Depression as a Terminal Disease
Depression can be a terminal disease. And not only depression, but every mental health condition that can have suicidality as a major component, from bipolar disorder to post-traumatic stress disorder to obsessive-compulsive disorder to schizophrenia, among others. This is a fact we see in the world around us, it's well documented in the medical literature, there is absolutely no controversy about this question. Suicidality is a life-threatening medical condition.
The painful question is why responses to suicide can be framed so differently than responses to deaths from other terminal diseases. Why do people call suicides “selfish” and “weak”, even when those same people would never use the same language for someone whose life had ended too young because of congestive heart failure or metastatic cancer?
There's a lot at work. There's a belief that suicide is always a choice. There's a belief that mental illness is somehow less potentially deadly than other illnesses. There's a cruelly false optimism about the availability and efficacy of treatment for depression and other illnesses with suicidality as a component. And, most heartbreaking of all, there's a lack of understanding about how suicidality works and especially about how it feels.
David Foster Wallace, whose life ended in suicide at age 46, wrote movingly about the inexorability of death for some suicidal people: “The so-called ‘psychotically depressed’ person who tries to kill herself doesn’t do so out of quote ‘hopelessness’ or any abstract conviction that life’s assets and debits do not square. And surely not because death seems suddenly appealing. The person in whom Its invisible agony reaches a certain unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise.”
My guess is that when most people think about suicide, they think of it as a choice. And it can be. People who choose assisted suicide when facing an excruciating death from a terminal physical illness are making a considered choice. People who resist armed terror against insurmountable odds are making a considered choice. People who self-immolate as a protest against brutal injustice are making a considered choice. Those are important and worthy choices that show courage and commitment.
Suicidality impairs or destroys the ability to make the choice to continue living. It's not a question of courage, or of commitment. It's your brain trying to make you die. And the main tool you have to understand this, and to fix this, is the very brain that is trying to kill you.
My own experience with depression and suicidality is a long one, as long as I can remember, from my earliest childhood. It's difficult to explain to someone who hasn't experienced it themselves (and of course everyone who has experienced it has lived through it slightly differently, to boot). Imagine if your brain were a magician, and that every time you tried to make a decision, it gave you a pack of cards and told you to pick one. “Should I get up and go to work?” I'd ask my brain. My brain fanned out the cards, the cards I knew had messages like “Go to work” and “Call in sick” and “Call in late.” But my brain was such a good magician that, almost every time, I'd reach into the fan of cards and pull out “Kill yourself.” Some trick.
It's hard to express how impossible it feels to live like this. Brains are good magicians. They're also great liars. What Wallace described as depression's “invisible agony” is also virulently metastatic. It attacks cognition from so many angles at once. The people preaching about how “selfish” a suicide was must surely not realize how many of the currently suicidal hear that only to have it transformed by their liar-magician brain into “But I would be being selfish to stay alive; if I died, it would only make the lives of everyone I love easier.”
Shaming and judging people who have died from suicide is the worst way to help others living with suicidality. No matter how deeply anyone wants to believe in a cosmically just world where everyone lives to a ripe old age and dies peacefully in their sleep, people die young from terminal diseases. They're not doing it to harsh your mellow. They're not “taking the easy way out.” Their body is failing them, and they die.
Because the brain is part of the body. It's a vital part, and a fragile part, just like our heart. And just like our heart, it can be terribly impaired, function disastrously badly, and wind up killing us. If we're lucky, we can find treatment that helps keep us going; I've been lucky for fifty years so far, and I'm grateful to the doctors and therapists who have been part of that. If we're not lucky, the treatment stops working. Or we can't get treatment at all.
If you're reading this and you're ever tempted to judge someone's death because the disease that killed them was in their brain, please look in your heart and find the compassion to refrain. You'll be honoring their memory and helping other people living with suicidality.
If you're reading this because you're experiencing suicidality yourself, please try to stay with us if you can. The amazing Sam Grittner keeps a list of some free resources for people currently in crisis. If you can reach out, that's a start. If you can keep going for one more day, that's a start. Please stay.
