe medication non-adherence and also substance use and also, you know, poor life or poor coping skills, life stressors, things like that. So we're like, well, you know, they, they don't have a lot of good ways to cope and also they weren't on their meds.

Mm-hmm. And also, you know, they don't have another like house to go live at if they broke up. So all that really was contributing, but we don't like, know the direct cause. It's like, 

Margaret: but they don't like how long our notes are. 

Preston: Yeah. Who's to say, you know? 

Margaret: Yeah. It's 

Preston: just, we're all just people swimming in this, this, um, stew that is the biopsychosocial model.

Margaret: Well, like psychiatry is also like, our nature is as a field has historically been, if we can't figure out why something's happening to the brain, it's not neurology, it's psychiatry. Like if there's not an organic cause. Yeah. Historically it has been psychiatry's purview. [00:11:00] Um. To be like, okay, we can't know.

Like when, when we can know it becomes neurology. 

Preston: Yeah, exactly. And, and I think that the more we run with it, the, I think the less effective that will become for our field. Mm-hmm. And, and maybe, you know, I think a hundred years ago is really relevant when even things like syphilis weren't identified. 

Yeah.

You know, so who knows? It's probably psychiatry, but like, people who had neurosyphilis back in 1905 

mm-hmm. 

Were, they were in psych wards, right. With psychosis. And they were kind of seeing the same as people with schizophrenia, because we just didn't know what aspire acute was. There's these microbes in their blood that are causing this.

Margaret: Why do you think, you're saying like the modern, modern psychiatry is allergic to having a cause. What do you think is like the cause of our allergy to causes? 

Preston: I, I think it's, it's because like the genesis of our profession is being a rule out specialty. [00:12:00] We, we were built on all medical causes ruled out first.

And I, it like, and everything is categorized in, is it a medical cause or is it a psychiatric cause? Mm-hmm. And like for some reason we're like annexed over here on this island. 

Mm-hmm. 

Like Napoleon or something. And we need to come back and click our arm. 

Margaret: We have to come back and conquer 

Preston: medicine. No, seriously.

Like I, I, I did that today on a note, I have like, our note template is like psych problems. Mm-hmm. And then medical problems. And this patient has like delirium and cerebral ataxia and hallucinations. And I'm like, these are all, like, this Venn diagram is all overlap. So I, I can't neatly divide them in their like psych problems and their medical problems.

So I just deleted all of it 'cause I got annoyed with it. 

Margaret: Mm-hmm. I was gonna say, we were talking about, I had a lecture yesterday that was like. Talking about defining normal in psychiatry and it's like a historical, ethical, clinical perspective. When we were talking about like going from DSM four to DSM five and that we like had the axes model and [00:13:00] you could have these, like this is a a little 

Preston: a field, they like numbers on a slider, right?

Margaret: They had like, it was like personality, I like, it 

Preston: was like, it was like 40% personality. 

Margaret: Well, but in some ways that's more accurate. Like it's, it would capture more Yeah. What you're saying, right? No, I agree. But there's still that not clear at the center of our work still remains the, like, is there a cause?

And then there's also the history of our job being like, we actually do know the cause and 

Preston: mm-hmm. 

Margaret: We'll fix it with malaria. Yeah, 

Preston: exactly. Yeah. Or like you 

Margaret: sinned. That's why like historically, we're still trying 

Preston: to get back against our Correct. For the complacency that we had early on. Yeah, that's tough.

You know, lobotomies are tough. They're really hard to have. So yeah, I mean, maybe we're in the right spot. We should still be humble. I, I, it just makes me wonder like, are we just gonna keep slowly finding mechanisms for stuff and psychiatry's gonna shrink until we inevitably like, map every neuron in the [00:14:00] brain and prove that free will doesn't exist, and then our field will just be completely absorbed into neurology.

Well, that's season three of the podcast anyways. That was just a shower thought I had this morning. You have been working a lot. Yes. 

Margaret: Sorry guys. 

Preston: Anyways, um, anyway, 

Margaret: I'm super cool. 

Preston: When we think about the mechanism for suicide, though, this is something that like, kind of is debated in a lot of like psychosocial circles, and I think it can be helpful to at least start to understand these different paths that people take when they approach it, which is ultimately the point of kind of this whole argument about looking for mechanisms in psychiatry because mm-hmm.

I often like kinda look at the neuroscience aspect of things and find mechanisms and I may have to, you know, sur surmise or make some generous leaps with, but the same kind of applies here on social stuff. So as pretend that we're getting on the Magic School bus and France, 

Margaret: this is so gonna be a really dark episode of Miss.

Preston: Yeah, sorry. If its Frizzle on, gone to France. 

Margaret: Is this not, this PBS [00:15:00] 13, like 

Preston: in 1897. And I'm not sorry because it's 1897. I'm sorry because it's France. Um, but anyways, there's this guy, Emil Durkheim. Have you heard of him? 

Margaret: I have heard the name, but I do not, I couldn't tell you anything more than that. I would say I probably should know more about him.

Preston: Okay. So he was, uh, a sociologist who was really interested in studying why people take their own lives. 

Hmm. 

And he wrote a book called Less Suicide. He, he had this really interesting theory as to, to what drives people to do this. And his, um, theory was all built around society. He was like, it's, he was like society.

It's all the connection to society.

Which, which is like wild as it sounds. His, his theories have survived the last 125 years for a reason, and it's because it, it actually assaults society, um, in a way. So, yeah. What did he think? He came up with four different [00:16:00] categories for kind of the different mechanisms of them. And I wanna, um, they all kind of have different levels of like people's connection to society and also different levels of like, their regulation within that.

So the first one I wanna start out with is like a very classic one that we see. And this is called, um, a no suicidality. 

Mm. 

So a meaning like without like atypical, like it's not typical. And then noic meaning like laws or norms. Mm-hmm. So without law lawless really. So this is the type of, um. Suicidality that like a couple different modern models are built off of.

But it's when you have a lot of extreme, um, emotional or psychosocial distress, maybe upheaval, maybe a big crisis mm-hmm. And you can't cope with it, and you immediately, in a way, you kind of extinguish this feeling. 

Mm-hmm. 

Um, turn to suicidality almost like you're panicked and you unplugged the game.

Mm-hmm. 

Is kind of how I think about it. 

Yeah. 

So a good [00:17:00] example of some of these that we've, we've probably seen are like during the oh eight crash when some stockbrokers lost and you and I were, were 

Margaret: were 12 and yeah, 14 and 

Preston: 12. I'm like on, we fit listening to like, my parents, you're 

locked. I'm like, like, I'm a freshman in high school.

I'm like, snowboarding,

my mom's crying. Why is your broken? She's like, we're upside down on our mortgage.

Margaret: You're like the, we just called me fat.

Preston: Yeah. So, so anyways, um, we didn't lose millions of dollars overnight, but some people did. Um, and we heard about them. Like, IM immediately like, jumping off of buildings Yeah. And, um, taking their own life. 

Margaret: Yeah. 

Preston: Um, another example of this could be someone who abruptly deals with a really big transition or a loss of identity.

So, or even like a large sentencing. So we've seen like footage of people who have been sentenced to life and [00:18:00] then like, take a cyanide pill in prison. Um, another good example of this could be that, um, in White Lotus season three, 

Margaret: I was gonna say away. Yeah. 

Preston: The, the dad was like becoming suicidal at like confronting like this huge change in loss of money for his family.

Right. 

Margaret: And you can see in the show like these like iterations of, of imagination that he can't. Think of a way in a lot of those moments of a life that is different and not subsumed by this current moment mm-hmm. Of the financial loss and arrest or whatever. 

Preston: Yeah, exactly. And he, and he's like, he's so dysregulated.

He is looking for a way out and he can't, and his has aspects of a different one, another one as well. Mm-hmm. But that's is a good example of it. So these are the patients that, um, weirdly enough, and we'll talk about this more in another episode on risk factors, but safety planning can be more effective for them.

Hmm. 

Just because a lot of this is kind of like a failure to cope with like severe immediate distress. 

Mm-hmm. Yeah. And 

this is kind of a way to [00:19:00] escape that. It's, it's kind of like, it's, it's failure of coping really. 'cause normally you can cope and make a feeling go away, but if you're like, I can't make any of this go away, this is like, this is going nuclear 

Margaret: really.

I wonder also, like with this kind of thing where there's this sort of sudden change and sudden like negative impact. It sort of intuitively makes sense, although I don't like using intuition for clinically reason, but 

Preston: mm-hmm. 

Margaret: That it's having another person's safety plan and come up with coping skills and a support plan, like to kind of in the dysregulated mind to have a regulated kind of executive function person come in and plan with them, versus when there's more of the element of like chronic hopelessness 

Preston: mm-hmm.

Margaret: Where there has been a lot of things that have been tried and not helped. Um, yeah. 

Preston: Great segue. Basically with dealing with this chronic hopelessness and trying different things and realize that the future can't happen being a reason for why you might wanna, um, take your own life. And that's with the fatalistic [00:20:00] concept of suicide.

The opposite of anomic, which is too little. Regulation is too much regulation. And then that's the concept of like just being a, a prisoner of your environment. So the, the way I kind of think about it is like you have this perceived hopelessness, um, from your shackles. And there's no way for you to like escape this situation.

And so then, then you say, okay, I'm not in a panic mode and I'm not thinking, I'm not, I'm just pulling the trigger. It's, I've thought about this a lot and there's no way forward. That's why I'm gonna end it. 

Margaret: How do you feel like, because I, I see how I could feel like I'm kind of confused on how that's different than the like crisis.

I see. No, like when we're thinking about like the white lotus guy situation, 

Preston: a hypothetical patient could be like someone who's like completely disabled. And they are incontinent. Mm-hmm. They get repeat urinary tract infections sometimes like so severe that they have to come to the hospital. And now they have extended spectrum bacterial resistance.

So they have these like [00:21:00] week long hospital stays where they get these like terrible hospital sores and they go back out to specialized nursing facility where they get PT and then they get delirious, get another infection, go back in, and then they finally get home where they have like no quality of life or anything that they wanna live for, and they just kind of like feel terminally trapped by their situation.

That person will come to the conclusion that I want to end it all. Yeah. And by too much regulation, I just, I'm, what I'm saying is like too many barriers, 

too many constraints, 

things like that. So this isn't out coming from them, out of this like crisis and immediate need to cope and try to extinguish this.

Transient, albeit intense feeling that's coming on from like that upheaval, like, oh, it crashed. This is a thorough and well thought out conclusion that there is nothing to live for because of my constraints. That would be more like the fatalistic picture. 

Margaret: It feels like [00:22:00] metaphorically, like the first one's kind of like if I, like, if I like you suddenly had appendicitis and there was something suddenly wrong versus you suffering with like Crohn's disease, like the emotional kind of insult is mm-hmm.

Acuity is 

sort of 

like the, the, there's like this longer lasting ongoing thing and like no way out versus like sudden really negative thing. Yeah. 

Preston: Possibly. There's a way out. I would say one is like getting shot and dealing with that immediate pain and the other one is like being trapped in a well. 

Margaret: Can you elaborate on this metaphor?

Preston: Yeah. So like, when you're trapped in a, well, you can look up and you can see sunlight. Mm. But you'd know, you'll never be able to reach it. Ah, okay. 

Yeah. And all you can do is sit 

around all day and contemplate how trapped you are. 

Yeah. Yeah. 

And maybe like you've tried to find ways to, to cope and to to live in the well, but ultimately decided that you're not happy 

mm-hmm.

With that, 

and that the things that you wanna live for aren't worth living for. 

Yeah. 

So [00:23:00] this can be come, like really relevant in how we conceptualize it For some patients who maybe because of their depression or other things that impair their cognition, may perceive burdens or assess burdens to be different than they actually are.

Mm-hmm. 

And so a lot of this is kind of tied to hopelessness, which is a, a really classic symptom of depression. 

Yeah. 

So in, in that case, like there are some people that very well like, like that, you know, disabled patient, that they do have these really strong barriers in their life. 

Yeah. And 

there's other people who maybe they have other options, but because of their psychiatric illness, they are, they have trouble assessing them.

Mm-hmm. Mm-hmm. 

Does it kinda like make sense? It's almost like they're not in the well, but they, their body's not in the well, but their mind is, I 

Margaret: guess. Yeah, yeah, yeah. I got you. But they're like, they're like, this can both, both be this, it's like this match of like external environment, negative things, internal mental, like health perception, [00:24:00] affective of state illness.

Mm-hmm. And how those two combine if they're in the well or not. 

Preston: So, so these are kind of like probably classic ones that you see and, and I imagine you're probably able to already like think of examples mm-hmm. That you've seen in clinical practice that kind of line up with both of these. 

Margaret: Yeah. The thing that's coming to my mind is like, I feel like a lot of times patients that are kind of challenging and outpatient are the people who maybe are kind of the in the well, but then suddenly someone shoots them in the well.

And, yeah. Sorry, sky. No, seriously, like bad metaphor. I'm sorry. We, 

we took the metaphor too far.

Preston: Yeah. Maybe, maybe one is like taking a shot's, like stubbing your toe 

Margaret: or No, like if it's like someone's chronically kind of like, maybe they have passive suicidal, like suicidal thoughts, but no plan or intent. But then like something, 

Preston: a crisis isn't super imposed on possible, on top of it. Yeah. So it's like 

Margaret: the, the both.

The both and I guess, 

Preston: yeah, these, these can stack [00:25:00] unfortunately. Mm-hmm. And like an example could be like if that character from the White Lotus had been depressed for a while. 

Yeah. 

And then now he's facing this. Yeah. Like everything is like kind of coming against him. 

Right. Right.

Margaret: Hey, Preston, what does the sound remind you of? Oh 

Preston: God. It, it makes me think about being on call. It's the pager. 

Margaret: Okay. Well, it's not my pager, but it is equally stressful. And is the timer I use for studying? 

Preston: Oh, we got a Pomodoro queen over here. 

Margaret: Do you know what is made studying Less stressful though. 

Preston: What 

Margaret: Now, you know, psych, you familiar?

Preston: Am I familiar? I, I use nine nosy for my in-training exams. Are, are we talking about the same thing? That excellent resource that has thousands of questions with associated flashcards, organized content in a user-friendly way. 

Margaret: You use it for pride. I'm using it for the board exams. But yes, we are talking about the same resource.

We, 

Preston: we can use it for both ao 

Margaret: Ready to take your [00:26:00] exam prep to the next level? Go to now, you know, psych.com and enter the code. Be patient at checkout for 20% off. That's now, you know, psych.com. 

Preston: Hey, so I wanna talk to you about this new podcast I think every clinician should be aware of. It's the sepsis spectrum from Sepsis Alliance, and it's done by this great critical care nurse, Nicole Kubic.

Margaret: You may be asking why are two psychiatrists talking about sepsis? But if you've spent any time, uh, in the hospital where psychiatrists or mental health practitioners go, you know that whenever someone's mental status is altered, we can be called and. Not knowing the signs of sepsis, whether that's in the ICU, the ED or other places in the hospital, can mean that we're missing things alongside the team for things that'll really impact our patients.

Preston: Yeah, I mean, delirium comes on quick and fast, and you have to keep it on your differential. It's hit me on the, the inpatient psych floor and mm-hmm. Even for nurses that work in mental health and don't think they're gonna come across this stuff, it, it's gonna come across you. So it, it's important just to, to keep it on your radar, and I think this is a great resource for it.

So if you want, you can listen to the sepsis spectrum [00:27:00] wherever you get your podcasts, or you can watch it on Sepsis Alliance's YouTube channel. 

Margaret: To learn how you can earn free nursing CE credits just by listening, visit sepsis podcast.org. That's S-E-P-S-I-S podcast.org for more information.

Preston: So the next kind of archetype or like, um, common theme. That was brought up by Durheim. It's actually probably something that neither of us has have come across in clinical care, and that's altruistic suicide. 

Margaret: Like Puku. 

Wait, that's honor Puku pu Yeah. You would know how to pronounce it correctly. 

Preston: Um, kind of, I guess, yeah, actually, so this is a way, this one is from regulation, but almost like too much connection to society where you've become so invested in society that your own life is more [00:28:00] important, is your own life has more value in what it serves to society than it does to you, I guess.

Margaret: So being like a martyr for a cause would also be 

Preston: Exactly. So kamikaze pilots in World War II would be an example of altruistic suicide, um, people that are willing to die for a cause. 

Yeah. 

So, and, and this is from. Radical, almost like, like hyper integrion into society. Yeah. 

Margaret: Versus into hyper individualism.

Preston: Yeah, exactly. Yeah. So these other, while these other ones that omic and fatalistic kind of have to deal with your emotional regulation response to the constraints of society, this one is in direct reaction to your integration in society. 

Mm-hmm. Yeah. And 

it's being like, you're so embedded in soci in society that you're willing to submit your life to, um, the cause or the purpose or whatever function that you hope society uses it for.

Margaret: Yeah. It's almost like, I feel like [00:29:00] when they talk about like bee colonies, how they're like, it's almost that level of integration where they're like, sacrificial, I don't know enough about bees to make this metaphor stick. Mm-hmm. But like that there is this like change of how bees evolve and then how they kind of, I mean, I, I think the, I mean it's in the military kind of in general.

Yeah. A level of. So I would, how much risk do you have to take for it to be counting as this? 

Preston: I would distinguish between tolerating risk and service of your, of your country. Mm-hmm. Like being willing to be in combat or something versus altruistic Suicide is like knowingly taking your own life. Yeah. For the cause.

So there's a difference between like being a part of a fire team and going into Uhhuh like a high intensity, dangerous environment where the intent isn't for you to die, it's for you to complete the mission, but if you do die, you're willing to lay your life down. Yeah. Versus I'm going to kill myself to detonate this bomb for the sake of [00:30:00] my organization that's trying to make some political point or something like that.

Which is something we define as terrorism. 

Margaret: There, there is kind of a spectrum of it where like, like these two examples, like have that clear delineation, but like if you're 95% sure you're being sent on a mission and like that, there's a 95% chance you die. Like. Not that you would necessarily know that, but you know, there's like different odds for different things.

I'm thinking about like different rescuers or like nine 11 rescuers, like 

Preston: mm-hmm. Yeah. Like, don't, don't go back into the burdening building, John. It's suicide. And he is like, I have to save those kids. Like that type of, 

Margaret: I say its just to not other, this as like something that doesn't belong in our current culture.

Just because like if it, if it's like either or, then yeah. It's kind of easy to be like, that's not here, but I think mm-hmm. It's somewhat an arbitrary line. Like how sure do you have to be like, does it, it's like it's only if you're a hundred percent sure you're gonna die. 

Preston: Um, no, you're, you're right. It is arbitrary.

It, the, the line is a bit arbitrary and it is a spectrum because [00:31:00] on one end you could say, I'm, I'm willing to risk 0% of my life mm-hmm. For like, the sake of my country. Like I, which is how I feel about 

Margaret: this podcast. 

Preston: Yeah. Yeah. You know? Why would you risk your life for a a, a man with an SM seven B pair of headphones in a lot of opinions.

So anyways, there, there's 

0%, right? Like I, like, I won't even enlist. Mm-hmm. I'm not, I'm not doing anything. This, and then there's like willing, willing to enlist, but I won't be in combat. Well, there's still the, like, the risk is higher, but it's not there. Mm-hmm. And then, you know, there's 99%, which is, you know, I'm indirectly putting my life at high risk by doing this, or even in those situations.

Like I'm jumping on a grenade for my fellow teammates. 

Mm-hmm. 

You know, I think that would be kinda like the one that rides right in between there where you're on a combat mission. Yeah. And then a grenade pops out and you jump on it for the sake of other people. That would be like high intense moment of like altruistic suicide.

Margaret: Yeah. I mean, I'm not gonna, this is what Ashley make this a [00:32:00] feminist podcast, which is also to say, uh, pregnancy and childbirth would fall on the spectrum. 

Preston: Sure. Yeah. Like, like risk to your own life for the sake of others. Mm-hmm. 

Margaret: Anyway. But maybe be more 

Preston: like if society wanted you to have that kid, like some handmaid and steel type thing.

Margaret: Yeah. Yeah, that's true. It would move the pers, it would move it more towards or away from that kind of like. Mm-hmm. 

Preston: And so I guess what's interesting about this and then the reason why we probably haven't come across it is because this type of suicidal behavior does not really considered psychopathology, I guess.

Yeah. Yeah. 

So this isn't something that you like find in the dsm. These aren't people that are like classically seen to have mental illness. They're just very bought in to whatever belief system they subscribe to. Yeah. Enough to do extreme acts and, and I think it's kind of fascinating because when Durhan was writing about this stuff, he wasn't really categorizing things in the DSM and like, this is sick and not sick.

He was just like, why do [00:33:00] people take their own lives? 

Mm-hmm. 

Question mark. And it's like, oh, sometimes they take their own lives 'cause they think there's no point to life, but sometimes they take their own lives because they're so bought into a cause that they're willing to lay their life down for it.

Right. Right. 

And we've taken some of them and said like, this is pathology. And the other ones we're just like, that's okay. Yeah. You know? 

Margaret: Yeah, 

Preston: you're welcome to. 

Margaret: Yeah. It gets at this core question that I think is at the center of a lot of medicine and, but especially psychiatry, which is underneath our diagnoses and things that we talk about is an implicit value system and philosophy of what makes like the good life or life worth living.

Um, what, what makes that, when is it, when is it a good reason to die, you know, kind of morally. Mm-hmm. Or when is it path, thought, path pathology to die? Because you could imagine a world, I don't know, I'm not entirely a relativist, but like you could imagine a world where we had a different set of values that 

Preston: mm-hmm.

Margaret: If we completely were like, life is about pleasure, and if someone's like been ill for this long, then [00:34:00] like, it makes a hundred percent sense to do that. And by a pleasure principle, it would make no sense to die for the valor or for, for the like, good of the community if the whole point of life is to just enjoy the most that you can.

Preston: Exactly. Um, my, my sidebar to like kind of, 

Margaret: sorry. Yeah. The, the 

Preston: philosophy of the good of life. Yeah. So, um, if the, the purpose of life is to achieve as much pleasure as possible, then by implication, the worst thing in life is the cessation of all pleasure and what is death, but the cessation of all pleasure.

So by kind of living this hedonistic life, we're taught that the worst thing possible is death. Mm-hmm. But in societies where the greatest good in life maybe is to serve others. Mm-hmm. Then death is no longer the antithesis of the greatest good of life. It's actually in line with serving others. Yeah.

And so in those other cultures that have like kind of a different idea of the greatest good, they fear death less, 

Margaret: or like even in our culture, people who are religious. 

Preston: Yeah. It can be. Yeah, exactly. I think I was kind [00:35:00] of referring to the, I don't know, passive nihilistic western culture where they're not like, particularly religious, but haven't like, thought forward a, a strong belief system or just kind of existing.

Mm-hmm. Mm-hmm. 

So that's fun and exciting. Sorry for that sidebar. That was a good, actually good, a good sidebar because, um, it kind of goes into the next one, which is the opposite of altruistic. So if altruistic was too much societal integration, you have one left. Just too little societal integration. And this is actually the one that most models are built on today, and that we've expanded upon a lot.

So we're gonna take a quick break, and then when we come back, we'll kind of go into the egoistic model of, um, suicidality and how we start to conceptualize it today.

And we're back to talk about the egoistic concept of suicide. 

Margaret: And is this part of [00:36:00] the, this is, 

Preston: this is Durkheim's final film. Okay. Final column. Yeah. So the complete opposite of the. Altruistic languages. Too much integration is egoistic, which is too little. So this is the person who's isolated or ostracized from society.

And the, the, while Durham kind of described these, these loners or people that, you know, felt this isolation then turned to suicide. This was the one that's actually been expanded upon the most. Mm-hmm. And so now I'm gonna kind of push this forward a hundred years to, um, the early two thousands with Dr.

Joyner. So Dr. Joyner is actually, he's a psychologist at Florida State. So he, his father died by suicide and a couple years later he wrote this book, why People Die By Suicide. And I am, as I was kinda like reading about what was happening and talking to mentors, I, I guess he was started on this project to really figure out like, what drives people to do this.

Mm-hmm. And he had read Durkheim and [00:37:00] other people that have like conceptualized this, but he started to focus more on this. He. Social isolation as a driver of suicide. Mm-hmm. And he, he read hundreds, thousands of suicide notes and started to put together a couple themes. And one that was already present is one that's coined by him, which he calls thwarted belongingness.

So being kicked outta society was already there. That, that like social isolation. But he, he saw this as actually like the starting block of, um, almost like a series of events that progresses, but it always started with that thwarted belongingness. 

Margaret: So like what would an example of, of that be? Of, of this?

Like would it be as some, something as common as like bullying? Yeah. In junior high. Okay. 

Preston: Absolutely. So a great way to not belong could be like being transgender as a teenager or a homosexual. Um, it could be. [00:38:00] Being from like a different race or something. Those are all like very easy ways to not belong.

But then, um, poverty can be another way to, to not belong in groups. So like, humans are social ba creatures by nature, and we have certain needs. And unfortunately, we're always looking for ways to form ingroup and outgroups. Mm. And as we do that, people are gonna inevitably end up in some of those outgroups.

There's this always like, initial insult of that. Mm-hmm. Loss of belongingness. And the way I kind of think about it actually is like, you have like your main things you need to survive. Like you have food, water, shelter, oxygen. Mm-hmm. Sleep. And then I would add the fifth is like belongingness. Yeah. Really 

Margaret: Maslow's hierarchy.

Preston: Yeah. Like it's, it's something, it's something that if you, if you take it away, it like eats at your soul. 

Margaret: Yeah. Yeah. I mean, I think. Like anecdotally, just thinking about being on call in the [00:39:00] emergency department over the last few years, there is that kind of sense of disconnection that is often reality based, but even sometimes not reality based, but just like the felt sense is so strong of like, I don't belong to anyone or with anyone.

Why should I stay alive for just my own sake? 

Preston: Yeah. And, and that, that question like why, why stay alive? Yeah. My own sake is, is something they wrestle with for a while, but when it starts to shift is when they start to feel like they're a burden to others. 

Yeah. 

So that's actually the next step that joiner identified, which was perceived burdensomeness.

Hmm. 

The, the problem's been identified that like, I don't belong and I'm not appreciated here. I'm not wanted. Mm-hmm. But now in addition to me not being wanted, my existence is making things worse for other people. 

Margaret: Yeah. 

Preston: And this is something that like I, I. I see a lot in like kind of the pattern of thinking of patients who they already feel like [00:40:00] they're unhelpful.

They maybe, um, it's like a divorce dad. Yeah. It's a common one. They don't feel like they belong in their family and now they're being told in all the ways they're making things worse for everyone else. They're causing conflict or that maybe they have substance abuse problems and people are telling them that like they're a burden and they kind of, they, they come to this conclusion that everyone will be better off without me.

Yeah. 

And that's actually like a really common theme that Joiner was observing in all these suicide notes. Is this, this kind of the phrase of like, the world be better without me? 

Mm-hmm. 

I'm, I'm doing everyone a favor by removing myself from this existence. 

Margaret: Intrinsic in, in that is such a, like, like a direct, how we would think about like nuclear families or just like close, you know, small circle of connection.

But it also makes me think about like c and how kind of. Deeply fragile. The social bonds became during that time, and I think in some ways are still recovering [00:41:00] of not just like who you live with or who you talk to frequently, but just like it's not, it's not just belonging to like a couple people that matter.

Mm-hmm. I think that ultimately matters. People, it's like the belonging across multiple communities and different parts of your life. And I just wonder with like COVID and then work, like people working remotely, everything being video and digital and less connected, how that impacts, um, how we think about this factor that you're talking about or cause 

Preston: the perceived burdensomeness 

Margaret: the burden, like the not belonging and then the burdensomeness Yeah.

Of just like, I, you, you don't kind of the, not the opposite of it, but the like sense of like, oh, I go to work and like, you know, maybe it's not the biggest thing, but I make this person laugh at the like water cooler and then I like. Talk to this kind of loose friend, and then I come home and maybe see someone that I like, I see my partner or my family, whatever.

But it's like those lack of [00:42:00] those positive things I could see contributing to the sense of being burdensome. Because it's like only a couple people that you're interacting with every day that like, if they, if you don't feel like you're good to them. 

Preston: Right. So like, um, when you're trying to assess your burdensomeness Hmm.

I, I guess I'd say you're trying to, you're thinking of ways you're unhelpful and imposing problems on others, which would be your burdensomeness, but then that's being countered by how am I helpful? 

Yeah. And how 

am I benefiting things? Yeah. And so as you're kind of like weighing the scale, if you're, if you live this life where you feel you don't do much good 

Yeah.

Or like help anyone else out, it's, it's easy for those thoughts of I'm not doing much, I actually cause problems for other people by existing, those thoughts can get louder and they have space to take up the whole room. 

Margaret: Well, I've had, I've had a few patients who have said like, I mean, I feel like I wanna die all the time, but I won't.

You know, people will say family members, but they'll also, I've had a few people be like, I don't want my pet to be confused and not know where I am, and I need to take care of them. Like mm-hmm. [00:43:00] But even that level of kind of burdensomeness versus usefulness is Yeah. Protective. 

Preston: No, and, um, we can get into this more in the, the episode that we do on risk factors, but having a pet can be a very strong protective factor.

You, you have something that you're responsible to in this world. Mm-hmm. And like, I could be a burden to everything else in the world, but Magnolia is dependent on me. She's count on me to get up the morning and feed her. 

Margaret: Not lilac. 

Preston: Lilac would find food on her own. She would chew through the door. She's 

Margaret: very industrious.

Preston: Yeah. She'd figure it out. So, um, but, but the, the important thing, and one thing that I find interesting between kind of both the egoistic and altruistic. Like concepts of suicidality is that they both start to have this turn where it is altruistic. Mm-hmm. So I'm killing myself for the benefit of society because I'm, I'm laying my life on the line for this cause and also I'm killing myself for the benefit of society because I'm [00:44:00] removing me a burden from society.

Yeah. But both are hoping to like, make the world better without them. Yeah. 

Margaret: To give another media example that I think gets at this, did you ever, probably not. There's this movie and book called Me Before You, and it's Sam Claflin is in it and, uh, he bas I think he, I don't remember, he had an injury and basically gets, is paralyzed from the neck down.

But the, the book in the movie are about this girl who becomes his like caregiver and he's like very grumpy and then they fall in love and the end of the book is about him choosing to live and or not. And this whole conversation of being a burden versus not. Um, comes up in a kind of non-mental illness, palliative sort of way.

Mm-hmm. Um, but has that altruistic component that you're talking about. 

Preston: Mm-hmm. 

Yeah. I, I found it really interesting how as individualistic as humans can be, we weirdly turned things into like [00:45:00] doing it for the good of the herd. 

Yeah. 

I was like, I wonder if there was like something in evolution that was like selected for this, like type of depressive or suicidal ideation like Hmm.

Where societies where people that determine themselves to be burdens more successful because they like went off into the woods and off themselves or something. 

Yeah. I 

don't know. That's, that's like kind of dark to think about, but yeah, it's, it's just like, it's just fascinating to me. Like, I wonder how this like consistently like came up in the, you know, 50 million years that we like refined like homo sapiens as these like hunter gatherers.

Margaret: I wonder also if it's. Kind of like how we talk about like modern bodies are not evolved to like current, like food technology, sedentary, things like that. When we talk in DBT, when we talk about like the function of emotions and what each does for us and what happens to someone doesn't have. Mm-hmm. Like shame was the thing that kept us in belonging and so 

Preston: [00:46:00] mm-hmm.

In some ways it's fear shame. 

Margaret: Yeah. So it was the thing that kept you safe and alive because you would do so much to belong to the ingroup that was gonna protect you and protect your children and help you eat and all these things. And so I wonder if there's something there along the evolutionary side of like, this shame can't make sense, or this like sense of belonging in the modern world is maybe so different from the stakes and how belonging looked up until the last couple hundred years.

Preston: Yeah. Like for context, uh, I think that like you could take a modern human, I. From our human from like 70,000 years ago, and they'd probably like integrate into society today and be able to like learn English and function like normally the way biologically we do. 

Mm-hmm. 

But that, that person, so the last 70,000 years of evolution, then everything before that was like refining them to be someone who would travel in a tribe of like 20 people.

Mm-hmm. 

Sometimes the last, sometimes a little bit more and like hunt, climb trees and gather berries all day. So like, your concept of belongingness is like how well you get along the campfire. Mm-hmm. And then [00:47:00] over the course of like 10,000 years, you know, like basically a few hundred generations, you know, or like few, few thousand generations we, we now pivot to like being a part of tribes of hundreds of thousands of people.

Yeah. With, without activities that we can actively like identify that we're contributing to. We work these nebulous subjective jobs where we contribute to this kind of like industrial behemoth that doesn't make a lot of sense. Mm-hmm. You know, you can, oh, I picked a lot of berries, therefore I've contributed to the group and I'm a useful member.

Mm-hmm. Like, I have these like really concrete, easy ways to identify like how I'm helpful. Yeah. And me belonging to the group is like, as easy as I'm like sharing food with me. Yeah. But now, now like we're burdened by like all these weird social morays and people are polite to us and they're passive aggressive and Yeah.

We're members of like eight different groups and we have, you know, these giant complex societies that like we, yeah. I think we just like socially haven't gotten the means to function in because it's just, it's happened overnight. 

Margaret: Yeah. We're, we're, we're creatures. We're like embodied. And [00:48:00] what is it mean?

I mean, we talked about this after, this is gonna sound odd, but like after the a PA, and I think I said to you and I said to one of my friends, like. It's actually like, it's both very like, kind and fulfilling and ama like incredible to meet people who listen to the podcast. And I don't think my human brain totally understands what's happening when like, I mean like the social media of all of this, of like what does it mean to belong and to connect kind of para socially.

Mm-hmm. Um, I like after the a PAI was like, that was both awesome and I feel confused 'cause I don't get to know people one-to-one. 

Preston: It's, it is really strange. 

Margaret: And it's like to to 

your point right of like, some of the work we do is like, what is going on? 

Preston: Yeah. It like, and, and I think like, kinda the point of the sidebar is that belongingness is really hard to define now.

And because of that, if you're motivated or if, if you have some kind of pathology that's affecting you, it's easy to [00:49:00] manipulate it to, to feel as though you don't belong. And. And like, it's, it's hard to navigate these like complex subjective systems. So, um, to, to recap. So we, we have this sort of blindness, then we have perceived burdensomeness.

Now we go onto the, the final step, which is increase capability. Hmm. So that's kind of, you've determined that it's altruistic to take your own life, but now you have to kind of practice the act of it. Because when you think about ending your own life or doing something that would put you in harm's way, it's extremely distressing.

Mm-hmm. And it's like there's every, every kinda like neurobiological mechanism that you have is telling you to like preserve your life. 

Mm-hmm. 

Everything you've been conditioned to, like, you know, like. We just talked about evolution for belongingness. But, but now, when you're actually looking at the act, evolution is screaming like, do not do this thing like this is, it's like, you know how many, like every single, the microbiome is 

Margaret: like my guy.

Preston: Yeah. Like every single one of your parents had to get laid to [00:50:00] get you to this point in life. And now you're just gonna like, unplug, you know, the like, dang, you know, your entire gene pool is like fighting you. So, and so it's hard to get used to that. So a lot of it is actually kinda like going through the motions and re rehearsing.

Margaret: I mean, again, I think the white lot, like, as triggering as it is, and obviously this entire episode needs trigger warning for this. But like, I do think though, like portrayal of, of the rehearsing on White Lotus this last season with the dad was like, 

Preston: it's extremely realistic. 

Margaret: Yeah. 

Preston: Um, and like if anyone's like, kinda see that and wonder if people are like, like that they do, there are like kind of scenarios and stories I've heard where people will, they'll, they'll unload the gun and they'll they'll deam it.

Yeah. 

And they'll just hold it to their head. Just to see what it feels like and they'll practice like pulling the trigger, knowing there's no bullets in there, but like, just to feel like what the click would sound like. And I think one of the most concerning things actually, when, when I talk to people and, and, and I can see them kind of like, I'll, I'll ask them about their belongingness [00:51:00] and their, their burdensomeness, and they'll walk me down this pipeline.

Mm-hmm. They're like, yeah, campus collision people are better off without me. And then they're like, and then I, then I kind of started like holding a gun to me and they were like, weirdly enough, I feel more comfortable with a gun at my temple. Like, I know that there's a way out and there's a part of me that's like, this isn't so bad.

Mm-hmm. You 

know, it's just, it's just a piece of metal against my temple. Mm-hmm. Like, I was picturing me like this terrible thing, but it's not so bad. And then paradoxically, there's, they get this like, sense of ease. 

Yeah. 

Like, Hey, I, I'm actually not out of options. Yeah. And this thing I'm doing is helping other people because now they're almost so bought into this belief that they are a burden.

The world would be better off without them. It, 

Margaret: it in some ways reminds me of the, the, the question that we have of on some studies, the increased suicidality and suicide attempts for particularly adolescents and young adults on SSRIs, and it reminds me [00:52:00] of it because one of the theories for why that's been found in studies is that there's like a level of activation from taking some SSRIs 

mm-hmm.

That can bring you into a place where if your depression had been like an hedonic and like slowed low energy, low motivation, that it can bring you into a place where there's almost this energy, which is, is also part of what you're saying, right? Like if you go from, there's the comfort in some ways of like, this is actually not as horrifying as my body's telling me it might be, but also the like going from feeling very depressed and almost vegetative to a flurry of activity before the end.

Preston: Yeah. And that kinda like last minute surge is, is a real thing. The, the switch that we're kind of describing is going from like ego dystonic, suicidal ideation to ego syntonic. So this idea of like, I'm no longer distressed by these suicidal thoughts, which I, I kinda wanna point out like when people at, at start, at, at [00:53:00] the beginning when they feel isolated mm-hmm.

They feel like they're a burden, the thought will pop into their head that like, maybe I should just end it all. Like, what if I just, you know, just took my life at first? That's a very distressing thought to have. 

Mm-hmm. 

And kind of as they progress through this sequence, the thoughts go from kind of being distressing to being reassuring mm-hmm.

And encouraging. 

Mm-hmm. 

Yeah. And, and almost easing. So now that kind someone is like practicing this increased capability they can, which is, um, actually what joiner describes as like the final step before. Um, a, a lethal or near lethal attempt. 

Yeah. 

This part has been refined. Mm-hmm. This kind of last part to say, there's like a couple things that go around this.

So there's, um, preparatory behavior. Yeah. And then there's a lot of people's, like suicidal risks that kind of get intertwined into this increased capability thing. Yeah. 

Margaret: Which is like what we have on what we do inpatient and outpatient, but especially [00:54:00] outpatient, at least our protocol is doing the Columbia suicide screening.

Mm-hmm. For 

almost every patient. For every patient, we basically, we see our intake and then following that up with the SRA, which is the suicide risk assessment that has a lot of these elements you're saying, and the change in like the quality or like the planning or going from it being non distressing or being distressing to being acceptable are all kind of mm-hmm.

Baked in there and why we do them every time. 

Preston: Yeah. I think the way that we and the. While the way we screen for them touches on all these things is definitely imperfect. Sure. And you know, like the problem with this too is that once someone has developed egosyntonic Yeah. Suicidal ideations, and they are presented with a screener that says like, have you ever thought about killing themselves?

They would reasonably understand that if they share that information mm-hmm. They people will take action. 

Yeah. 

And that's something that they actively wanna prevent. So like, weirdly [00:55:00] enough, um, the people that answer no to those questions on screeners are both the lowest risk and the highest risk. 

Margaret: Yeah, 

Preston: yeah.

Yeah. The, the, then the other kind of like signs of preparatory behavior where they get this like last second surge, um, within this, this ego organization are things like giving away their belongings. 

Mm-hmm. 

Um, suicide letters. So kind of like, or like finalizing their thoughts and then, and then setting up.

Um, pet care or like other, like afterlife events.

And, and then at the last kind of bit before the act, even 

with all this buildup and all this like, um, thought about how it's like the right thing, the good thing to do and practicing capability, there still is [00:56:00] usually this like moment of impulsivity that has to like, be that final spark. 

Margaret: It's like the kind of moment of terror.

I'm, I'm almost picturing like an amplified moment of terror, of like before you jump off the high dive that you just kind of stand there thinking about it. 

Preston: Yeah. So I, I, and that, that's, that I guess is like the final part of like making yourself capable. Like there's like rehearsing it, there's preparing, there's reframing, and then there's like that mm-hmm.

That impulsive moment for a lot of, um. People or, or patients. I'll see them try to use substances to get over this. Like, last mark. Ah, yeah. Yeah. So like a really, um, common one will be drinking a lot. Yeah. Right. Before, interestingly, um, I was looking at some of the, um, DMV or like Department of Transportation mm-hmm.

Uh, statistics on car crashes. So I, and I don't remember the exact number, so I'm not gonna try to quote them, but we had this, um, this event, [00:57:00] um, back in medical school where a patient, um, completed suicide, um, right after a car crash. And they weren't like screened and people were kind of like wondering what happened.

And it was a, an MVC, like so motor vehicle, like crash that was versus a tree in the middle of the night on a back road. Oh, okay. Yeah. And you know, in the ED they told everyone that they weren't suicidal, they denied everything, and then basically went home the next day and. And, uh, took their life. So I was kinda like looking more into that.

And there's a lot of estimates that if, if it's like a male or like a mid fifties male or something and they're inebriated and it's a high speed collision on a back road that's like against a tree or like an object or something. It was, and, and I feel, I'm just gonna give a range here 'cause I don't wanna misquote myself, but I think it was like somewhere between like 10 and 20% of those are estimated to be related to suicide.

Yeah. 

And 

yeah, 

and I think that what's interesting is when they come into the, the emergency [00:58:00] department, the initial thought is like, oh, drunk driver crashes. Okay. And then they're usually unconscious and everything else. And so they don't get the like, same risk assessment. Um, but the, like, interestingly protective against suicide would be like if it was a car crashing into another car.

Mm-hmm. Because. People that are getting drunk to try to go through this act, don't usually want to take anyone with them, which is why they're on a back road going fast. Try to like work up the confidence to be drunk and then just slam their car into a tree. 

Margaret: Yeah. Yeah. 

Preston: So, so weirdly enough, I've had, I'm, I'm on a consult service right now and I've had a lot of conversations with like care teams who will have this like uncertain, like yes or no question about like, Hey, this person came in drunk from a car crash and we're not sure if they have safety concerns, but like their family was worried and like, I'll, I'll be very reassuring.

I'm like, Hey, like I think it's really reasonable for you to be worried about this. And I kinda like tell them like, if, you know, this was like MVC versus poll middle of the night and like they have alcohol in their system. Like, like it's reasonable for us to like do a safety assessment or kind [00:59:00] of like have a conversation with them when they wake up.

Margaret: It's, it's interesting because I, I remember looking into the data on this at one point of suic, like people say the term drunk cidal, um, and that there seems to be with alcohol specifically compared to other substances, like people will. Report suicidality in the, like if they come in in the evening and when they sober up, they take, they kind of say, no, I would never do that.

And are there cases with that that may be like, it's similar to this where there's kind of like, I don't want someone to know, and this is still true. Yes, but I also think it's speaks to the impulsivity or the, like, the decrease in anxiety and inhibition that alcohol allows, that kind of increases this ability to access this somewhat like terrifying, maybe impulse that is present in someone.

Um, I just, I feel like that's alcohol and suicidality and including driving [01:00:00] is a really complicated, like interwoven, I think. 

Preston: Yeah. 

Margaret: Psychiatric presentation. 

Preston: I think what you're describing, and I say this after I've probably, I've done two years at the VA here. This like kind of ocid presentation is of someone who is probably like pretty chronically unhappy with their life.

They, they may not be necessarily depressed, but like dysthymic. Yeah. And they get very drunk and in their kind of drunken ruminations come this conclusion, there's no point. 

Yeah. Or 

that they, that they're frustrated and hopeless. 

Yeah. 

And then as they start to, to sober up, the hopelessness kind of diminishes or dissolves.

And, and that's like I would say distinctly different from the person that's contemplated suicide for a long time as, and has fought through all these things has come to these conclusions as to why they want to die. And then they're using alcohol as almost that final flint to ignite. 

Margaret: Yeah. No, I [01:01:00] totally agree.

I totally agree. There's definitely a distinct difference there. And I wonder like, 

Preston: but we don't see that distinct differences as actually a great point. Um, all we see on the, on the chart is drunk and suicidal. 

Margaret: Right. And then it's like, uh, that's all the consequences. It's not like it's your out long-term outpatient like that, you're like, oh, I know this person and I know what they've been.

Mm-hmm. It's kind of like, okay, I'm gonna do a consult and we'll decide if they're safe or not, and if they need to go to the hospital, whether they, you know, ideally if they want to, and we think it would be a good idea. But often also, like, right, like the choices are so delineated for a nuanced situation, like suicidal thoughts while intoxicated or in general.

Preston: Yeah. And, and often people will push towards hospitalization. Yeah. In a lot of those, those cases, just because it, it's seen as the less risky thing to do, which I think we all have our own opinions about. Mm-hmm. That, yeah. We could do a whole episode on that. Yeah. So, so we'll kind of, we'll table that [01:02:00] for now, but it, this kind of is also a good segue into, to my final point, which is these are all describing like the ways in which people develop.

The ideas and capabilities of taking their own life. Mm-hmm. Whether it's for the greater good or whether it's because of they're trying to eliminate distress or they've come to the conclusion that there's no way to escape from the bounds of their situation. These are all, all have in common that they're related to our connection to society and also our ability to regulate our own emotions.

Mm-hmm. 

But all, everything we've done to understand these things doesn't necessarily help us to predict who will actually die by suicide. Mm-hmm. 

Mm-hmm. 

And what you brought up, which is I'm gonna go see this patient in the ED and decide whether or not they're at a high risk or a low risk and need to come into the hospital is ultimately what a psychiatrist's job is.

Yeah. In a lot of these settings. 

Yeah. 

So that's actually been like the largest criticism of this. Joiners interpersonal theory of suicide, which is kinda the one we just talked about, or, or even heim's concepts, is that [01:03:00] when we're trying to look at a population and, and people are asking the hard questions, which is which of these members of the population are at the highest risk to die by suicide?

Is that these theories don't give us a lot of answers. 

Right. 

And there are a lot of other studies that we do. So when we are trying to answer that question, who instead the question why we have to look at other sets of data, which is something that we will address in another episode that will be led by Margaret.

Margaret: Yeah. 

Preston: So we do, um, look at suicide risk factors, 

Margaret: suicide risk factors is also kind of the emerging idea of like suicide crisis syndrome, which is trying to get at this kind of like really high acuity who is like the people, the people that we're like much more certain and how do we, like how do we strat, like how do we stratify them by risk?

But also like, I think there's also patients we think about, I. If someone is like chronically suicidal and has had multiple inpatient stays and they've actually felt worse after them, or they're, they've been always followed by, you know, resumption of substance [01:04:00] use when they were like not having that, like, or they're traumatizing in some way.

Mm-hmm. Um, I think thinking about risk factors and then also thinking about this question, like you say of, well what, what do we do with them? Because it's not like we have like a solution that's like, and now that we've found the right people, here's our solution that fixes it a hundred percent of the time.

Preston: Um, yeah, exactly. There there's a lot of discomfort with tolerating that we have identified this problem and we may be powerless to, to solve it. Yeah. And, and that and 

Margaret: inpatient stay, in some cases, not, not most, but in some, can worsen people's. The, the highest time of risk for suicide attempts is the week to two weeks post discharge from a psychiatric hospital.

Preston: And, and data shows that like. When people are involuntarily committed, they're much less likely to seek like psychiatric treatment and other things outside of the hospital. 

Yeah. 

And, and so Yeah. Yeah, like the, we, we basically have this hammer and we're like, [01:05:00] we just have to treat everything like a nail.

Mm-hmm. 

And, and some things like we just don't have a tool for. And it takes a lot of humility to say like, yes, this person's at an increased risk compared to the rest of the population for their lifetime, but the only treatment I have to offer them is not something that will improve that risk. 

Yeah. 

And, and it's, it's hard to do and it's scary to do.

Yeah. So we will get into that more during that episode. But yeah, that was all I had for today. 

Margaret: I just. This is a heavy episode. I know some of our episodes we talk, we al we're talking about mental health and that can be heavy always. But this in particular, I think it's important that we talk about both the theories and then also talk about concrete examples, whether that's in media or common clinical situations, but also to recognize explicitly, uh, the listener.

This is a heavy episode. It may feel a little bit different. Go easy on yourself after listening, if this is kind of impacting you, um, in any way, just as I think it can be. Even when you're in the field. You can be desensitized to it [01:06:00] sometimes, but sometimes the human in us also recalls how heavy this is and just what this topic means to so many people who have been impacted by having suicidal thoughts or actions themselves or the families of those who, who have had lost people, um, from suicide.

Preston: Mm-hmm. Yeah. There. It's very possible that if you know someone who's died by suicide, that they've gone down some of the paths that we're describing here. 

Mm-hmm. 

And it's only natural to kind of see your loved one in these stores that we're describing. But also remember that, that they had their own struggles and things were.

No individual person can fit any of these theories. Well, on that note, I would like to say thank you so much for listening. Um, we're still kind of going forward with this Margaret episode, Preston episode thing, so if, if y'all like it, we honestly like it. It's kind of fun 

Margaret: too. Damn bad. 

Preston: Yeah, so we're, we'll probably do it anyways.

This is 

Margaret: our [01:07:00] reputation era. Did you hear she got her albums back? 

Preston: Taylor Taylor, 

Margaret: she got her albums back for she own. She owns all them now. Good for, 

Preston: oh, yay. So she's, she's making double the revenue. 

Margaret: Okay. I hate her. 

Preston: But, but we still like your feedback on other things and we actually, we like have been going through a lot of your submissions and using that to determine like, episode content and topics or at least parts of episodes.

So if you're DMing us and we don't respond to you, we, there's probably a chance we've seen it, but just haven't got a chance to get back to it. And there's some that I've seen and maybe haven't responded to, but I've like banked. So I want you to know that like eyes are seeing your dms, we're trying to respond to them.

Um, but we can get like overwhelmed and busy. If you want to come chat with us, you can always, um, contact us at Human Content Pods where Shanti will respond. She's much better at being on top of that than we are. Or you can email us directly at, um, how to be patient pod.com. You can see more from me on YouTube.

Uh, all this podcast will be on YouTube at its pres, or you can just find me on Pres on all my [01:08:00] socials. You can find Margaret at Bad Art every day on. TikTok and Instagram and Substack. She hides really interesting stuff behind the paywall. I mean, I heard, it's interesting, I've never been allowed behind the paywall.

So 

Margaret: you could pay, you could pay for a woman's worth. 

Preston: Yeah, that's, that's an option. And you set that up. But I'm a friend.

Margaret: You heard it. You heard it here first. 

Preston: You heard it here first. We're your hosts, Preston Roche and Margaret Duncan. Our executive producers are me, Preston, Roche, Margaret Duncan, will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman and Shanti Brook. Our editor and engineer is Jason Portizo. Our music is Bio Mayor Benz V.

To learn more about our program, disclaimer and ethics, policy submission verifications and licensing terms in our HIPAA release terms, go to how to be patient pod.com or reach out to us at how to Be patient@humancontent.com with any questions or concerns. How to be patient is a human content production.[01:09:00] 

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the [01:10:00] background.