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       HEALTH
                                                                                                               ment. Roughly 35,000 Americans commit
                                                                                                               suicide each year—more than die from
                                                                                                               prostate cancer or Parkinson’s disease. An-
       SUICIDE                                                                                                 other 1.1 million people make attempts, while
                                                                                                               8 million have suicidal thoughts. Among
                                                                                                               those aged 15 to 25 it is the third leading cause
                                                                                                               of death. Yet researchers know astonishingly




       The
                                                                                                               little about how to treat people who contem-
                                                                                                               plate killing themselves. The subject has been
                                                                                                               so roundly ignored that the 900-page bible
                                                                                                               of psychiatry, the Diagnostic and Statistical
                                                                                                               Manual of Mental Disorders IV, offers no ad-




       Forgotten
                                                                                                               vice for doctors on how to assess suicide risk.
                                                                                                                     Fear, logistics, low research funding and
                                                                                                               more risk than reward for drug companies
                                                                                                               all conspire to make suicide the neglected
                                                                                                               disease. The National Institutes of Health is




       Patients
                                                                                                               spending a paltry $40 million in 2010 study-
                                                                                                               ing suicide, versus $3.1 billion for research
                                                                                                               on AIDS, which kills half the number of
                                                                                                               Americans. (Another government agency
                                                                                                               spends $48 million on hotlines and preven-
       The mental health industry ignores the 35,000 people                                                    tion.) Therapists often don’t want to treat
                                                                                                               suicidal patients, and university clinical
       a year who commit suicide. A few researchers are trying                                                 study review boards are skittish about
       to change that. By Robert Langreth and Rebecca Ruiz                                                     studying them, says the University of Wash-
       ILLUSTRATION BY KOREN SHADMI FOR FORBES. PHOTOGRAPHS BY RICK DAHMS FOR FORBES
                                                                                                               ington’s Linehan.
                                                                                                                     Big pharma routinely excludes suicidal
                                                                                                               patients from their tests of antidepressants




       A
                         LEXSANDRA WIXOM START-             it reached a tragic end. But after her last hos-   and other drugs. There’s no commercial im-
                         ed experiencing uncontrol-         pitalization Wixom was referred to Univer-         perative to crawl out on that limb. Trials in
                         lable bouts of sadness when        sity of Washington psychologist Marsha             at-risk patients would cost millions of dol-
                         she was 15. “I was emotion-        Linehan, one of a handful of researchers who       lars and could take years to perform; they
                         ally off. I cried all the time,”   specialize in suicidal patients. Linehan di-       might yield murky results—or worse. A sui-
       recalls the Seattle-area resident, who is now        agnosed her with borderline personality dis-       cide in the drug group could be used by com-
       25. Her mood swings eventually became so             order, an extreme inability to regulate            petitors to destroy even a promising drug.
       wild the former honors student had to quit           moods, and prescribed a type of counsel-           The legal overhang is real. GlaxoSmithkline
       going to high school. Over the next eight years      ing called dialectical behavior therapy.           has paid $390 million to settle lawsuits re-
       she saw a psychiatrist every other week. Her              Wixom spent the next year in group and        lated to patients who attempted or completed
       doctors tried everything from Zoloft to              individual sessions learning practical skills to   suicide while on Paxil, Bloomberg News
       mood stabilizers to heavy-duty antipsy-              manage her emotions so that they didn’t spi-       estimates.
       chotics, but none of them helped for long.           ral out of control. They included distress tol-          As a result, mental health experts have
            By her late teens visions of suicide started    erance techniques like plunging her head into      little data on which treatments work in those
       floating through her mind. In one nightmare          ice water, devising ways to distract herself       prone to suicide. In younger patients anti-
       she was a character in a videogame and lay           when bad thoughts arose and learning not           depressants sometimes backfire. Suicidal pa-
       bleeding at the top of a castle and wanted           to leap to the conclusion that one bad day im-     tients end up in the emergency room, where
       to die. On her 21st birthday in December             plies a life of misery. She has not been hos-      there is no clear standard besides hospital-
       2005 the urges became so intense that                pitalized since. “DBT is the best thing in the     ization. One unproven method is to make
       Wixom checked herself into a hospital for            world. It changed my life,” says Wixom, who        people sign pacts promising not to harm
       a week. Her second hospitalization came in           got married halfway through therapy and is         themselves before the next appointment.
       early 2007, when she was struck with a de-           raising two daughters, aged 10 months and                “You would think it would be bread and
       sire to die while grocery shopping. A month          2 years. Now with a high school diploma and        butter for psychiatry,” says Harvard Medical
       later she ended up in the hospital a third time      an associate’s degree, she is pursuing a career    School psychiatrist Ross Baldessarini, whose
       after tripling her daily cocktail of psychiatric     in online marketing. “Nobody in my boat            studies have shown that the old drug lithium
       drugs in hopes of poisoning herself.                 should be without this.”                           may be especially effective at quelling suici-
            Her behavior might have escalated until              Few suicidal patients get such good treat-    dal impulses. “But the therapeutic research

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       HEALTH
       has been very limited.” When he organized                                 Psychologist Marsha Linehan treats suicidal  heart risk factors into life-
       a conference on the subject in the 1990s, “no-                              patients at the University of Washington.  saving cholesterol drugs.
       body had anything to say,” he recalls. Colum-                                                                          The logistics of suicide are
       bia University psychologist Barbara Stanley                                                                            far more daunting, given
       says, “It is one of the most under-researched                                                                          the relative rarity of actual
       areas in all of psychiatry.”                                                                                           suicides among the mil-
            A handful of researchers are fighting to                                                                          lions of troubled souls.
       change this. They argue that it’s not enough                                                                               Suicide is one of the
       to throw antidepressants at suicidal patients.                                                                         last remaining medical
       Doctors need to treat suicidal thoughts and                                                                            taboos. “People are afraid
       impulses directly and teach patients coping                                                                            to talk about it,” says
       techniques. They should test drugs specifi-                                                                            Daniel J. Reidenberg, exec-
       cally for antisuicidal effects and not assume                                                                          utive director of the
       that drugs that help nonsuicidal patients will                                                                         Bloomington, Minn. non-
       have the same effects in suicidal ones.                                                                                profit Suicide Awareness
            “There is a very smart group of people                                                                            Voices of Education.
       who think that suicide is simply a symptom                                                                             Among family members
       of a mental health disorder: Treat the dis-                                                                            who have lost a loved one,
       order and you will eliminate the symptom,”                                                                             the stigma “totally elimi-
       says Catholic University of America psychol-                                                                           nates the conversation
       ogist David Jobes, who counsels suicidal pa-                                                                           from the moment of death
       tients. “But there is little data to support that.                                                                     on.” Survivors of suicide
       So far the best data we have shows that going                                                                          attempts might have valu-
       after the suicidal [thoughts] and behavior has                                                                         able insights for re-
       the biggest impact.” Some patients can be                                                                              searchers but “want to
       depressed for years but not have suicidal                                                                              move forward and forget
       thoughts, he says, while others are plagued                                                                            the experience.”
       with suicidal thoughts, yet have only mild                                                                                 Risk factors for suicide
       depression. Says Vanderbilt University psy-                                                                            are myriad and confusing.
       chiatrist Herbert Meltzer, who has studied                                                                             As many as 90% of patients
       schizophrenia patients who are at high risk             “MY FUNDAMENTAL THEORY IS THAT HIGHLY                          who kill themselves are
       of suicide: “You need a specifically targeted           SUICIDAL PEOPLE DON’T HAVE THE SKILLS TO                       depressed or have other
       antisuicide effect.”                                        REGULATE THEIR BEHAVIOR AND EMO-                           psychiatric problems. The
            The research is beginning to show                 TIONS....YOU HAVE TO TEACH THOSE SKILLS.”                       biggest risk factor is a pre-
       results. Two rigorous trials have demon-                                                                               vious attempt. Alcohol
       strated that therapy that targets the distorted                                                                        abuse, insomnia and anx-
       thinking patterns in suicidal patients and           killed themselves. This year there have iety put people at risk, says University of New
       teaches coping techniques can reduce the             been 156 so far. Among other projects the Mexico psychiatrist Jan Fawcett, who is push-
       rate of suicide attempts by half. Other stud-        Army is spending $50 million on an epi- ing to get suicide risk assessment into the next
       ies have shown that something as simple as           demiological study that will search for risk DSM edition. External stressors such as job-
       periodic “caring letters” or checking in on          factors that predict which patients are likely lessness play a role. (National figures on
       patients, say, once a month can help prevent         to attempt suicide (see box, opposite).           whether suicides increased in the 2008 re-
       suicides. Researchers are evaluating safety               Mary Cesare-Murphy, who heads the be- cession are not in yet, but suicides generally
       plans, written documents that patients carry         havioral health program at the Joint Com- go up in bad economic times.) The very el-
       in their pockets to help cope when suicidal          mission, a nonprofit that accredits hospitals, derly once had the highest suicide rate, but
       urges strike. Studies suggest two drugs—             says health workers are becoming more aware middle-aged men and women, 45 to 54
       clozapine for schizophrenia and lithium in           of the role they can play in preventing sui- (see graph, p. 36), have surged recently and
       bipolar disorder—are particularly good at            cide. In the past “you would hear people say- surpassed them. Why? It’s unclear.
       preventing suicide attempts, but both have           ing, ‘Well, that’s the natural course of the ill-    Many suicide treatment researchers
       side effects that limit their use.                   ness,’” she says. Now, she says, workers are stumbled into the field. In the 1990s Colum-
            The suicide treatment push is gaining           much more inclined to believe “interventions bia University’s Stanley wanted to offer state-
       support from an unlikely source: the mili-           can reduce people’s drive to kill themselves.” of-the-art treatment to suicidal patients
       tary. It has been stung by suicides in the wake           But will early leads in suicide prevention participating in a brain neurochemistry
       of the Afghanistan and Iraq wars. In 2009            be followed up with breakthrough therapies? study. “I went into the literature and found
       a record 244 soldiers (active and reserves)          It took decades to translate early findings for nothing—zip,” she recalls. “It was a huge

       34    F O R B E S     SEPTEMBER 13, 2010
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        shock.” When she spoke up about the prob-
        lem at scientific meetings, she got a frosty        SAVING SOLDIERS FROM SUICIDE
        reception. Psychiatrists were all too famil-        HIT BY RISING SUICIDE RATES IN THE WAKE OF TWO LONG WARS, THE PENTAGON HAS SUDDENLY BE-
        iar with the state of affairs, she says, but were   come a prime mover in researching treatments for the suicidal. “They are leading the charge.
        pessimistic anything could be done. “I was          There is nobody doing more for suicide prevention than the VA and the DOD,” says Catholic
        astounded. If you don’t study it, how do you        University psychologist David Jobes.
                                                                 The suicide problem first emerged in 2004 among soldiers in Iraq, says Colonel Carl Cas-
        ever have hope of making progress?”
                                                            tro, a psychologist at the Army’s Medical Research & Materiel Command. Now the suicide rate
             The field has a stop-and-start quality
                                                            for the whole Army, which historically has been low, exceeds the rate for civilians.
        about it, with promising leads emerging oc-              The centerpiece of the Army’s efforts is its $50 million, five-year study with the NIH that
        casionally that aren’t followed up for years.       will follow more than 90,000 soldiers to identify risk factors for suicide. It is modeled on the
        In the 1960s UCSF psychiatrist Jerome Motto         famous Framingham Heart Study, which helped spot cholesterol and other risk factors for
        came up with the idea of sending periodic           heart disease. A second $30 million project just getting going will create a suicide research
        caring letters to suicidal folks—expressions        consortium of top researchers to conduct a dozen rigorous trials of various therapies and
        of concern about their well-being. In 1969          drugs in suicidal soldiers and vets. One talk therapy trial is ongoing at Fort Carson, where
        he convinced the government to fund an              infantry soldiers have had multiple combat deployments. The Air Force also has a well-known
        843-patient trial in which half the people got      suicide prevention program it has been running for years to spot at-risk airmen.
        letters and half didn’t for five years. For the          The VA, meanwhile, has put suicide prevention coordinators at all its hospitals and set
                                                            up a 24-hour national crisis hotline. Unlike other hotlines, phone counselors can link directly
        first two years, when letters were most fre-
                                                            to the VA’s computerized medical records to ensure that patients get prompt follow-up care
        quent, there were half the number of suicides
                                                            at their local center, says Janet Kemp, who directs the VA effort.                         —R.L.
        in patients who received them. But Motto re-
        tired in 1991 and didn’t publish the full find-
        ings in a major journal until 2001.                 convince the university human subjects           people lack any ability to control everyday
             The University of Washington’s Linehan         board that it was possible to treat suicidal     emotions. Their feelings spiral out of con-
        deserves much of the credit for demonstrat-         patients outside of the hospital. Her argu-      trol at the slightest push, like a car parked
        ing that suicidal patients can be treated. Now      ment: “There’s no evidence hospitalization       on a steep hill without an emergency brake.
        67, she almost became a nun but realized            has kept anyone alive five minutes.”             It has a 10% lifetime suicide rate. “My fun-
        she was too nonconformist. She got into the             Reading the literature, she realized that    damental theory is that highly suicidal
        therapy business in the 1970s after decid-          many patients suffered something called          people don’t have the skills to regulate their
        ing there was too little evidence backing psy-      borderline personality disorder, in which        behavior and emotions. ... You have to teach
        chiatry. “She started decades                                                                        those skills,” Linehan says.
        ago and has paved the way for                                                                             She spent years coming up with a com-
        others to treat high-risk pa-                                                                        bination of techniques to help. Her DBT is
        tients,” says psychologist David                                                                     an offshoot of cognitive behavioral therapy,
        Rudd, dean of the University                                                                         which focuses on correcting distorted
        of Utah’s college of social and                                                                      thought patterns that can make people de-
        behavioral science.                                                                                  pressed. Among other things, she added Zen
             After getting a doctorate in                                                                    acceptance techniques she learned from liv-
        psychology from Loyola Uni-                                                                          ing one summer in a Buddhist monastery
        versity in 1971, Linehan                                                                             in California and from a Zen master in Ger-
        wanted to devote her career to                                                                       many. DBT teaches patients to tolerate the
        helping the most miserable                                                                           stresses of the moment, accept that imper-
        people in the world. She got                                                                         fect lives are worth living and gain the skills
        hands-on experience as an in-                                                                        to cope with raging emotions. The therapy
        tern at a suicide crisis center in                                                                   often starts with crisis control. Over the years
        Buffalo, learned behavior ther-                                                                      her group has had a doctor who played Rus-
        apy at SUNY Stony Brook and                                                                          sian roulette with a loaded gun, patients who
        eventually landed at the Uni-                                                                        kicked in walls and one who threatened to
        versity of Washington. “I called                                                                     kill the President. Some patients come in
        up all the hospitals and said,                                                                       using so many psychiatric meds they can
        ‘Give me your worst.’ They                                                                           barely stay awake. Linehan tapers them down
        were only too happy to send                                                                          to the essential ones. Sometimes she prac-
        them,” she recalls. Her patients                                                                     tices tough love. When one patient had her
        had suffered horrifying past                                            Arif Khan can’t get drug     stomach pumped in the ER after an attempted
        traumas and were prone to                                                companies to test their     antidepressant overdose, Linehan told her
                                                                               meds on suicidal patients.
        crises at all hours. She had to                                                                      parents not to come, and had her take a cab

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       HEALTH
       home and report for work the next day. “That                    patient, she says, “went to a bridge, reached        GlaxoSmithkline and Pfizer also say studies
       was the best thing that ever happened to me,”                   into his pocket, realized the safety plan was        on at-risk patients would be unethical.
       says the woman, who recovered, got married                      there—and didn’t do it.”                                  Nonsense, says psychiatrist Arif Khan,
       and is raising a 2-year-old boy.                                      Research into how drugs affect suicidal        who runs the Northwest Clinical Research
            Linehan’s first small study (1991) show-                   behavior is less advanced. Only one psychi-          Center in Bellevue, Wash. He has spent years
       ing that DBT reduced suicide attempts was                       atric drug—Novartis’ clozapine, long used            lobbying drug companies to test their psy-
       criticized because the patients got intensive                   to treat schizophrenia—has been shown to             chiatric drugs in suicidal patients but got-
       treatment by experts like her, which might                      prevent suicide attempts in a large trial, pub-      ten nowhere. “They say it is too risky, we
       have accounted for the improvement. But in                      lished in 2003, in which it beat Eli Lilly’s         don’t know how, we don’t have the money—
       2006 Linehan assigned 111 suicidal patients                     schizophrenia drug Zyprexa by 25%. That              lots of excuses,” he says. The real reason, he
       to receive either DBT or intensive treatment                    result has had little impact on everyday prac-       suspects: drug companies “think that if you
       using other techniques. Patients on DBT had                     tice because the drug’s side effects (especially     exclude patients with suicidal thoughts you
       half the rate of attempted suicides over the                    a rare but life-threatening blood disorder)          will make the drug look better. … It is cover
       next two years and were hospitalized less                       complicate its use. A Finnish study last year        your ass and hope for the best.” The FDA says
       often for suicidal thoughts, according to the                   found that clozapine’s antisuicide effects out-      it supports studies in patients at high risk
       results in the Archives of General Psychiatry.                  weigh its risk. Numerous factors work                of suicide and is not holding things up. “We
            DBT usually requires six months or a year                  against testing psychiatric medicines on sui-        have never stopped any studies from going
       of twice-weekly sessions, but shorter courses                   cidal patients, says Novartis Chairman               forward,” says Thomas Laughren, director
       of therapy can also help. University of Penn-                   Daniel Vasella. (Vasella, a doctor, insisted on      of the psychiatry products division.
       sylvania researchers found that ten weeks of                    the trial over the objections of some under-              One drug that shows promise in suici-
       cognitive behavioral therapy reduced the rate                   lings.) So little is known about the biology         dal patients is lithium, which has been used
       of repeat suicide attempts by half in patients                  of suicide that the outcome is unpredictable.        for decades to treat bipolar disorder and has
       who reported to the emergency room after                        Conducting such research, “you are certain           been largely displaced by heavily marketed
       an attempt. One key was logistics: A huge                       it will take lots of time and involve a high         new agents. Bipolar disorder has a very high
       effort had to be made in tracking the pa-                       bill,” Vasella says. “You start to ask, ‘Are there   correlation with suicide; as many as 20% of
       tients and making sure they came to the ses-                    other things we can do with our money?’”             such patients will kill themselves. Numer-
       sions, says University of Pennsylvania psy-                           Antidepressants, amazingly, have basically     ous studies by Harvard’s Baldessarini and
       chologist Gregory Brown.                                        not been tested on suicidal patients. The lack       others have gathered medical records of pa-
            For frontline docs, Brown and Colum-                       of good data makes it almost impossible to           tients on lithium (in clinical trials and every-
       bia University’s Stanley are testing a safety plan              resolve the ancient controversy over whether         day practice) and found an 80% reduction
       that patients write out with a clinician and                    antidepressants prevent suicide. Eli Lilly,          in suicide rates, compared with those tak-
       keep with them at all times. Essentially a list                 maker of Prozac and Cymbalta, says in an e-          ing other drugs. No one is sure why, he says,
       of distracting things to do and people to call                  mail it would be “neither safe nor ethical” to       but lithium may be good at suppressing ag-
       when suicidal urges arise, “it is the equiva-                   enter suicidal patients into a trial where they      gressive and impulsive behaviors that push
       lent of ‘stop, drop, and roll,’” says Stanley. One              might get a placebo or unproven treatment.           people over the edge.
                                                                                                                                 If the findings hold up, putting more
                                                                                                                            people on lithium could save thousands of
            DEADLY DATA                                        Age group            Rate per 100,000 population             lives, especially among those with severe gar-
                                                               85+                                         15               den-variety depression. But lithium is a
            Suicide rates fluctuate with age,
            gender and ethnicity for reasons                  75-84                                             16          tricky drug—small overdoses can be toxic—
            that aren’t always clear. Men kill                65-74                                  13                     so doctors are unlikely to change their prac-
            themselves more often than                        55-64                                        15               tice without definitive evidence. Because the
            women; whites more often than                     45-54                                                  18
            blacks. Suicide rates generally rise
                                                                                                                            drug is not patented, “there is very little com-
                                                              35-44                                             16
            with age. The elderly had the high-                                                                             mercial interest” in doing a rigorous trial to
                                                              30-34                                     14
            est rate but recently were sur-                                                                                 prove it, says Baldessarini.
            passed by the middle-aged. The                    25-29                                  13
                                                                                                                                 Fed up, Khan is spending $2 million of
            numbers here are U.S. suicide rates               20-24                                   13
                                                                                                                            his own to study a combination of lithium
            per 100,000 population based on                   15-19                       7
            2007 CDC data.
                                                                                                                            and Forest Laboratories’ old antidepressant
                                                              10-14      1
                                                                                                                            Celexa in 80 at-risk patients, aiming to show
                                                                                                                            this reduces suicidal thoughts and impulses.
               MALES                 FEMALES                  WHITES                  BLACKS           HISPANICS            Khan has applied for a patent on the combo

               18
             PER 100,000
                                         5
                                     PER 100,000
                                                               14
                                                             PER 100,000
                                                                                         5
                                                                                     PER 100,000
                                                                                                             6
                                                                                                        PER 100,000
                                                                                                                            and formed a company hoping that positive
                                                                                                                            results will convince someone to fund a larger
                                                                                                                            trial. Says he: “I am hoping we can shed some
         Source: Department of Health & Human Services Centers for Disease Control & Prevention.
                                                                                                                            light into this darkness.”                    a

       36     F O R B E S        SEPTEMBER 13, 2010

				
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