In advance of World Suicide Prevention Day (September 10, 2023) St. Joseph’s Psychiatrist, Dr. Maiko Schneider, penned a very personal editorial about the depths of mental suffering, and the difference between physically dying and mentally dying. The opinion piece was published in The Spec, and is available to read here:

Death and Dying in Mental Health: what do we not know about it?

Dr. Maiko Schneider, Psychiatrist, St. Joseph's Healthcare Hamilton

I have been practicing psychiatry since 2017, but initially trained as a medical physician. The shift in career focus happened slowly after reading a book, “Death and Dying” by Elisabeth Kübler-Ross. In the book, Kübler-Ross attempts to understand the difference between “death” and the process of “dying.” The author’s research includes interviews with people who were physically dying. However, something was missing from the study: what about patients that are in the process of “mentally dying.”

As physicians, we are trained to assist people in life, and we can forget about death itself. I still remember how distraught I was the first time in my career I had to inform a family their loved one died of a heart attack. First, it made me realize how ill prepared we are to communicate death. Secondly, I began to imagine how difficult it must be to inform a family their loved one has died by suicide.

I remember vividly my first patient who died by suicide. I needed some time, some silence to fill the gap that was left in my life following that loss. We are not ready to lose people from physical illness. No wonder a mental health death is so intangible for all of us. 

Since then, I started to perceive suicide as a way of dying, like a heart attack or stroke. The brain is an organ of the body. Like our lungs, our kidneys and our heart, the brain is susceptible to injuries, inflammations and cellular errors.

We can acknowledge there is high risk of dying when someone has a progressive organic illness, such as an advanced stage of renal failure or heart disease.

Death also happens in mental health. It is the only ‘hard outcome’ that we have in mental health. All the other methods of assessment, treatment response, cognitive functioning or behavioural changes can be seen differently by different professionals. Death, however cannot be misinterpreted.

Possibly the most challenging state of mind a person can encounter is when they conclude that stopping the course of their life is the only way out of the mental pain and when they perceive that all attempts to mitigate their mental health suffering have failed. It is not like one day you wake up and make the decision to leave everybody you love behind. Working in a specialist centre for mental health care, I have started to talk more about how much suffering people endure when they are suicidal. By asking how people feel about having the desire to die, I am learning more and more that we have no clue as to the true level of mental suffering. 

Suicide is not heroic or romantic. It is an outcome from mental suffering. It is the course of an illness that sometimes we can remediate, sometimes we cannot.

It is ultimately a state someone arrives at: a place where all the ambivalences, hope and despair converge. It is someone’s brain trying to solve a conflict that makes them feel caged and tortured by their own body and mind. As a psychiatrist, I have seen many stories of success when we treat people with suicidal ideation. Stories of people who were deemed high risk for suicide, that improved with medication or therapy or both. All of us who work with persons suffering from a mental health disorder have had experiences with people who respond to treatment and this continues to inspire us. Yet, we are devastated when someone dies by suicide under our watch.

What we do not know about a person’s death by suicide is everything. It is very unique to their life experience, and the level of mental suffering they have endured. It is about thoughts and emotions that compose this unique experience, and it differs from person to person. Understanding that someone might die by suicide, despite providing the best therapies, does not mean we are giving up. It does mean we need to continue having conversations about risk with patients and their loved ones. That, in itself, is extremely supportive and therapeutic.