Hope springs eternal, but so do financial crises in hospitals. Once, while researching the history of the hospital in which I was working at the time, I discovered that it had been so short of money in the 1840s that it had been forced to sell some land to a railway company that wanted to build a line near the hospital. The physicians were against the sale, for they feared the noise of the trains might kill the patients, “especially the brain cases.” They were overruled, and when the first train went by they observed the patients anxiously to monitor the adverse effect on them. There was none.
However, psychiatric hospitals seem often to be built near railway lines, which act as a magnet to the patients who are suicidal. Patients of such hospitals who commit suicide while on the premises usually do so by hanging, while those who do so outside usually jump from a tall building or throw themselves in front of trains.
A paper from Germany in a recent edition of the British Journal of Psychiatry analyzes the characteristics of 100 suicides of psychiatric patients who threw themselves in front of trains conveniently near to the hospitals in which they were resident at the time. It took the authors ten years to collect their sample, whom they compared with other patients of the same age, sex and psychiatric diagnosis who did not throw themselves in front of trains. The object of the exercise was to see whether such suicides could be predicted and therefore prevented. The authors rather laconically remark that when a man throws himself in front of a train — and nearly two-thirds of the cases were men — it is likely that he really means to die.
Most of the suicides were among schizophrenics. They had been ill either for a short or a very long time. Not surprisingly, they had tried suicide before. But by far the strongest association with suicide among such patients was a change in therapist – the person principally concerned in their care – shortly before. Distressed people want to think that there is a particular person who is concerned for their welfare, and change is probably experienced as further abandonment by those who already feel abandoned. This is an important finding as psychiatric practice around the world becomes more and more depersonalized.
But there was one association upon which the authors did not much remark: the fact that the suicides were more likely to be taking SSRI antidepressants than those with the same diagnosis who did not commit suicide.
This does not by itself prove causation, of course; but it was striking that those with the same diagnosis who were taking another type of antidepressant, the tricyclic, did not have an excess of suicides. This is important, because it has long been suspected that SSRIs increase the frequency of suicidal thoughts in those who take them. Indeed, ten years ago the FDA issued a warning that the drugs increase suicidal thoughts – though only in children and adolescents. In the case of the German suicides, the combination of benzodiazepine tranquilizing drugs such as Valium to SSRI drugs (which can cause agitation) was particularly associated with suicide.
The patients who committed suicide on railway lines were also more likely to be treated by polypharmacy, defined as the prescription of more than three different drugs at a time. This, however, may only have been an indication of the intractability of their symptoms.
The development of SSRI drugs was once heralded as a great advance. I was skeptical of this from the first: the older, cheaper drugs were better. Such is often the way.