To force the issue, insist that he’s “a danger to himself or others.”
For about a decade, my dearest love was a man I’ll call Hans, who became a suicidal alcoholic. His illness crept up slowly but in the last year of his life he didn’t leave his apartment. I was in touch with his psychiatrist and spoke to Hans every day, though he kept refusing to have me visit and sometimes missed his psychiatry appointments.
Hans endearingly had the ability to sound kind and engaged with me, despite his own decline. When he began to seem remote, I knew a shift had occurred, One Sunday, against his wishes, I traveled to see Hans (about a 45-minute trip by subway in New York City) and he didn’t answer the bell. I left a note with his super who had his keys, asking him to go in.
When I got Hans on the phone that evening, he was too weak to speak. He was touched I’d tried to see him and said “goodbye.” “You’re going to die if this goes on,” I said. “Good-bye,” he said. I called his psychiatrist immediately and left a phone message saying, “I think he said a last goodbye to me. Please get him into the hospital.”
This is a cautionary tale: I learned later that the super knocked on the door and left when Hans told him to go away. His psychiatrist tried to reach Hans by phone for four days. I kept calling the psychiatrist and Hans and getting answering machines. On Friday, the psychiatrist finally called to tell me that the police had entered Hans’ apartment that morning and discovered him dead.
Hans fell through the cracks in a mental health system riddled with cracks.
Sometimes mental health crises come as a complete surprise to other family members, but that’s rare. A psychotic break, bipolar mania or depression, or suicidal depression usually is the latest sign of an evolving illness.
When you see someone developing disturbing symptoms, prepare yourself by finding the mental health services available locally. Check the listings online at the Substance Abuse and Mental Health Services Administration (SAMHA). Should you run into a crisis, a hospital ER may not be your best choice. The waits are long and the psychiatric services limited. Before that day comes, also locate a psychiatrist you trust. A psychiatrist will be one of the first people you speak to when you sense an emergency and provide care after your family member leaves a psychiatric facility.
If you have guns in the house, keep them locked up and unloaded. Keep dangerous medications out of reach, too.
When you’re caring for someone in crisis who lives alone, as Hans did, take precautions early on while he’s still cooperative, even if it seems overly dramatic at the time. Things can deteriorate fast. Remove guns and unnecessary dangerous medications. Get a set of keys.
Learn as much as you can about the illness and know the danger signs. There are a number of myths about suicide, for example, that will lead you astray. One myth is that a person who talks about suicide just wants attention and isn’t serious. Don’t count on it. Take it seriously if you hear someone talk about having no reason to live, being a burden to others, feeling trapped, or experiencing unbearable pain. You’re right to be alarmed if someone you care about is giving away possessions, visiting or calling people to say goodbye, withdrawing from activities, shutting out family and friends, or acting recklessly or aggressively. Alcohol is estimated to be a factor in at least 25 to 30 percent of all suicides, and in one study, heavy drinking increased the risk of a suicide attempt 16-fold.
When should you call 911 or take someone to a psychiatric facility or emergency room yourself? If you can honestly say, “He’s in immediate danger to himself or others.”
I had done some of the necessary steps. I was in touch with a psychiatrist and told him when I sensed an emergency. I’d alerted the super who had his keys. But I didn’t say the magic words, “He’s an immediate danger to himself or others.” Many people told me later that I had to say those words to the pscychiatrist or call 911 and say them myself.
Take fast action if you see people showing signs of psychosis that affect their functioning — delusions, or intense fear, extreme agitation, and an inability to sit still or sleep. Behavior changes that come out of nowhere could be a sign of poisoning.
Handling a mental health crisis will wear you down, sometimes in unpredictable ways. I am frugal. I entered a strange mental state on the day Hans wouldn’t let me in his apartment. On my way home, I stopped to buy a pair of $300 shoes. No, I couldn’t afford them. I mostly wear sneakers and rubber sandals. I did other strange things, too.
Get support from family, friends, or support groups. Mental health crises aren’t rare. In 2013, 16 percent of females ages 12 to 17 experienced a significant depression, according to government figures. You already know someone who has seen a family member go through one, or suffered one himself.
Don’t be passive and trust that your loved ones as adults will seek the help they need — sadly, it’s just not true. SAMHA estimates that about a third of American adults with severe mental illness in 2013 did not receive treatment. People typically go for more than two months between the onset of symptoms and treatment, if they do get it. Many people with severe mental illness don’t recognize that they have a problem and may resist treatment or medication. Most people with alcohol and drug problems don’t get treated, either.
Don’t assume someone else will intervene. It may not be obvious who needs to step up. Hans had a college-age son and an ex-wife who lived nearby. But I knew he was more in touch with me. Clear up this kind of confusion well in advance. You also can’t trust medical professionals to act quickly or decisively unless you push. You need to be the advocate.
Persist — anti-psychotics and mood stabilizers dramatically cut the chances that your loved one will commit violence.
After Hans’ death, many people said to me, “There was nothing you could do if he really wanted to die.” This didn’t comfort me. It also isn’t true. Hans died because the psychiatrist didn’t believe my warning was an emergency and I didn’t call 911 myself. I also hadn’t educated myself to know the magic words. I didn’t have his keys.
Even when a sick person tells you to go away, barge in. Statistics and my gut tell me that but for our inaction Hans would be alive today. He might well be thriving. Most suicidal people get better. Even among people who have been hospitalized because they were suicidal, according to one estimate, less than 9 percent actually die by suicide.
Remember the words “He’s an immediate danger to himself or others.” Don’t let your loved one commit violence against himself — or others. That’s one news story in which you never want to read your name.
September 22, 2015
Christopher Nystuen, MD, MBA