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    Robin Williams' suicide creates 'teachable moment'

Dawn Brazell | News Center | August 18, 2014


Robin Williams suicide
 
AP Photo/Matt Sayles
Actor Robin WIlliams from the film "World's Greatest Dad" poses for a portrait in Los Angeles on Friday, Aug. 14, 2009
 

Even before the news of Robin Williams’ death, Mark George, M.D., knew his grand rounds talk would be on the neuroanatomy of suicide.

“Today is a teachable moment hopefully about suicide,” said Mark George, M.D., to a packed auditorium Aug. 14 at the Medical University of South Carolina where health professionals gathered to learn about how brain disorders may predispose patients to suicide.

First, he shared the statistics about its prevalence and impact.

  • It’s the No. 2 killer of 18-to-24 year olds. “Other than cars, this is what kills kids this age. It’s tragic when that happens because they have untapped potential in their lives.”
  • A veteran kills him or herself every hour, 24/7. “So during my lecture there’s some poor veteran in the States who will decide life is not worth living and act on it.”
  • More soldiers involved in the Iraq and Afghanistan conflicts killed themselves than were killed by the enemy. “If the enemy came up with a new weapon, we’d spend billions trying to figure out how to combat it. We don’t think about suicide as being a new weapon used in war, but we should and we should devote billions to coming up with ways to prevent it and stop it when it becomes a crisis.”
  • It is estimated that on average the United States loses as many as 400 physicians to suicide each year (the equivalent of at least one entire medical school). “If we had another disease taking out doctors like this, we would be talking about it. So I’m glad you’re here,” he said to colleagues.
Dr. Mark George suicide prevention 
Dr. Mark George spoke to a full house at MUSC's Neurology Grand Rounds Aug. 14. 

It’s a natural topic for George, who is a distinguished professor in the Department of Psychiatry and Behavioral Sciences and director of MUSC’s Brain Stimulation Laboratory. The lab is spearheading important treatment options for mental disorders that can predispose patients to suicidal impulses.

This may be the last truly stigmatized area of medicine. “Suicide we don’t talk about. It used to be that way with cancer, epilepsy, substance abuse and other conditions.”

George talked about two colleagues who died by suicide. He’s dedicated the last few years trying to get more data about effective treatments to have more to offer patients experiencing a suicidal crisis.

In the spirit of destigmatizing this, he spoke of his own struggle. “I have researched depression all of my life and tried to understand it for patients. And back in 2004, I found myself in an episode of depression, first one ever.  It was funny - you study something forever, but then it happens to you, and it’s a whole different perspective.”

George knew what to do. He consulted a psychiatrist and got on medication and was doing talk therapy.

“But before I actually came out of the hole, I will never forget one Sunday morning when I felt acutely suicidal. I just felt like life was not worth living.”

Living out on Sullivan’s Island near Breach Inlet, George thought through the details, including how he would ride down on his golf cart to the bridge. “I had the whole plan. It was a moment when I actually, rationally thought that was a reasonable thing to do. I discounted totally my life’s work, the impact on my family and all the other stuff. I slipped into this state.”

It was a distorted way of seeing things, he recalled. “I think what happened to me for those few hours, happens to a lot of other people.”

Fortunately, George confided in his wife and got through the crisis. The experience renewed his commitment to finding better treatments and raising awareness to decrease the stigma of suicide.

A slim percentage of suicides fall into the category of being a reasoned, moral decision relating to end-of-life, terminal illness. Those types of suicide are rare and cloud the real issue, he said. “The vast majority are impulsive acts and what I call a suicidal crisis. If you look at the epidemiology, about 80 percent of suicides arise in patients with a diagnosable depressive disorder or bipolar disorder that is often compounded by substance abuse.”

One in five people will experience depression during his or her lifetime. Fifty to 60 percent of people can be helped with medications. “That’s me. I’m in that group. I got better over a year and am now off medications.” Not all people respond to the medications, though. “That group really struggles with their lives and has a very, very high risk of suicide.”

suicide brain disorderIllustration/Emma Vought 
The right hemisphere of the brain. Arrows represent the communication, dysfunctional in depressed people, between the frontal cortex (in pink) and the limbic system. 

George said there seem to be three systems in the brain that don’t work well in a suicidal crisis. The limbic system, which supports a variety of functions including emotion, behavior and motivation, involves the nucleus accumbens, the amygdala and hippocampus. It also is tied to the hypothalamic-pituitary-adrenal axis, which is dysregulated in depression.

In a suicidal crisis, signaling from the prefrontal cortex, which is normally the part of the brain used to regulate the limbic system and help someone 'get over it,' simply cannot do its job, he said.

Brain disorders can be a function of an over-limbic drive, an under pre-frontal cortex regulation, or dysfunction in the orbital-prefrontal cortex, which allows someone to inhibit impulsive behaviors. The categories may overlap, or operate alone, but they can provide a helpful framework for doctors to view neurological disorders, which may predispose patients to depression and potentially suicide.

The limbic drive gets involved when there’s intense psychic pain. Disorders of increased limbic drive that can predispose people to suicide include anxiety disorders, epilepsy, intense periods of grief and loss, bipolar disorder and limbic tumors, he cited as examples.

A limbic tumor was the case with Aaron Williams, a local teen who died just shortly before his 17th birthday after setting himself on fire in a local school parking lot.  “This was a tragedy in our own neighborhood,” George said, remembering the sadness his family felt since his daughter attended the same school. “Everybody talked about it as a metaphysical, moral problem we’ll never understand. They couldn’t understand it… Did anybody talk about the brain? No.”

It turned out the teen was born with a rare congenital condition called neurocutaneous melanosis, that had been treated when he was a child but then developed into a recurrent tumor in his limbic region and orbital-frontal cortex, right in the area that can drive suicide, he said.  “It’s important to talk about this as a brain disease.”

Researchers know that they can stimulate an area of the brain through DBS, or deep brain stimulation, to induce suicidal thoughts in a patient. George plays a video of a patient who had an electrode implanted too deeply into the nucleus accumbens in the brain. She instantly experienced suicidal emotions when stimulated, and had never before suffered depression or had suicidal thoughts.


Sarah Pack
 
Dr. Mark George (right) and Dr. Baron Short demonstrate how transcranial magnetic stimulation works. 

“Is this a brain disease? Can we immediately create suicidal crisis? Yes. There is an anatomy here,” he said. “We can create it with DBS. We can knock it out with TMS (transcranial magnetic stimulation) or a medication. It’s a brain disease.”

George referred to another study that showed that patients who suffered a traumatic brain injury, or TBI, that required hospitalization will go on to develop depression within a year, and a subset of those will attempt suicide.

“It sets the stage.”

The good news is that there are new treatments that show promise, including forms of neurostimulation, such as TMS, and the anesthetic drug ketamine, which for some reason in lower, subanesthetic doses, seems to be able to quickly knock people out of a suicidal crisis. MUSC has a small clinical service involving ketamine to test its effectiveness in helping treatment-resistant depressed patients, led by Dr. Baron Short.

In the future, he hopes another promising, treatment area for research is the use of responsive stimulation to help depressed, suicidal patients. This technology already is being used to treat epilepsy. Epileptic patients have a device implanted that is able to detect problems in the brain and fire electrical signals through implanted wires to stop a seizure from happening.

“We need to talk about suicide and not brush it under the rug. We can’t ignore this. Suicide attempts and completions commonly arise in a crisis that sits on top of another brain disease. To the degree that we can treat the underlying brain disease, we can take people away from being at risk. That is important.”

As new treatments continue to develop, it changes the way doctors practice, which changes public awareness and decreases stigma. “If we come up with new treatments, it re-enforces that this is a brain disease. So people shouldn’t sit at home and be embarrassed and suffer in silence. Go see a doctor.”

SUICIDE PREVENTION TIPS

  1. See it as a brain disorder in reaching out to loved ones, George said. When someone is in a suicidal crisis the part of the brain that helps us size up who we are and how we fit in the world, and our self-worth, is simply not doing its job. They often fail to see all of life's blessings, and actually think that they are worthless and the world would be better without them in it. This is not like an hallucination, but it is clearly the brain distorting reality in a funny way as doctors sometimes see with strokes or in patients with eating disorders, who, although they are rail thin, actually think they are fat. Someone in a suicidal crisis is distorting their own worth in the world at a terrible cost to him or herself.
  2. Eighty percent of people who commit suicide have depression or bipolar depression, often compounded by alcohol or other drugs. If you see someone who looks depressed and they are not getting treatment, encourage them to. If they can get that treated, then they stop the risk of falling into a crisis. People with terrible depression or anxiety will often turn to alcohol to stop the pain. This can slightly help, for a few hours, but then they set up a cycle of addiction and chronic alcohol actually turns off the prefrontal cortex. In the long-run drinking is the last thing they should be doing.
  3. If you suspect someone is depressed and thinking of harming themselves, simply ask them about it. There is no harm in doing that, and it can do a world of good in terms of opening up a conversation, George said. Ask them if they are safe. If they are not safe, they will often tell you. If they refuse to answer, then call a suicide hotline (1-800-273-TALK - 8255) or take them to a clinic or emergency room. Don't delay, just like you would not delay if you thought someone was having a heart attack or a stroke.
 

 

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Resources >>

National Suicide Prevention Lifeline

MUSC Brain Stimulation Lab

MUSC Neurosciences

MUSC Brain Stimulation fellowship

MUSC Department of Psychiatry and Behavioral Sciences

MUSC Comprehensive Epilepsy Program

Featured Expert: Mark George

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