The sometimes terminal nature of mental illness
Content warning: suicide, the state of mental health support in Australia
I read that when creative writing students are starting out, one of the things they write about most is suicide. It’s a “gimmie subject,” professors say (their words, not mine!), “like the Holocaust.” It’s easy to write about it evocatively. It’s easy to create a passionate and tortured story. But what of suicides that are not evocative? Not a tragic, twisted, macabre shriek but just a silence at the end of a life sentence? Not despair and heartbreak and shock but just the inevitable end?
In 1980 my father sat in a room in Adelaide’s Flinders Medical Centre with his own father, who was recovering from carbon monoxide poisoning. They were both young men — dad in his 30s and my grandfather in his 50s — but the weight of what had happened made them old.
“What should we do?” dad said, and the doctor said, “Prepare yourself to be back here again soon.” Two weeks later they were, this time to view the body.
As a society, we lack empathy when it comes to matters of depression, delusion and fear. And we demand recovery of the mentally ill in a uniquely aggressive way. We expect sufferers of incurable and treatment-resistant mental illnesses to tough it out, to brighten up, to think differently. The fact that these illnesses are borne from brain function must mean the brain can also fix them, that through neuroplasticity we may be cured. There is rarely a consideration of non-recovery. Even the incurableness of mental illness does little to deter friends and family from their insistence that things will improve. Tomorrow is a new day. What have you got to be sad about?
We lack a nuanced way to speak about mental health treatment. We insist on trying new things in perpetuity. Many treatments have known limited periods of effectiveness. Many treatments have challenging and sometimes dangerous side effects. Many treatments reduce quality of life. If this all sounds familiar, it’s because the same is often true of end-of-life treatments for patients with terminal physical illnesses.
We think about terminal illness as a physical inevitability. A body with stage VI cancer will die. A person with degenerative neurological disease will die. Someone with progressive organ failure will die. What we don’t do is consider the terminal nature of mental illness. That to be diagnosed with specific mental illnesses is to carry around a probably-terminal illness. People with bipolar disorder die, on average, 20 years earlier than people without. Up to 80 per cent of people with schizophrenia die by suicide. There is an inevitableness to these illnesses in the same way that there might be in a cancer diagnosis. There is a reasonable likelihood you will die as a result of this illness.
In fact, when it comes to bleak life-ending illness, we don’t even necessarily expect the patient to die of the illness. Most of the time, the body becomes weak and therefore more susceptible to infection, disease, etc. A broken immune system exposes a patient to respiratory illness, organ failure, cardiac arrest. They don’t die of their disease but just because of it.
Mental illness is usually not the direct cause of death but the reason the mind and body is exposed to fatal circumstances. Is suicide as a result of having a chronic and incurable mental illness different from succumbing to pneumonia because of a compromised immune system? People who make a serious attempt on their own life (which we will gently and empathetically differentiate from a “cry for help”, a completely valid experience not intended to end in death) are more than 80% likely to make another serious attempt within six months. This number is even higher when limited to people with “serious” mental illnesses — including schizoid and psychotic-type illnesses and mood disorders.
Euthanasia, the subject of much debate in this country, is always spoken of in the context of terminal physical illness. Supporters promote its availability to people who will eventually succumb to their painful, debilitating or otherwise life-worsening condition. In these cases, the patient is empowered not only by the assisted suicide but also by the people around them who support it. There is oblique support of the terminal nature of brain disease: we accept the degenerative nature of neurological disorders like ALS and dementia, but not the endless reinforcement and battering of illnesses like borderline personality disorder or chronic psychosis. Having a mental illness is not a “good enough reason” to sign on for euthanasia. The inevitability of death is only explicit if the body is in decay, not the spirit. And by excluding mental illness from the “terminal” definition, we ignore the many ways in which mental health can have an impact on physical health. Studies have shown that people with mental illnesses are also more likely to suffer from heart disease and stroke. They are more likely to be obese, to have higher cholesterol, to have higher blood pressure.
Which isn’t even the whole truth about mental illness. Different disorders affect the patient in different ways. Not every illness has a depressive symptom, where the patient becomes severely melancholy. A deep sadness is not necessarily required for suicidal ideation. Manic symptoms — where a patient may experience feelings of extreme euphoria — can be equally debilitating. Then there are people, like my grandfather, who have a resigned sensibility about their suicide. He asked that no one make a fuss, spelled out his wishes for his funeral and subsequent arrangements for his adult children, then signed off. It was devoid of despair. His wife had died, his children had grown up, and his business here was simply finished.
Here’s an unpalatable fact to consider: mental illness is a big bucks industry. Medications like SSRIs, SNRIs, tranquilisers and beta blockers from a substantial part of a multi-billion dollar pharmaceuticals industry. Psychology, psychiatry and other therapies can command upwards of $500 per hour. Mental health care plans bring in approximately $160 to a clinic every time a patient requests one. I have been told by psychologists that their local GPs are referring more patients than they can fit into their books for just one session, because the financial benefits of MHCP offer such a good time-to-money ratio. There are financial incentives for prolonging the treatment of mental health patients. There is a dichotomy that must be recognized in the “wellness” of a patient also being the end of their invoices.
There is no palliative care for people with mental illness. There is no, “here is a person at the end-stage of their life with a chronic mental health issue.” I have a treatment-resistant kind of mental illness. I’ve been on anti-depressants, anti-anxiety medication, anti-psychotics and beta blockers. They had different effects: one made me lactate, one stopped my ability to orgasm, one made me suicidal. These medications work for lots of people, but not me. I’m not “terminal” now, but one day I might be. In many ways, my eventual inability to drum up the energy to face any more days seems inevitable. I hope, when and if that time comes, someone shows me the same kind of empathy they’ve been taught to show their oncology patients.
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Beyond Blue 1300 22 46 36