Out of mind

The young psychiatrist shifted uncomfortably on the bench outside the court, a file of notes gripped in his sweaty right hand. The newspaper article clipped to the outside of it was entitled "Teenage suicide," and was half hidden, like a guilty secret, under the arm of his suit.

He had only met William Holden once, six months before, on the first day of a new job. He had been meeting his predecessor's patients, all of them for the first time, and it was proving complicated as he attempted to disentangle psychiatric phenomena from their understandable reactions to meeting a new doctor. William, however, appeared relatively straightforward. His appointment lasted 20 minutes, and provided welcome relief between one angry patient with a history of assault and another whose paperwork had been mislaid.

Fortunately, William's notes were in order and documented how he had come to the clinic. The sparsely written professional letters suggested a difficult childhood. He was an only child whose parents had split when he was seven. His father moved away and he lived with his mother. Physically he was a slow developer. He was bullied at school. It sounded relentless. But compared to many patients the teenager had proved resilient, at least superficially. He had finished school, passed A-levels and started a foundation course in art. He may have smoked a bit too much dope, yet to the casual observer he had survived adolescence. He now had a dog and the beginnings of an adult identity.



But whether from the genes of a melancholic father or his childhood experiences, William had developed a tendency to depression. This was his second clinical bout. On both occasions he had described the pervading feeling of anhedonia: that all the joy had drained out of his life. When he had first approached his GP, then aged 18, she had prescribed an antidepressant for six months and advised him to see their practice counsellor. When the low mood returned a year later, she had referred him to the local psychiatrist. The young psychiatrist's predecessor had prescribed Venlafaxine, a stronger drug, and suggested a referral for CBT, which William had declined. They had been having monthly appointments, and this was a routine follow-up.

Willliam had walked into the room in an oversized Parker jacket and faded red T-shirt. He had a pale complexion, with brown eyes and dark uncropped hair. At first he'd appeared hesitant. He'd answered the young doctor's questions in a straightforward manner. "Things are all right now." "I don't know what caused it." "I guess I was worried about college." The inflection of his speech had perhaps been a bit flat, but as the conversation continued, his posture relaxed and, the psychiatrist thought, they had developed some rapport. "No, I sleep all right now… yes, I can concentrate normally."

"But I can see from your notes that you were quite low a few months ago. Did you ever think of hurting yourself?" The phrase sounded odd, despite a training that emphasised repeated risk assessment through questions of this kind. "No, perhaps at the beginning it may have crossed my mind, but not now. I am much better now." He had written down "not suicidal" and arranged to see William for one more appointment in six weeks' time. With hindsight, the young psychiatrist knew he should have asked more.

The article was printed in the local paper five weeks after that first clinic and was picked up by one of the admin staff. The young psychiatrist had felt the blood vessels in his thorax constrict, his breathing becoming tight. He had scanned the close-typed paragraphs. "The driver reported a man falling from a bridge. He was pronounced dead at the scene." He searched for the name, which he had somehow missed: "William Holden." The coroner's letter arrived a week later—on the day of the follow-up appointment.

Suicide, like murder, is violent and difficult to predict. In both there are established risk factors, but little that allows reliable prediction for any given individual. Unlike parasuicide (attempted suicide), a suicide's mental state remains private and unreachable, taken to the grave. But the means do provide important clues: shooting, jumping or hanging lend a peculiar finality, whereas a razor blade or a handful of pills leave room for second thoughts. Psychopathology turns its own screw: 10 per cent of those with schizophrenia die by suicide, typically early in the illness, while those with severe depression often only find the motivation to kill themselves as they start to improve. Paradoxically, those who make frequent threats and regularly commit parasuicidal acts are less at risk, leaving staff feeling manipulated and exhausted.

The light above the court door flickered on. A group of relatives were making their way in. One man with grey hair looked at the young psychiatrist. The father? It occurred to the psychiatrist that William Holden had killed himself after yet another father figure had left him to his own devices. The card binding under the young doctor's hand had crumpled, leaving tiny flecks on his palm. He tried unsuccessfully to wipe them off on his thigh. Then he stood up stiffly, collected himself and walked into the court.