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Considering the Implications
Arango is working with people who are already dead. What can all this information do for the living?
While knowing the levels of 5-HIAA holds great promise as a predictor of future suicidal behavior, measuring those levels in a living person requires a spinal tap—an expensive, painful, and difficult procedure. The next step for Mann and Arango is to develop something along the lines of a Positron Emission Tomography test to detect those who might be at risk for the "dysregulaton" of suicidal behavior. Such a test would be vastly less invasive and could become a feature of sophisticated clinical practice. Patients shown to be at risk would then be referred to early, preventative psychiatric treatment (both pharmacological and psychotherapeutic). As Mann has written, "Protecting the patient against suicide in this way buys time for the treatment of the depression and other psychiatric disorders that underlie their suicidal wish." Arango and Mann's work could ultimately save many lives.
I realize I've been thinking, somewhat despondently, of Juan and Michael throughout my visit to the lab. I'd been intensely involved in their lives, because they were so needy, and because I liked them both a lot. I did my best, under the circumstances, to help them—to get them into treatment, to help find them a decent place to live, offering counsel and advice, but mainly just listening to their problems and stories. Based on their brain chemistries, though, was everything already stacked against them?
I ask Arango: was it all for nothing?
"No, absolutely not," she says. "Biology, mental illness, life events, personality traits, and genetics—all are involved in suicide. While I think that nobody will kill themselves without biology, it is just one part of it," she adds. "Environmental factors, or factors that are influenced by the environment—life events, personality traits, psychiatric disorders—are all huge players. And even genetic expression is related to the environment. My work involves the interactions of all these factors. In other words, we are not biologically predestined."
Indeed, recent research shows that mind and brain are inseparable. The work of Eric Kandel, and others, has shown that the common metaphor that compares the mind to a computer, with unmodifiable hardware (a brain) and malleable software (thoughts, memories), is entirely misguided. Rather, thoughts and feelings can actually change the structure of the brain—that is, the software modifies the hardware. It's all a two-way street—one's life experiences are capable of changing the biochemistry of the brain.
But the current trends in psychiatry are mostly toward altering the brain's chemistry, rather than working with the mind. I worry that that subtleties of Victoria Arango's message are lost on some practitioners, who don't realize that the mind, personality, free will, and—dare I say—soul all remain central to the question of whether, and how, we live or die.
As I leave Arango's office, my thoughts flash to something I once read about the pattern of suicides from the Golden Gate Bridge. Since the bridge opened, in 1937, more than 1,200 people have committed suicide from it, making it the most "popular" place to kill oneself in the world. Ninety percent of those suicides plunge to their deaths from the San Francisco side of the bridge, with its views of the city. Only a small portion chooses to spend their last moments on the Pacific side of the bridge, with its endless void of water and what Jack Kerouac called an "end of continent sadness." While there may be a practical explanation—the city side of the bridge is easier to access—the overwhelming discrepancy in numbers is striking.
It seems to me that these figures indicate the persistence of an essential human characteristic. Even in their final, desperate act, soon-to-be suicides yearn to be connected to people, to society, to all those myriad human influences—positive and negative—that have led them to the precipice.
Charles Barber is the author of Comfortably Numb: How Psychiatry Is Medicating a Nation and Songs from the Black Chair: A Memoir of Mental Interiors. He's a senior administrator at The Connection, a social services agency, and a lecturer in psychiatry at the Yale University School of Medicine. Contact: firstname.lastname@example.org.
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