Suicides are not "mental accidents" (thoughts on Ajdacic-Gross et al., 2019)

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 certainly unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise...Their terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the window just checking out the view, i.e. the fear of falling remains constant. The variable here is the other terror, the fire's flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors.  

David Foster Wallace, Infinite Jest

Of course, suicide is often approached from a mental health/psychological disorder perspective. At the same time, suicide can be studied at an epidemiological level, in terms of, for example, national rates over time (questions include whether economic recessions are associated with increases in suicide rates). A provocative paper from a couple of years back took the approach of proposing an interdisciplinary paradigm for suicide research. Although it caught my eye, it doesn't seem to have had much uptake in the scholarly literature; as far as I can see, the review hasn't been cited as yet on Google Scholar (which tends to catch citations from a wide variety of academic sources).    

The authors cite epidemiological research suggesting the association between suicidal ideation, suicide attempts and completed suicide is weaker than one might intuitively expect. They highlight that reasoning often begins with completed suicide and tries to work backwards to explain what caused this outcome, rather than starting with risk factors and working from ideation to attempt to death. This latter approach is important for identifying preventative measures, and also for not underestimating or under-emphasising the greater prevalence of ideation and attempts compared to deaths by suicide (there is evidence of a high lifetime prevalence of suicidal ideation in the general population). 

The authors acknowledge there can be different temporal dynamics to suicide, where some individuals with previous good mental health may die quite suddenly following a severe stressor, whereas others may die following a long struggle with severe distress and previous uncompleted attempts. In the latter circumstances, the authors recognise their paradigm is less applicable. They also recognise a cognitive component to suicidal ideation, relating to appraisals of factors such as whether one has hope for the future. This weakens the idea of a paradigm where suicide is understood as a "mental accident".

At an epidemiological level, the authors draw an analogy with fatal road traffic accidents, where although there are many traffic accidents, very few will be fatal. However, notwithstanding that some fatal road "accidents" may actually represent death by suicide, traffic accidents are generally unintentional. 

Although suicidal ideation may be deliberative, a lack of resistance to such ideation may be much less deliberative. They highlight the importance of broader situational factors such as economic recession and austerity in precipitating suicidal ideation, along with an increase in help-seeking behaviour over the last few decades. However, and perhaps more importantly for the "accident" hypothesis, they also cite immediate situational factors relating to the availability of lethal methods, suggesting that the high impact of easy availability of lethal methods, such as having a firearm in one's household, suggest that completion may be prevented by relatively small hurdles. However, I think the authors would admit that this is more to do with suicidal impulses (of sufficient strength to drive an attempt) sometimes being relatively transient, rather than death by suicide being understood as a "mental accident". 

I'll admit the title of this article caught my attention. Framing suicide as an accident seems highly counter-intuitive. However, this review ultimately left me unconvinced that even a subset of deaths by suicide should be thought of as mental accidents. In my mind, an accident doesn't involve genuine intent, and for a death to be classified as suicide it must surely involve some level of intent. In my opinion, what this article does indicate is that death by suicide involves deliberative suicidal thoughts combined with a loss of control of competing motivations. Although research in suicidology and efforts in suicide prevention may have much to learn from work in the area of fatal accidents that actually are accidental, I fear the authors may have prioritised a provocative title/statement of their thesis over a more nuanced summary of what they are really saying. I hope I'm not just attacking a straw argument here, but I do regret the possible tabloidisation of scholarly publishing, particularly with a subject as serious as this.

Ajdacic-Gross, V., Hepp, U., Seifritz, E. & Bopp, M. (2019). Rethinking suicides as mental accidents: Towards a new paradigm. Journal of affective disorders, 252, 141-151.

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IASSIDD Webinar: People with intellectual disability and family carers during the lockdown

On 2nd February 2021, I attended an interesting webinar from the International Association for the Scientific Study of Intellectual and Developmental Disabilities (IASSIDD). Three different talks treated of the situation of people with intellectual disabilities and the COVID-19 pandemic and associated lockdown. 

   Faridah Ali Chang: Support for families and their high needs children during the COVID19 pandemic

Faridah Ali Chang (Rainbow center), works with clients caring for children aged 3-35. At the Rainbow center, there's an emphasis on carers recognising their own stress triggers or risks to their mental health. They identify high-risk families or people with greatest needs. Singapore went into full circuit breaker mode with the pandemic-all schools were shut down, and parents had to move to home-based learning. There was a significant rise in domestic violence and a large increase in calls to mental health hotlines.  Many families had lack of space. The Rainbow Centre continued coaching with caregivers online. They still accepted new referrals as well. Faridah Ali Chang gave an example of a mother with an autistic son who was having a lot of "meltdowns" and a poor sleep pattern. She was becoming depressed herself. She engaged in WhatsApp support with keyworker at Rainbow and found the coaching helpful, even if it was provided entirely online. Help included visual support system to organise her child's daily routine, as well as community supports-the parent in question went on to help/advise other parents as part of the community support.

Paul Willner & Biz Stenfert Kroese:  Effects of the pandemic on informal caters of adults and children with intellectual disabilities in the UK

Paul Willner, Swansea University, has been involved in a clinical trial for PTSD for people with ID. However, this project was paused in March. His team designed a survey at speed to find mental health effects of lockdown on family carers of people with ID. They surveyed carers of adults with disabilities, children with disabilities and children without disabilities (Willner noted the sample was relatively affluent). They also interviewed a small subset of those surveyed, and assessed feeling of being "defeated/trapped" as well as anxiety and depression. People with children (including adult children with ID) reported worse outcomes compared to a comparison group of people with children without ID. Depending on cut-off points for clinical depression estimated with the Patient Health Questionnaire, carers for children with ID had 4-10 times higher levels of depression. Notwithstanding the sample size was limited, the effect size for this effect was substantially higher than suggested by pre-pandemic meta-analytic results, suggesting the pandemic had rendered this differential more severe. Interestingly, although family carers received more social support from professional helpers, they received less social support from family, friends and neighbours. 

Biza Stenfert Kroese described more in-depth interviews with these participants, who spoke of feelings of abandonment, as well as being stigmatised by people around them-there was suspicion that they were breaking rules around lockdown, although they had permission based on their sons'/daughters' needs for exercise etc., with bystanders in some cases claiming that the person didn't "look disabled". There was also fear of challenging behaviour, powerlessness or uncertainty of when things would change. Policy implications discussed include providing more key workers (for adults and for children with less complex needs), improving mental health awareness for nurses/care workers working with clients with ID, and creating more community/peer supports, as well as the utility of encouraging neighbour support (similar to what is done for older adults in the community). 

Regi Alexander: Guidance for the treatment and management of COVID-19 among people with intellectual disabilities

Regi Alexander pointed out excess mortality from preventable causes in people with ID even pre-COVID, but the situation is more stark under the pandemic. He underlined that distress is a normal response to disruption to normal routine, particularly where one is dependent on routine. Many people with ID also dealing with loss, either from the someone's death or someone is no longer available or close. He also emphasised the risk of diagnostic overshadowing (i.e. all problems being attributed to a diagnosis ID/mental health issues), meaning other problems and underlying causes might be missed. Diagnostic overshadowing is concerning when you see the statistics about excess mortality. In this vein, he also highlighted a high degree of physical health problems in people with ID.  He also indicated that there a number of relevant resources available on the NHS radiant website, and the resources from Beyond Words are useful for explaining issues around COVID-19 and the lockdown etc. to people with ID.       

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Webinar: "Research for Public Policy: Opportunities for Ireland"

The research for Public Policy seminar series is a joint initiative of the RIA and IRC, aiming to bring diverse expertise together on the subject of evidence-based policy. The webinar on research for public policy on January 27th was one of three webinars in a series, with a discussion paper by Mary Doyle setting the scene for the meeting

Professor Jane Ohlmeyer described this webinar as part of a broader conversation. Professor Ohlmeyer introduced Minister for Further and Higher Education, Research, Innovation, and Science Simon Harris, pointing out the impact of the creation of the new Department in this area. Minister Harris pushed back against the (by now) old saw about people "having heard enough from experts", saying that policymakers are more likely to make mistakes when they don't listen to experts. He suggested that something good can come of the pandemic if research and innovation can take a more active role in society at large, and also mentioned the importance of multiple disciplines and their collaboration. He emphasised the importance of investment in research and innovation. Notwithstanding the pandemic crisis, he recognised we shouldn't just call on research just during times of crisis, but need to engage in long-term planning. He noted that innovation is not just about business, but also about policy; to this end, he mentioned ideas and programs about secondments for researchers into government agencies to allow researchers to be more cognisant of policy and how it gets made and implemented. He mentioned planning a drive for greater engagement between the general public and the research sector, on a greater scale than had previously been seen in Ireland. 

Panel conversation

Professor Jane Grimson (Trinity College Dublin) talked about how policymakers may identify a need but can't find researchers who are willing/able to conduct the required work. However, she suggested that a positive counter-example in health research in Ireland is the Health Research Board, which does a lot of policy-centric work. The bench-to-bedside journey is usually very slowly, but this was accelerated with unprecedented speed due to the pandemic crisis. Funding suddenly became available, policymakers and researchers started communicating more closely, more rapidly and openly, with knowledge being pooled internationally (on this note, she championed the importance of open research, and systematic reviews). But the rapid successes achieved during the pandemic were built on the back of years of slower research, from work on mRNA to methodological advances in epidemiology and data analytics.   

Professor Peter Clinch (University College Dublin) noted that the phrase "we've had enough of experts" often based on a politically-motivated decision that goes against evidence. Professor Clinch said that there is a desire for research findings in Ireland in the UK, but civil servants and researchers are coming with very different approaches, and there needs to be better communication about what different jobs involved. Currently researchers and politicians often don't understand the rather different pressures they face in their careers. He highlighted the importance of investment, both for National Economic Plan and for National Development Plan, and that researchers should present a united front in their requests for greater funding at a broader level. 

A video of the webinar is available on the Royal Irish Academy's youtube channel. 

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Have women been missing out on chances to maintain cognitive reserve?

 

At present, the majority of people with late-onset Alzheimer's disease are women. While there are a variety of reasons why this may be the case, one possible factor is reduced opportunity to maintain cognitive reserve. (Although it has been defined in subtly different ways, cognitive reserve is essentially the maintenance of cognitive performance in the presence of brain pathology due to a "bank" of greater cognitive resources over the lifespan, such as formal education or an intellectually stimulating job). For example, some women may have (or have had) less cognitive reserve if they have left formal education earlier. 

A recent review paper has looked at this in depth. The authors highlight that much of the evidence that has been used to propose models of cognitive reserve has not looked at whether these models hold to the same extent for men and women, and so there may be underappreciated sex differences. Nonetheless, the authors did identify a number of studies that did grapple empirically with sex differences and cognitive reserve. (Although sex and gender are not the same thing, the authors noted that some studies referred to sex and others to gender, and sex differences may be conflated with gender roles; overall, it was unclear whether existing data would allow anyone to tease apart sex differences and gender differences).    

Focusing on education in particular, the authors found two longitudinal studies that indicated that more years of education led to reduced incidence/prevalence of Alzheimer's disease, and this effect did not differ between the sexes, although two other studies found that years of education were correlated with reduced Alzheimer's risk, but only for women. So it would seem the studies did agree that education reduced Alzheimer's risk for women, although the evidence was more equivocal for men (one might speculate that perhaps young males are more likely to enter more cognitively stimulating work if they leave school early, compared to young females, or at least this has been the case in the recent past). 

However, a cross-sectional study found that men with Alzheimer's disease had better performance on the MMSE than women of the same age with the same level of education, suggesting reserve was more beneficial for men (the authors of the review point out that this study did not assess neural pathology, so it may be the case that the women in this study had more advanced neural pathology than the men).   

Although I've briefly focused on education and women in particular above, it is likely that people from various disadvantaged groups have less opportunity to develop cognitive reserve over their lives. Internationally, there are substantial differences in the average number of years people spend in formal education, and although great progress has been made globally in closing the gender gap over the last century, the female:male ratio for years of schooling is still around 85% for Asia, Africa and the Pacifics. The full paper below looks in more detail at other factors that can help to maintain cognitive reserve:

Subramaniapillai, S., Almey, A., Rajah, M. N., & Einstein, G. (2020). Sex and gender differences in cognitive and brain reserve: Implications for Alzheimer’s disease in women. Frontiers in Neuroendocrinology, 100879.

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SOOTHE webinar: Learning about mental health from people with intellectual disabilities

 

This morning I attended the SOOTHE webinar Learning about mental health & well-being from people with intellectual disabilities. The SOOTHE project is working on mental health in people with intellectual disabilities, with the aim of developing an international community of practice. The webinar was bilingual, with some presenters speaking in Spanish but presenting slides in English. I found this quite refreshing, given usual Anglophone hegemony at events/in science globally.  

A key output of SOOTHE has been its E-quilt: an artistic means for expressing understanding of mental health. The quilt is still accepting submissions at this link. On the broader point of art, Professor Wolter Paans highlighted how artwork by people with ID can be included in an exhibition with an entry fee, underscoring the social value of the artwork.

Research in understanding mental health with people with ID was discussed. Some people with ID had quite biological understandings of mental health, even though they linked challenges to mental health with negative experiences in the past (feelings of rejection was often a theme, as well as not feeling heard/understood). There was a bidirectional effect; it seemed that participants not only gave their own viewpoint, but participation in the project broadened the participants' own understanding of mental health.

Beyond understanding mental health itself, the session went on to discuss innovations and ways of improving mental health. Among ideas discussed were relaxation/mindfulness workshops, musical spaces, use of technology, spaces to reduce stimuli, getting professional support to talk about difficult emotions, and enjoying meaningful activities in company of others. Social interactions as well as faith/religion were highlighted as helping to foster a sense of connectedness. Unsurprisingly, COVID-19 cropped up, with negative emotional impact of lockdown restrictions.

Pablo Alvarez discussed a Learnovate approach: going from ideas to implementable solutions, using storyboards to workshop how ideas might be implemented (e.g. physical activity, social interactions, music activities). The project involved working though how to make music available and accessible online, and how to share it. The team developed a prototype app, then had a Q & A session to feedback on user experience with the app, which can be used to create agenda for daily activities. When I say "team", it should be noted that there was a consistent focus on co-creation with people who will be using app. 

In a final discussion, one panelist sounded an optimistic note of how people are increasingly understanding that we're all on a continuum of mental health. COVID-19 was described as a natural experiment no one asked for, meaning that people in general have no choice but to use technology if they wish to communicate with others. The participation of people with ID in the process was highlighted, so there's an ongoing need for the information generated by the project to be available in an accessible way for people with ID, and that people with ID might be able to recruit others and become mental health advocates.

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The Impact of COVID-19 on People Ageing with an Intellectual Disability in Ireland

 

The Irish Longitudinal Study on Ageing (IDS-TILDA) has been studying ageing in people with intellectual disability (ID) for over a decade. Now in its fourth wave, a number of its research activities had to be paused due to the COVID-19 pandemic and associated lockdown. However, the IDS-TILDA team has taken the opportunity to study the impact of COVID-19 on participants in this longitudinal study. To mark the release of the report of the findings of this research, an online launch was held on 3^rd December 2020, International Day of Disabled Persons.

Attendees were welcomed by Professor Mary McCarron, Principal Investigator of IDS-TILDA. Minister Anne Rabbitte, TD, Minister of State with Responsibility for Disability, gave a speech highlighting the context and main findings of the study, and praising the work of the IDS-TILDA team, those people with ID who have taken part in the study, and those who have supported them during this pandemic. Minister Rabbitte acknowledged that the pandemic and associated lockdown have been difficult for all of us, but it has often been even more challenging for people with ID, who can be more vulnerable, and often have less autonomy than the general population.

Professor McCarron then presented key findings from the COVID-19 survey. The COVID-19 survey had a response rate of 96% from the IDS-TILDA cohort, meaning this survey was representative of the population with ID in Ireland. A majority of participants were tested for COVID-19, with many being tested multiple times. Of those who did test positive or had symptoms, a clear majority had a plan in place to manage self-isolation. Key sources of stress and anxiety were being unable to do one’s usual activities, not seeing friends/family, loneliness and isolation. At the same time, many participants reported there had been some positive aspects to the lockdown, such as trying new activities or using technology to communicate with relatives and friends. Most importantly, there were no reported deaths due to COVID-19 in the IDS-TILDA population.

Following this summary of the results, broadcaster Olivia O’Leary led a panel discussion with a variety of stakeholders, exploring different perspectives on the pandemic and lockdown. Participants on the panel highlighting how best practice was implemented for people with ID in Ireland included Professor Sean Kennelly (Consultant Physician in Geriatric and Stroke Medicine, Tallaght University Hospital), Dr Alison Hartnett (Acting CEO, National Federation of Voluntary Service Providers), Dr Kathleen MacLellan (Assistant Secretary, Social Care Division, Department of Health), and Lisa Lavelle (Director of Nursing, Daughters of Charity Disability Support Service). From an international perspective, Professor Chris Hatton (Manchester Metropolitan University) praised the work of services in Ireland in protecting people with ID, and the research of IDS-TILDA, saying he hoped similar research (conducted at a more localised level) in the UK would be published soon. Professor Philip McCallion, Co-Investigator of IDS-TILDA, highlighted the heterogeneity of experiences across the United States, given the size of the country, but drew particular attention to the deep impact of COVID-19 in the North-East of the USA, where he works at Temple University, Pennsylvania. Mei Lin Yap, a PPI contributor and steering committee member with IDS-TILDA, spoke of her lived experience of the lockdown, and of the importance of social contacts during the lockdown.  

Following final comments from Professor McCarron, the launch closed with the original song “We’re in this together” by Sunbeam House Services. The song and its accompanying video, made by the service users, was a great way to finish the launch and underscore the importance of solidarity with each other at this time.    

You can download the report at this link.

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Writing workshop: "Novel Problems" with Niamh Campbell

I recently attended "Novel Problems" at the Irish Writers Centre The course was conducted entirely online, given the pandemic. The course is run by Niamh Campbell, whose debut novel This Happy has been getting very positive reviews. I had previously attended Fundamentals of Fiction, which combined a didactic aspect with workshopping of work, whereas Novel Problems focused more heavily on workshopping throughout. 

The quality of writing at Novel Problems was very high, and some of the participants were progressing quite well in the publishing game; one person in particular had already secured an agent, and their novel was in the process of being sent to publishing houses. Whereas the participants at Fundamentals worked in a mix of genres, the pieces workshopped on this course tended to be  more grounded in realism (in contrast, my current work combines the surreal, hyperreality and magic realism, so I felt like somewhat of a black sheep in this regard). During some of the discussions I realised that I would have benefitted from reading through the circulated extracts a few times; a lot of subtleties of people's work can go over one's head at a first read.

For the last week, we spent some time talking about an interesting article by Zadie Smith which led to much discussion around issues of identity, and authenticity in writing. I think this discussion was very pertinent for many of the writers in the group, whose work had a semi-autobiographical quality. My current work in progress is a totally fictional piece that is not based on anyone I know, but the article by Zadie Smith does make a fair point that the writer's personality will come through in their writing (regardless of how outlandish their story might be). 

This course is geared towards writers who have been working on a novel for some time, but I wouldn't write it off if you're starting on something, as long as you're passionate about it. If the course is running again, it's a great chance to get feedback from other motivated writers. 

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