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Should we be treating suicide differently?

About the author

David Robson is BBC Future's feature writer. Follow him on Twitter: @d_a_robson

(Thinkstock)

(Thinkstock)

Robin Williams’ recent death has triggered many discussions about suicide. But as David Robson discovers, scientists are finding new ways to identify those at risk – potentially opening the way for better targeted treatments.

It is so easy to read meaning into the smallest things after a tragedy. In a 2006 interview, Robin Williams talked openly about his mood swings. “Do I perform sometimes in a manic style? Yes. Am I manic all the time? No. Do I get sad? Oh yeah. Does it hit me hard? Oh yeah.” He didn’t say that he’d been clinically diagnosed with a specific disorder, but his publicist has confirmed that Williams had been battling depression in the months leading up to his suicide.

Among the hundreds of tributes to Williams’ warmth and comic genius, many have pointed out that his death highlights, yet again, the many misconceptions and stigmas surrounding mental health problems. NBC News has a thoughtful piece about the “deadly stigma” surrounding this “silent epidemic” – suicide is rarely discussed, despite the fact that it is a growing issue; more people in the United States now die of suicide than in automobile accidents. Then there are people who still consider suicide a “selfish act” that can be cured with willpower. It is sad we are even having these discussions. Tony Blair’s former spin doctor, Alistair Campbell, who has himself suffered from mental health problems, best described the misunderstandings in an article for the Guardian: “If he’d had a heart attack, lost a fight with cancer or been knocked over by a car, would there be a need for a debate about what this says about the state of heart disease, or cancer care or road safety?”

(Getty Images)

Fans of Robin Williams have paid tribute to the comedian, who was honest about his struggles with mental health problems (Getty Images)

Yet even once the taboos have been broken, we still have a long way to go if we are to treat suicidal feelings with the same precision as other diseases. Anti-depressant drugs and cognitive behavioural therapy seem to reduce suicidal thoughts for many people with depression – but they are not a perfect cure for every patient. Why some respond, while others don’t, has been the matter of much soul searching, but recent research is helping to shed a little light on this dark state of mind.

Self-awareness

For instance, there is a growing recognition that the disease we call “depression” could be an umbrella-term covering many distinct problems, each with a different biological origin. In particular, a suicide attempt may be foreshadowed by a string of neurological changes that are not found in people with other kinds of depression.  Of the most noticeable differences, patients who have tried to kill themselves seem to have less  of the white-matter connections that transmit information in the dorsomedial prefrontal cortex  – the part of the brain right behind your forehead’s hairline. That’s significant, since this region helps us process our self-awareness.

People who try to kill themselves seem to get stuck in ruminative, negative styles of thinking full of self-criticism – so the study’s authors wonder if the neurological changes could lie behind those destructive trains of thought, blinding people to the hope and promise of the future, and even of their sense  of their own self-worth.

People feeling suicidal thoughts also seem to have reduced connectivity in the frontal areas of the brain associated with emotional control and inhibition. Again, the consequences of this are hypothetical, but suicide is considered to be an impulsive action, so it could be that the abnormal wiring in these regions makes it harder for someone to cope with the urge for self-destruction. On top of these specific changes, the brain cells themselves seem to be wasting away across diverse regions of the brain, potentially impairing problem solving and decision making – cognitive problems that are commonly seen in people who have attempted suicide.

At the moment, it’s not clear what triggers these anatomical changes and whether they are the primary cause of the suicidal urges – it could be that they are just a side-effect of the depressed, desperate feelings that the patient is already experiencing. Most likely, the psychological symptoms and the altered brain wiring are both the result of a complex interplay between your genes and your circumstances.

Brain fibres (Science Photo Library)

Brain fibres, as seen in this MRI scan, could leave physical clues of depression (Science Photo Library)

Once we have picked apart the specific mechanism, this new understanding could eventually change the way we treat people with depression. Firstly, it could help identify who is most at risk for suicidal tendencies. Many suicidal patients are unlikely to tell anyone, even their doctors, about their darkest feelings – but a brain scan might reveal those characteristic anatomical changes, giving doctors an insight that they couldn’t have gained from an interview. Since neural degeneration – such as the death of neurons – has certain chemical signatures, some have suggested that blood tests could one day reveal the early signs that could precede a suicide attempt. Preliminary explorations of the technique have been positive, but much larger trials will be needed before any form of this test could be used in the clinic.

Once the patients’ particular needs have been identified, the work could then tailor treatments that best suit the particular type of depression they have. Doses of lithium, for instance, seem to replenish the grey matter in damaged areas of the suicidal brain; and studies have found that the drugs do indeed reduce the risk of a second suicide attempt, when applied to people with bipolar disorder who have already attempted to take their life once. Other drugs could have a similar function.

New options

Kees van Heeringen at the Unit for Suicide Research in Ghent University in Belgium has proposed that upcoming, non-invasive forms of brain stimulation like transcranial magnetic stimulation (TMS) could also be of interest. Using a magnet on the scalp, TMS can boost or reduce the electrical activity in specific parts of the brain – sometimes with long-lasting effects. It has already helped bring relief to people with other kinds of depression that had resisted treatment, and it could potentially target the regions most affected in people with suicidal feelings, curtailing their destructive urges. A better understanding of the brain changes involved – and the way it influences someone’s thinking – may even help refine the talking therapies by helping to identify the thought processes that are most severely disrupted as a consequence, says van Heeringen.

It is unlikely that any single treatment will ever be a panacea for people suffering from severe and suicidal depression. Instead, the strength of this new approach lies in the many different strands; where there was once a murky darkness, neuroscientists and psychiatrists are now beginning to see a kaleidoscope of new options. If they can be adapted to each patient’s specific circumstances, that might save an enormous number of lives from being needlessly taken from the world.

If you feel suicidal yourself, or know someone who might be, the advice is to seek medical help as soon as possible. The International Association for Suicide Prevention has a list of global agencies that may also be able to provide immediate support.

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