Abstract
This issue contains important articles, not least of which is an incredibly valuable review of stimulant formulations from the executive editor of the journal, Ron Steingard, MD. Elsewhere, the focus of these articles is squarely on depression, from investigations of functional connectivity (McVoy et al.) and behavioral predictors of treatment response (Kujawa et al.) to the pharmacokinetics of sertraline and escilatopram (Strawn et al. and Poweleit et al.).
The importance of this study to understand and treat depression was highlighted for me recently when we saw two people die from suicide who had experienced terrible loss because of mass shootings: Jeremy Richman, the father of a child who was murdered in the Newtown shooting in 2012, and Sydney Aiello, a teenager who was present and lost a friend at the Parkland shooting in 2018.
I asked my colleague Jamie Howard, PhD, to help put together these practical thoughts about countering the contagion of violence in our communities. I hope you will find this useful for your practice.
Depression, posttraumatic stress disorder (PTSD), and suicide risk are higher in people who have survived traumatic events or who have lost loved ones in violence. In his book Myths About Suicide, psychologist and researcher Thomas Joiner outlines the basic precursors to suicide: a desire to die and the ability to die. The desire, he says, comes from believing that you are a burden and that people are better off without you.
Guilt is also a factor in the desire to die among people who have experienced violence and loss of life. One of the most problematic symptoms of PTSD is “survivor's guilt.” A recent qualitative study in the Journal of Traumatic Stress Disorders and Treatment proposes a model where people with survivor's guilt are stuck in an ongoing cycle of trying to make sense of why they survived. They ruminate about it, which keeps them thinking about the trauma, which makes people depressed, which we know is correlated with suicide.
Joiner's second precursor to suicide, the ability to die, is a behavioral habituation. It comes from systematically overriding your drive to self-preserve. This is one reason why military members have a higher rate of suicide—because they have repeatedly faced the brink of death and they have habituated to it. The same is true for top-performing athletes and people with mental health disorders, such as women with eating disorders. And it is true of people who have been exposed to a violent loss of life.
Joiner's fundamental point, however, and the one that is central to my study and to the studies of my colleagues at the Child Mind Institute, is that we can take steps to prevent suicide. Knowing how guilt and traumatic experiences provide the necessary precursors to suicide, we can use this knowledge to change trajectories. Here are some basic guidelines for helping people to cope with guilt and trauma: Talk about suicide matter-of-factly. Talking will not inspire individuals to die but may help them. Encourage young people to tell you what they are thinking and listen nonjudgmentally. Suicidal actions develop quickly, so repeated checking in is not bothersome; it could be lifesaving. Some kids may feel guilty, feeling that there is something they could have done to prevent it. Let them know that this is a common feeling when a loss is very difficult to accept. Coming to terms with a disturbing death takes time. We cannot hurry the process. Encourage young people and adults alike to seek treatment. Remember that suicide should be conceptualized in terms of an untreated psychiatric illness.