Where – and how – do we even begin to talk about suicide? In psychiatry, we understand it as a product of mental illness: an act borne of the hopelessness of depression or as a way to escape psychic torment. In that sense, it is understandable and preventable: All we need to do is educate people about the symptoms and destigmatize the disorders so that those who have them will seek treatment. Suicide is an epidemic, and tens of thousands of people die this way every year. The figures quoted are that 90% of those who die from suicide suffer from a psychiatric illness, most often a mood disorder.
It’s a simple equation, and often the assumption is made that the suicidal person did not recognize his illness, did not know how to get help, did not believe treatment would work, was fearful of the stigma or consequences of seeking help, could not access care (because that is no simple task), or did not get the right care. It’s perplexing that suicide rates have continued to rise when the rates of antidepressant use also have risen. And while we don’t want to stigmatize mental illness, we do want to stigmatize suicide; it shouldn’t be anyone’s answer to life’s inevitable rough patches.
Dr. Dinah Miller
Soon after his death, it was made public that Robin Williams suffered from Parkinson’s disease, then later that was revised – he had Lewy body dementia.
On Sept. 27, his widow, Susan Schneider Williams, published an article called “The terrorist inside my husband’s brain” in the journal Neurology (2016. 87[13]:1308-11).
Mrs. Williams writes about the joy of their relationship, and she notes that many months before he died, her husband was under the care of doctors for a multitude of symptoms, including gastrointestinal problems, insomnia, and a tremor. His symptoms worsened, and he became plagued by anxiety and panic, memory difficulties, and delusions with paranoia. She describes a change in his personality and a preoccupation with his anxiety, physical failings, and memory problems that interfered with his ability to memorize movie lines. Robin Williams was changing and declining. He was treated with both psychotherapy and psychotropic medications. He went to Stanford for hypnosis to treat his anxiety. He exercised with a physical trainer. In May, he received the Parkinson’s disease diagnosis, and while he was told that it was early and mild, his wife wrote,
Robin was growing weary. The parkinsonian mask was ever present and his voice was weakened. His left hand tremor was continuous now and he had a slow, shuffling gait. He hated that he could not find the words he wanted in conversations. He would thrash at night and still had terrible insomnia. At times, he would find himself stuck in a frozen stance, unable to move, and frustrated when he came out of it. He was beginning to have trouble with visual and spatial abilities in the way of judging distance and depth. His loss of basic reasoning just added to his growing confusion.
Just months later, Robin Williams took his own life.
The story doesn’t fit the simple equation: Mr. Williams knew something was wrong, he sought help, he received psychiatric care, and he ended his life, anyway. Could more have been done? Of course, there are always more treatments that can be tried to address depression, but more may not have helped. The article notes that he was scheduled to have an inpatient neuropsychiatric assessment. But the truth is that even if a treatment were found that would have lifted his spirits, Robin Williams was suffering from a severe form of an incurable dementing illness, and his wife describes that he was in a great deal of distress with both his symptoms and his decline. This illness is a tragedy, but perhaps his suicide was a rational decision and not a preventable death. As a psychiatrist, it feels like taboo to suggest that suicide might ever be anything but the ultimate failure on both the part of the doctor and the patient, or that there isn’t always hope to be had. Robin Williams most certainly missed out on some good moments in the time he had remaining; his wife describes the pleasures of their last day together. But if he decided that he wanted to escape his suffering and avoid the undeniable decline and debility that he saw in his future, can we – or should we – blame him and call this a preventable tragedy? Is this the suicide that should be stigmatized and used for our “get help” slogans?
Obviously, I can’t know if Robin Williams was competent to make such a decision, or if his family would have suffered less if he’d lived out his natural life, but the truth is that competent or not, he made a choice and without anyone’s input, he took the action he chose.
The issue has become a heated one as some states have legalized physician-assisted suicide. In Belgium, intractable psychiatric illness is considered a valid reason for euthanasia, even in a young person. Make no mistake about my sentiments on this: Doctoring is about healing, and we have no business killing people or aiding in their deaths. Psychiatry, in particular, is about hope. Each person’s life has value, but each person’s life also ends. And while there is tremendous societal value in stigmatizing suicide, not all suicides are the same.