My name is Tyler Black, and I am a Child and Adolescent Psychiatrist at BC Children’s Hospital in Vancouver, British Columbia. I have been the Medical Director of the Child and Adolescent Psychiatric Emergency Department for 9 years, working approximately 400 admitted youth and families and over 1,000 emergency department patients per year.

My primary research interest is suicidology. I have published articles on the utilization of emergency departments for psychiatric services, the use of psychotropic medications, and authored and edited textbooks on Emergency Psychiatry and Psychopharmacology.

Today is World Suicide Prevention Day – where a (hopefully appropriate) spotlight on suicide prevention raises awareness to the tremendous amount of resources and support that exist out there in the world for people who are struggling with suicidal thinking.

So please, Ask Me Anything about the science of suicide, suicide prevention, suicide prevention training, the media’s reporting of suicide, risk documentation, or other topics you can think of!

WARNING: Suicidal thinking can be increased by reading about, or discussing, topics relating to suicide. Please be aware that the topics inside this AMA could be triggering or overwhelming for some. If you find yourself needing to reach out, please be aware of local and national crisis lines ( has a helpful list), find someone to talk to, or seek help at your local emergency health facility. Help is available and people with suicidal thinking receiving help experience significant relief and positive outcomes!


Today is a work day for me so I will be responding throughout the day starting at 8amPST/11am EST. I will be replying through the day.

Edit 1230EST I am slowly pecking away at responses throughout the day, between patients and work. Please be patient! I'll focus on the most upvoted for now but I will look for unique questions as well!

Edit 1400EST 838 new messages in my inbox - it's unrealistic at my pace I'll respond to everything but I'm doing my best.

edit 1530EST - I'm replying and now it's at 1125 new messages. Thank you all for your contributions and I am continuing to work at my plodding pace. I couldn't dedicate today to replies like I have done previously, so it's nowhere near fast enough to reply.

edit 1800EST I have to formally say here, and sorry that those who don't get a reply, that I can't provide specific medical advice on reddit. I'll do my best but there are many people who are posting their personal stories. I've read them. I care. I hope help is available and I feel my other responses have addressed a lot of what my general advice would be. I will reply where I can but there is an overwhelming amount to get through.

edit 2030 EST I have to tap out now... I will try my best to get to questions I feel are left unanswered but I should probably turn off the faucet now. For those who have shared stories, thank you, and I'm sorry I couldn't get to everyone. Today was truly epic and eye opening to how much more I need to get more public messaging out there.

If there's one thing i want everyone here to know, it's the following phrase for the people in your life: "hey just to let you know, if you ever need me, give me a call, I really care about you."

edit 0430am: thank you all! I put my best effort in and thank you to amazing redditors who also stepped up. Good night reddit!

Comments: 3942 • Responses: 39  • Date: 

IncompleteBagel6089 karma

I have noticed that while I no longer want to kill myself, I would still welcome death if it presented itself. Should people with that mindset still be on watch?

Dr_Tyler_Black4352 karma

There are grades of suicidal thinking, from the very active (I will die by x method at x time) to the very passive (i'd rather be dead), and whether or not "watch" is necessary depends a lot on the type of watch. Supervision is preferred for more active/pressing suicidal thinking but it doesn't guarantee safety - people can and do hurt themselves with direct 1:1 nursing observation.

I certainly think that in the road to recovery from active suicidal thinking, there should be regular-ish check-ins, hopefully with a trusted and helpful professional, or a family member/friend who is going to be able to be of assistance. the main reason I advocate for this, is because the question "Is there anything right now I need to make my situation better?" is often minimized vs the "things aren't as bad now so don't rock the boat" type of thinking that people have.

I really wish you well on your path; and thank you for asking such an excellent question!

slimewitch2294 karma

If a friend texts or calls and tells me they’re suicidal and thinking about committing suicide, what’s the best thing I can to do to help them in that moment? Especially if they are refusing to get professional help?

Dr_Tyler_Black3144 karma

I think its important to do what you can, but people can still make their decisions. Many jurisdictions in the world have mechanisms to trigger mandatory assessments, and often this involves *you* calling a hotline in your area, or *you* calling an emergency service (for example, in Vancouver, there is a police car with plainclothes police officers and social workers that can be specifically called).

The general tips are:

  • "what can I do to help?" - they called you for a reason, don't let them go halfway and just make you worry
  • distraction often helps in the moment, but it doesn't solve the problem. still, "lets go do something" is an appropriate way to reduce an emergency, and once things are calmer, then maybe direction is more possible
  • Offer to see the person or talk to them in person, as its a lot harder to imagine isolation when someone is with you
  • direct to care in all your statements - "I know you don't want to talk to a professional, but this sounds like something that needs one."
  • There is no confidentiality when safety concerns are emergency. Reach out and get your own help, call that person's parents, do what you need to do, if you think there is serious jeopardy here. The balance of "but I don't want to violate their trust" is never worth it if something bad happens, and most suicidal patients i've talked to very much understand why their friends/family did what they did. it does NOT ruin friendships to ask for help.

AdministrativeFarmer1651 karma

Being a doctor specializing in this field in Vancouver, what are your thoughts on the current wait times to access psychiatric care in this city (I was recently quoted 6 months+ before an appointment is likely), and what do you feel is the best way to remedy this issue in the short term?

Dr_Tyler_Black1188 karma

I'm busier than I want to be, and despite the wonders of our healthcare system (I truly do love Canadian healthcare), we still have to work on inefficiences. Your 6 months wait is unacceptable to see a psychiatrist if you are struggling with a possible illness, and so you will need to reply on primary care (family doctors, walkin clinics). there are really good volunteer organizations at well which might be a good stepping stone.

in Vancouver specifically, I think about SAFER for adults, Kelty Mental Health for kids, and and its affiliated programs.

Call your MLA!

Policymakers and advocates need to work hard to improve our system. We need tiers of service that are readily availalble:

a) primary prevention designed to reduce the likelihood of BECOMING suicidal

b) detection pathways (school counselors, teachers, doctors, police, family, etc) and find people who are suicidal and direct them to services

c) non-emergency "urgent" interventions designed to reduce passive suicidal thinking or reducing risk factors that emerge

d) emergency interventions designed to rapidly respond to people who ARE suicidal (where most "resources" currently available apply

e) robust follow-up systems for all people who need it

We need strong leadership, advocates (community, medical, and governmental) to make the bolded items a priority.

Swyftheart9 karma

Also, why does it seem like there's no discussion of suicide for the Vancouver area besides the corner's report? You hear about people jumping off of Lions Gate bridge all the time by word of mouth but it's never in the news.

Dr_Tyler_Black20 karma

The largest answer to this question is that reporting on suicide is complicated due to concerns of influencing suicide (suicide contagion). I do things like this, and there are groups out there promoting wellbeing and mental health for this very reason.

LeeYael281464 karma

Hi, what is one misconception about suicide that you want people to stop believing in?

Dr_Tyler_Black2721 karma

Probably the biggest would be that suicide behaviour or thinking is only for people with mental illness. Risk factors and protective factors don't work like that. Just like all humans are at risk for heart attack (some, very very very low compared to most humans, some very very very high), all of us have various risk factors that push us towards suicidal thinking and protective factors that push us away. Mental illnesses add to our suffering but so do physical illnesses, stressors, bad news, poor sleep, etc etc. There are hundreds of risk and protective factors that all work in different directions to influence suicide risk.

The reason I want this misconception to change so much is that:

  1. we tend not to think about suicidal risk factors as bad things until they are a crisis
  2. we tend to think that we don't need to worry about people until they show significant dysfunction/suffering
  3. we minimize our own daily influence on others, forgetting that every moment we're with another human being, if they are struggling with something, we could be helping
  4. we overvalue what psychiatrists do in "predicting" suicide risk. Many times, my job is not treating specific mental illnesses, but teaching coping strategies, connecting people to resources, advocating for time off school (because school is a major stress that not every person can handle every day), etc. I am happy to help, but many many other people could be helping more people.

YuriTheRussianBot836 karma

I've been struggling with suicide thoughts every since my early teens. Depression been a part of my life since same age all the way into mid 30s. IMy therapist says its because our brains constantly try to solve the problems and this is the ultimate solution it can come up with if it doesn't see any other options.

It's been getting better with therapy but still when under stress the thoughts of self harm come back. My dad committed suicide when I was in my late 20s and I want to avoid same lifepath.

Will the thoughts of self harm ever go away completely? I'm proud of the progress I've made so far but it scares me sometimes how quickly I can regress. Thank you.

Dr_Tyler_Black848 karma

Our brains are quite incredible things, and patterns that seem locked in now can and do regularly change. I'm sorry to hear about your struggle, but also I'm glad to know things are getting better for you, and congratulations at the success of all your hard work.

It's quite easy for us to minimize our progress when we improve, so careful for that! Often, I work with people who are at the phase you describe and one of my efforts is to make sure that thinking isn't biased towards mistakes (which all brains make) vs successes (which you have already described!). Any road to recovery has backsteps, bad days, struggles, but the road is getting you to a point where you can feel "recovered".

I'm not sure if this is helpful or not, but many, many helpful people, when under stress, experience thoughts about extreme measures (from "I'll burn this whole place down" to "I should just leave him/her" to "it'd be better if i didn't exist" to "I want to KILL that guy that cut me off in traffic"), and it's very important not to take a look at those thoughts and think "what's wrong with me?" The thought itself isn't abnormal, its the distress caused by it or our ability to process in a healthy way that is more important.

kristmasdestroyer609 karma

What sparked your interest in suicidology?

Dr_Tyler_Black1479 karma

One of my first days as a psychiatric resident included a patient on another ward dying of suicide, and I had the misfortune of watching all of my colleagues (my bosses, my co-residents, the nursing staff) and the persons family get torn apart by the event. Almost everyone had something to say about it, and the things they were saying were not compatible with each other. I dove into the research and found how important a topic suicide is, and it sparked a research passion in me.

Iocronik572 karma

What is your opinion on humor regarding suicide? I have a friend with pretty bad diagnosed depression and we will often make suicide jokes. We've talked about it and feel like it helps normalize it as something to talk about while keeping the mood lightish but I figure as a professional on the topic you might have some fun facts about it

Dr_Tyler_Black1025 karma

I use humour (with a Canadian "u") a lot with my patients, because humour is a helpful way to show genuineness. If you acted fake around your depressed friend, and carefully manicured your behaviour, that friend could feel a burden they are placing on you, or they would see through it and feel pitied (which often is a horrendous feeling for a depressed brain, which experiences abnormal levels of guilt). Genuine, honest conversation should include humour if that's what care and support means to you.

Often in clinical interviews, I try and "inject" humour, because it a) tests affect for me, to see how much range there is in their mood, and b) because genuinely I enjoy connecting with my patients on a human level, and shared laughter generally makes kinship possible.

However, I do think that people (especially online) think that there is automatic humour in suicide jokes. If you are going out of your way to poke at a person who is marginalized, depressed, suffering, ill, or you wish to ostracize, I can plainly state that it's actually a painful thing that can cause harm. We have a long way to go to make online spaces free of the type of bullying/attacking that can actually make situations much worse.

RyanXera548 karma

What do you think about assisted suicide? If someone decides they do not wish to live anymore, why do they have to be prevented from taking their own lives instead of helped?

Why is someone with no will of living considered mentally ill? Why is being happy and full of life the norm and not the other way around? I understand there’s some mental illnesses that have as an effect suicidal thoughts, but if someone has no problem whatsoever, no traumatic experiences, but decides life is not worth it in the long run and wants to end it now instead of waiting, why is he/she considered mentally ill?

Dr_Tyler_Black784 karma

There is no mental health illness called "suicidal thinking" - we evaluate for the presence of mental illness in people who have suicidal thinking, and if we identify illness, we offer treatments for those illnesses. Major depression, for example, has a variety of treatments, from evidence-based medication to evidence-based therapies. This is a hard concept for many clinicians, who see all suicidal thinking as abnormal, when in fact, suicidal thinking can be a reasonable reaction to certain circumstances or some decision-making. I care very much about making sure that illnesses or external, solvable situations are not used in that decision-making, and that's what my job is about.

Physicians in Canada are rather divided about Medical Assistance in Dying. I personally believe that if someone has a terminal or life-disfiguring illness that has no recognized treatment, or all reasonable treatments have failed, that physicians who wish to embark on MAiD have a role in making sure that person not suffer. I do not want people to hold onto a painful life, I see my job as reducing or solving that pain, or making it possible for that person to enjoy their life despite it. I do not see my role as prolonging suffering when I can't accomplish those tasks.

eyecaneven526 karma

My 11 year old daughter's school will be talking about suicide in the next few weeks. Our high school has had an alarming number of suicides and attempted suicides over the past several years.

I want to talk to her first. Are there resources you recommend?

I have struggled with depression since early childhood and in fact had a failed suicide attempt when I was about her age. I'm terrified of her experiencing the same thing.

Dr_Tyler_Black847 karma

It's a plug for a local resource in my hospital but is a great resource for information for kids and families on all issues related to mental health. the American Assosciatio of Suicide Prevention article linked here is more tailored to younger children than yours, and I just googled specifically for teens and I read through this NYU article was good as well.

the basics are:

a) be honest and open

b) allow any reaction, and validate it

c) euphamisms ("went to sleep") are NOT helpful and ARE harmful

d) be explicit with your endless care and support. Children are horrible at interpreting reality, despite being very good detectors of emotion. They need explicit messaging, like "I don't care how much trouble you think you are in, my love for you is bigger than that, and I'm always going to want to help you" or "If you're ever in trouble, come to me at any time" or "nobody should make you feel worse in life, if anyone is doing that, please let me help you" etc.

hellohellno491 karma

I was at my therapist today and bumpt into a girl standing at the door. She looked lost, so i asked her if I could help her with something. Her eyes were teary and she said that she didn’t have an appointment, but was there because she wants to kill herself. I felt in shock and told her to come inside with me, and that i would find her a therapist she could talk to. It took a while for someone to arrive. In the meantime I was waiting with her. What was the appropriate thing to say to her or to do at that moment? And in a hypothetical situation, if there are no professionals available, what should you say to someone that has specific suicidal plans?

Dr_Tyler_Black464 karma

Holy cats, you did awesome!!

The best phrase when you're stuck is some form of: "I really want to help, what can I do right now while we wait to find a professional, even if it only slightly helps?" If they have nothing, then provide some suggestions "maybe lets go chat over a hot chocolate?" or "would you like to go for a walk?"

But you're a hero!!

JaceJarak484 karma

In US not Canada but: what is the best way to help suicidal vets who refuse to talk to the VA because they are too afraid of getting a PTSD label or any paper trail what so ever (could affect job etc)? I am a vet and it hurts incredibly much not knowing how to help other vets who refuse to get help because of this. I know a few who have lost their battles after they came home and it puts me in tears far more often than I would like to admit...

Dr_Tyler_Black367 karma

There are many non-professional ways to help people who are suicidal, though ultimately, I have to confess, one of the goals (sort of sneaky) is to get them to see a professional.

a) if you detect something, be your human self and don't be afraid to approach them. Simple statements like "How are you doing, like really?" or "I'm a bit worried because it feels like you're going through something" or "Hey is there anything I can do to make your day better today" can be amazing lifesavers despite their minimal investment

b) many people who are afraid of stigma or labeling feel like they are alone in their struggle. Sharing your own experiences, for example, the pain you feel when people don't get help and you watch them suffer, can be a helpful way to normalize suffering. Many people, vets included, see suffering as weakness, especially combat veterans who have been trained to push through suffering to a goal.

c) many suicide prevention societies actually exist for you too! They are generally opened to friends and concerned people, and it might be a great way for you to find some strategies, find some people, and more importantly, process some of the pain that you are experiencing watching friends suffer or die.

Thank you for the excellent question, and I hope it was a helpful answer.

-Xal-480 karma

Is it considered normal to have casual suicidal thoughts? In which they're not 100% serious but no where near a joke, either.

Dr_Tyler_Black470 karma

I struggle with the word normal. A minority of people have suicidal thoughts in any year, but that doesn't mean that suicidal thoughts are themselves abnormal. 17% of teens, for example, consider suicide in any year, according to the CDC, and not all of these are abnormal experiences.

Suicidal thinking is, generally and VERY simplistically, a sign of distress (increased pressure vs decreased ability to cope with it). So I think it shouldn't be discounted at all, but it's not a red-alarm crisis. Self-care, modification of lifestyle, increased connection to professionals or friends or family, or disconnection from people who are negative to you, are all important maneuvers to consider.

0x44444444253 karma

When do you know you're suicide thoughts/idolation are bad enough you need protection from yourself ?

Dr_Tyler_Black327 karma

My recommendation to most people is that there is no soon a time to reach out for help, to a friend, family member, or professional. Most people out there would want to help earlier rather than later.

But when it comes to safety, any "active ideation" (suicidal thinking that is specific, like methods, locations, dates, etc) is probably a sign that the risk is significantly higher than most and one should seek help.

sirijoh221 karma

How do you take care of your own mental health while working in your field? I imagine that it might be hard to leave "work at work".

Dr_Tyler_Black327 karma

I love what I do, being a doctor and trying to help others gives me energy, not removes it. I do take on a strong emotional burden but I have an awesome family, a love for basketball (200 3 pointers a day!!), video gaming, photography, and travel. Self-care is important.

But it's not exaggeration to state that many times, I have a lot of energy for it and I will spend a weekend researching a topic, or volunteer a weekend to give a talk, because this area is truly an area of passion for me.

foreverwasted214 karma

Why is holding someone for 72 hours against their will considered to be the first answer by professionals when someone expresses their wish to commit suicide?

Dr_Tyler_Black305 karma

Formalization/Certification/Involuntary care is a very harsh solution. It should not be the routine approach to suicidal thinking, as 16% of kids in America consider suicide in any year, and I definitely don't want 16% of kids to be hospitalized!

When safety is the primary concern, and interventions are necessary in a rapid fashion, emergency admission is very helpful. But hospitalization can be traumatic. It can rob us of friends, activities, job, it can expose us to violence and illness, and it is NOT a benign thing. I absolutely HATE that many care providers treat hospitalization as a "oh you said the word 'suicide' off to the bin you go", and the world is getting MUCH better at this.

Risk reduction is all about REDUCING RISK FACTORS and IMPROVING PROTECTIVE FACTORS. If someone's suicidal ideation would be made worse by hospitalization, there should be a pretty dang good reason to hospitalize. Many times, children who present to me with suicidal ideation are offered time off school, a counselor to talk to, come see me again and we can sort out some problems, etc.

Thoughtless application of a severe reduction in rights, autonomy, while exposing people to potential negative effects is NOT good medicine.

SlashBolt194 karma

Do you think there is ever a scenario where a perfectly healthy adult can decide he doesn't want to be alive anymore and would it be ethical for him to follow through with such a notion?

Dr_Tyler_Black244 karma

Healthy people, under significant stressors, for example, can and do rationally choose suicide. People who value quality of life over longevity do as well. Even within illness, I am personally in support of Medical Assistance in Dying (MAiD) for conditions for which there is an expectation of severe suffering with no treatment, or palliative care.

The ethics of suicide are tricky, because we are social beings connected to others. People are severely negatively effected by the death of a friend, coworker, colleague, former classmate, current classmate, family member, etc (even angry ones). It is NOT a harmless move. The ethical principles of autonomy apply, but when it comes to harm and beneficence, there is usually a significant imbalance on the harm aspect to others vs the beneficence.

Hopefully this answers the question. Due to the high visibility of this thread and concern about contagion/misinterpretation, I tend not to like to publically post about ethical reasons justifying suicide. But I would be happy to discuss in private.

gunslinger6792146 karma

I work at a major hospital in the ER. Why are there so many suicidal children under the age of 10?

Dr_Tyler_Black141 karma

Suicide is exceedingly rare under 10, so the risk is phenomenally lower (one in millions) than any other age in the future. Suicidal thinking or behaviours in younger children are almost uniformly a combination of a few of :

a) anxiety or depression b) significant academic pressure or change exerted on the child c) parental conflict or poor family functioning d) trauma e) social or familiy pressures, or losses

lol_ginge146 karma

I always thought the Netflix 13 reasons why glorified suicide by displaying how committing suicide is a way of inflicting pain on perpetrators of bullying and I thought it could have negative effects on people who are feeling suicidal.

What's your personal opinion on 13 reasons why? And have you come across any evidence, anecdotal or otherwise which demonstrates it positive or negative effects on young people?

Dr_Tyler_Black275 karma

13 Reasons Why (the first, compelling season, not the nobody-cares-about-it second season) was an egregious example of a complete failure of a media company and storyteller to protect the public from suicide contagion. We will have to wait until 2019 for the statistics to show it, but anecdotally I have had many young patients directly come to hospital in crisis because of the distress caused by the show.

Choke_M104 karma

Is there any correlation between brain chemistry and suicide?

Dr_Tyler_Black154 karma

It's such a broad topic, but as broad as the question, absolutely.

Suicide rates are incredibly related to intoxication, for example. Whether its a psychotic episode caused by methamphetamine, or a depressive episode caused by withdrawal, or a manic episode caused by cocaine, suicide rates are, in some studies, hundreds of times higher than the average.

The serotonin theory of depression is routinely (and lazily) "debunked" by people who don't understand the foundations of this theory. Serotonin is heavily impacted in brain function, including mood, and tryptophan (the amino acid that makes serotonin) depletion can significantly worsen depression and suicidal thinking. However, it is insufficient as there are many other pathways to the clinical thing we call "depression", and serotonin isn't required for all of them. Fluoxetine, for example, is a serotonin-modulating drug but works on other receptors too, and likely does owe its entire clinical effect to simply changing serotonin.

There are genetic markers that are highly correlated with suicide, and genetic combinations usually lead to proteins, and these proteins are in study as we speak.

So, brain chemistry seems very related to suicide.

Reuelthomas100 karma

Hello Mr. Black,

I struggle with depression and have had in the past had suicidal thoughts but never came close to an attempt. I have been on meds for about five years and it has helped tremendously.

My question is regarding my children. We have two a 10 year old girl and a six year old boy. My son has started saying "I want to kill myself" when he gets in trouble. My wife and I have talked to him about how serious that is, and sometimes that will change the conversation from what he is in trouble for to a more serious discussion. But I don't want to train him to be able to use this as a way of getting out of a punishment.

I have to get back to work, but I have some questions that I will try and post in a little bit.

Overall what are the starting steps to see if my children also suffer from depression?

Dr_Tyler_Black73 karma

I can't provide specific advice, unfortunately, so I have to go a little general here.

Depressive symptoms in a child (from WebMD)

  • Irritability or anger
  • Continuous feelings of sadness and hopelessness
  • Social withdrawal
  • Increased sensitivity to rejection
  • Changes in appetite -- either increased or decreased
  • Changes in sleep -- sleeplessness or excessive sleep
  • Vocal outbursts or crying
  • Difficulty concentrating
  • Fatigue and low energy
  • Physical complaints (such as stomachaches, headaches) that don't respond to treatment
  • Reduced ability to function during events and activities at home or with friends, in school, extracurricular activities, and in other hobbies or interests
  • Feelings of worthlessness or guilt
  • Impaired thinking or concentration
  • Thoughts of death or suicide (I guess this one is obvious)

This is a very general list and it does not MEAN depression. But changes in behaviour and particularly sleep, withdrawal from social activities, boredom, and declining performance at school are key factors to focus on.

NorthernWhiteRhino81 karma

I've been suicidal off and on since second grade. It almost seems to be a bad habit, a thought pattern I fall into when my discontentment reaches a certain level. My attempts were obviously not successful. I wouldn't fail if I attempted again. I've been in therapy for three years now and on mirtazapine, venlafaxine, and trazodone. Is SI this persistent something I should just accept as part of me, or could I really expect to stop feeling this way? I had a dream of swimming out into a dark, stormy sea and it felt so peaceful. Am I wrong to long for that feeling of escaping the physical pain, disappointment, loneliness, and boredom I feel in my life?

Dr_Tyler_Black57 karma

Unfortunately many of these great questions could be interpreted as specific medical advice, and I can't do that for reddit reasons.

There are other modes of therapy that might be helpful to someone whos tried the 'traditionals'

  • dialectical behavioural therapy (specifically and proven helpful for ongoing suicidal thinking)
  • mindfulness based cognitive behavioural therapy (where a lot of DBT comes from, more commonly available)
  • interpersonal therapy (excellent results in depression having to do with interpersonal angst or situations)
  • psychodynamic therapy (this type of therapy is not my area of expertise, not meaning to open a can of worms here)

If someone is still experiencing discontent to a level that causes them distress or loss of function, switching therapy strategies can be very helpful

minimize73 karma

Hi Tyler, thanks for doing what you do, it's an important and ever more necessary field!

What would you say in your opinion is the best way to help someone who's in the depths of a suicidal episode? I've found while I'm well equipped to deal with my friends' day-to-day depression I always struggle for words when things get particularly hard because having been there myself it feels like nothing I could say would be particularly useful. What does the science say about positivity Vs letting them know you understand and sitting with them in their sadness?

Thanks again!

Dr_Tyler_Black90 karma

Validation is a key part of genuine support. Being positive when things are negative, if its a "stretch", will feel unrealistic to people who are struggling. Being positive about true and genuine things "I want to help you get better, because I know I can help" is never unrealistic and is better than "Things'll work out".

I think an underused tactic is externalizing the depressive thinking. "This depression is really affecting you today, what can we do to attack it?" or "That thought seems to be bringing you down, what other thoughts can we think of that are other ways of looking at it". Many times, one of the biggest struggles in depression is the internalizing "this is who I am" dynamic.

As to the science of positivity, its a mixed bag. Many articles of social science research tend to not hold up to a lot of scrutiny in the whole "cause and effect" game. I suspect that genuine, authentic care and concern for another person, and a redirection to positive thinking, is very likely a protective risk factor for suicide. Positive thinking that is isolated within the individual ("If I act happy I don't need help") is a form of unhelpful positive-self-talk. Positive thinking that is thinking about impact on others, or activities that are positive, are often helpful in suicide risk. An example of a citation (it's a science-y article, and the title is NOT saying "positive thinking causes suicide", it's actually referring specifically to self-based positive thinking opposed to other forms) is here.


I want to kill myself. I think about it every day. I have dreams about it. I work for $12 an hour, 40 hours a week for about 21k a year before taxes. I have a 3 month old son and an unemployed wife. I get home from work and spend hours playing games on my phone so that I can block out the noise from the rest of the world. I struggle to fall asleep, I struggle to wake up. I know I’m depressed, but without health insurance I worry that my “in and out” prescription writing doctor that I pay $35 to visit won’t take the time to properly diagnose me and put me on the medicine I need. I worry that taking the wrong medicine will just make it worse. I smoke two packs a day and it drains the little money I have. I know I need to stop, I want to stop. Seems like I just make more and more excuses not to, mainly being the small bit of stress relief I gain from it. I have Xanax from the black market that I take on occassion, no more than once every week or two. It helps, but it’s really just another way to block out the stress. Doesn’t fix the problems, just helps me hide from them. I know my son will be taken care of if I’m gone. That’s something I tell myself. I know there are other people out there dealing with this, I’m sure there will be people in this thread in similar situations. I just feel like nobody around me understands. Nobody that I try to talk to can truly feel what I’m feeling. This is just the tip of the iceberg. Petty drama and family issue culminate with each passing day. I’m losing hope. Where do I start?

Dr_Tyler_Black37 karma

I can't provide specific advice, but I do want to provide general advice that others and you can heed in situations like this:

  • talk to your employer about any health programs they may have
  • talk to a distress hotline and explain your situation, there are MANY programs designed to tackle subsets of problems as well, such as quitting smoking, or medication assistance, or finding another doctor
  • spouses and family members would want to help if they knew someone they loved were suffering, so talk to them
  • there are very helpful online groups to share with, and you've started this with a throwaway account here! keep reaching out, there are many many people who don't know you yet that would care for your wellbeing and help

kJer54 karma

How do you deal with those who use suicide as a threat? In other words, I recall people who were distraught and in rough times in a relationship use it as a flag of "I don't care, I'm just going to kill myself".

Dr_Tyler_Black72 karma

My thoughts on this are complex.

Someone who is expressing suicidal thinking, even if they aren't genuine about it, or even if its to achieve another goal, is in distress and I do want to help them. but helping them by reducing suicidality when, in fact, they had no intention on dying, won't help them. So we do keep an eye to other factors that may be at play.

That being said, many people STIGMATIZE suicidal thinking in a way that diminishes it to "attention seeking" - when it doesn't have to be that way. Some people truly do consider suicide as a reaction to severe distress because of their problem solving strategy.

I think one has to be very careful about interpreting motive, and to try and understand the person by examining what's going on to hurt and help them.

BlackbirdTango52 karma

Are hotlines really helpful? I've reached out before and while I am still here, I'm not sure what they are supposed to do.

I found the distraction helps but it feels like kicking the can down the road.

Dr_Tyler_Black78 karma

I've posted on this above... hotlines are interventions and are not well designed for true prevention. I'm really glad they're there, but it's not enough. After the intervention, the hope is to get connected to a resource that will help reduce risk factors and improve protective ones.

SwampDrainer50 karma

Thoughts on memeification of suicide (e.g. /r/2meirl4meirl)?

Dr_Tyler_Black65 karma

I love humour, so I can see some benefit. But I also know that art, memes, and even expressions can influence how we think and feel. I think a browse over it to think or ponder or laugh or feel is probably a human, helpful thing. But living there, or seriously getting into the philosophy of "can't do anything about who you are" is probably not helpful.

A lot of memes like this are really based around "I'm me and me sucks" and I don't like either the static nature of "I'm me" or the judgment of "me sucks". there are many ways to change how we see, do, feel, or act about things, and there are many ways to find groups of people who accept and care about us.

RevolutionaryDot648 karma

Throwaway account for obvious reasons.

I live in the US and I've struggled with mental illness for most of my life and have made a couple of suicide attempts, which I was fortunate to recover from. I still struggle. During the period when I was being hospitalized, I was subjected to a number of indignities, including being placed in 5 point restraints for multiple hours, being denied food and water, being denied restroom use, etc. I have never been able to find anything within the mental health field that was competent, kind, effective, and accessible. Because of this I have mostly lost faith in the mental health field.

What do you recommend for people who can't find help? I understand that part of the problem is the US system, but there's not much I can do about that.

Dr_Tyler_Black43 karma

While I'm glad you're better, what you're describing is absolutely abhorrent. I am the medical director of an inpatient unit for psychiatry for children, and we almost never use restraints, and if we do, we have significant safeguards in place to preserve dignity, and a commitment to immediately removing restraints when possible.

Help comes in all sorts of flavours. There is a draconian medical variety, in some jurisdictions, that I loathe. Help can be writing time off work. Help can be weekly outpatient sessions. Help can be an exercise program. Help can be literally helping to solve life problems. Help need not be inpatient lockup.

Community will help best... /r/swresources is a good place to start or just google for volunteer mental health associations in your area.

HaratoBarato45 karma

Is suicide always because of a mental illness?

Dr_Tyler_Black42 karma

No, definitely a common misconception. There are hundreds of risk and protective factors for suicide, and mental illness is a major, but not required one.

I believe that people who are requesting euthanasia are often experiencing a rational, logical, mental-illness-free reaction to their autonomy in deciding how to deal with end of life issues.

I would sacrifice my life for my family, and this could definitely be a suicide, and completely free of mental illness. Someone can decide suicide is the easy way to hurt someone else and avoid consequence (for example, murder-suicides), without mental illness.

CatsSaltCatsJS42 karma

Some people (who obviously don't understand mental illness, depression or feeling suicidal) make extremely disparaging remarks about people who are suicidal or have attempted suicide. How would you respond to those people? And how would you reduce the stigma of talking with loved ones about suicidal thoughts?

Dr_Tyler_Black45 karma

I like to "intellectualize" and make people understand that all of us are at the mercies of the risk factors that make something worse, and the protective factors that make it better. My risk of cancer, my risk of heart disease, my risk of dementia, and my risk of suicide. Seeing "suicide is a 'other persons 'problem" is a dishonest thought, that leads to a ton of stigma.

Reaching out when someone is in trouble, and reaching out when you're in trobule, helps to normalize this whole thing. I wish i could change the "mental illness isn't real illness" mindset so many have, but conversations like the one we are having right now, hopefully, helps :)

AuntieAv40 karma

What is your opinion on crisis hotlines - are they helpful or not? And if not, what would be a better alternative to fund?

Dr_Tyler_Black50 karma

I do think the volunteers and providers on these lines are amazing people who want to help, and many times, they direct people to help. anyone who hasn't called one but is experiencing suicidal thought should, preferrably earlier rather than later! The sooner you call, the less dire the situation and the more a hotline can help.

And I am glad they are there but they are routinely touted as "prevention" when in fact they are "intervention" - its so far down the waterfall of suicidal thinking/concern that it limits the helpfulness from the start.

We need far more "prevention" type of interventions - friends reaching out in concern, teachers lessening academic burdens on children, validation and acceptance, reduction of bullying, reducing child abuse. These are huge issues with complex solutions, but they will allow "crisis intervention hotlines" to truly flourish by reducing the overall volume and gating that occurs.

Digitaldude55534 karma

How does one train or what qualifications does someone need to be an operator on a suicide hotline?

And Happy reddit birthday.

Dr_Tyler_Black17 karma

As another user has said, it really varies. contact the one near you and ask! There are peer support groups of mildly trained teenagers, so the bar can be "I just want to help people" as long as you're willing to learn about the best ways.

Izel9830 karma

Does everybody has suicidal thoughts ? And what is the difference between a normal person that sometimes thinks about commiting suicide and a person with depression with suicidal thoughts or is the normal person not "normal" anymore once he has this thoughts.

Since I can't go in other people's minds I don't know if I am not the only one having "casual" suicidal thoughts since being 13, not with depression right now (I think), but this kinda stuff never seems to go away, it just kinda lurks around.

Dr_Tyler_Black33 karma

A minority of people will report suicidal thinking on a survey, but I suspect most people have thought about, in desperation, an escape via death or even pondered death seriously. So I imagine there's quite a spectrum of majority thinking there.

I don't think there is too young an age, or too minor a thought, to talk to someone about it. Existential (thinking about life and death, where we fit in) is one of the MAJOR GOALS of 12-18, and it can get hard. There are cosmic arguments of "we don't matter" that are hard to deal with, and there realities of being a human "i have limits to my potential" that we all deal with growing up. Talking about these issues with people that are going through or who have gone through them is an important part of navigating it!

SemutaMusic24 karma

Can you speak a little bit about the comorbidity of suicidal ideation and bipolar type II? I understand the frequency of depression is correlated with suicide, but why does it seem more common in in BPD?

Thanks for the AMA.

Dr_Tyler_Black16 karma

Bipolar disorder is, by nature, a more severe form of mood disorder. The Bipolar Type I risk of suicide is significantly increased, and type II is less than that. The downside of Type II is that depressions can be profound, but the mania is shorter lived and less significant. People with Type II spend a predominant time in the depressive phase of illness. Mood stabilization is an important aspect of help with bipolar disorder.

We struggle SO MUCH with bipolar depression in psychiatry. I really wish we had better tools. In my patients with bipolar disorder, it's why I work so hard to stabilize mood to avoid depressions.

SebastianLestrange19 karma

Hello Dr Tyler. I have a question: what does it mean if I've gone from wanting to kill myself to wanting to kill people in general?

Dr_Tyler_Black23 karma

Its concerning and needs immediate help and attention. Call a crisis line. Anyone at this level of thinking is at increased risk for suicide or homicide.

I can't not take that seriously, and you shouldn't either.

Olbdau17 karma

Hi Tyler. I'm from Vancouver, so I can see how badly people like you are needed here.

My question is, I see a lot of articles saying social media can play a huge part in people's mental well being. How much do you see social media affecting your patients? Is it really that big of a problem?


Dr_Tyler_Black23 karma

Social media is a mixed bag! There is so much optimism and activism and kids are doing incredible things with social media that I can't comprehend! We older turtles tend to look at "kids today" and say "look at their short attention span!!!" when in fact, all the science is pointing to an increased attention span, and in fact, children today are WAY better at multitasking that we were as children.

Social media is also a place of bullying and ridicule. I haven't read all the comments here, but I'm sure some of them will be negative or insulting. The John Gabriel something-something Theory (NSFW if you google) is fully applicable in 2018. There are people who ENJOY hurting others, and they have ample space to do so.

I suspect, like most things, the fears will be addressed and it will be a net benefit. We do know that kids tend to overvalue their social media identity, so I think we as adults still are in the role of providing context of importance. No, your 13-year-old boyfriend is not going to really matter when you're 15. and No, what some person says about you on social media doesn't really change a whole lot.

Fyrefreeze10 karma

Happy birthday! What's a normal day like in the office?

Dr_Tyler_Black12 karma

Today is definitely not a normal day. The flood of questions is overwhelming!

Arrive at 8. Sign reports. Check the board. See my patients. Meet the families. Do some reading. Go home. I take a day off each week to work on research or personal activities as well, and I'm only on call once every 4 weekends.

ferrouswolf210 karma

What is your motivation? How does this work not depress the ever-living daylights out of you? How do you feel when someone you’ve worked with or spoken to actually commits suicide? How do you cope with the kind of existential stress that’s involved in this? Do you just get on with your job by grim determination or are you fascinated? How about other people in the field? What do you talk about at conferences, after hours at the bar?

Dr_Tyler_Black12 karma

I love what I do! I am helping to treat, research, and advocate for one of the major factors of suffering and death in the world. It's like being a cancer researcher, or a heart researcher. I'm motivated by passion, and I'm a thinker, so I might as well be thinking about important things.

I have a great family, great hobbies, and I have come to terms with death and dying well into my medical school training. I get sad, I cry, I feel horrible, I hear horrific things that affect me, and then I process them, and (freud would say) defend with something positive (like altruism, or intellectualization), and move on!