Breaking a conspiracy of silence

Kay Jamison wants more done to combat student suicides. Olga Wojtas reports.

Kay Redfield Jamison, professor of psychiatry at the Johns Hopkins Medical School, Baltimore, exudes cool, patrician elegance. It is difficult to imagine that she has spent years suffering from psychotic manias and suicidal depressions.

She first planned suicide aged 17, checking access to tall buildings and the fastest moving traffic flows, and learning how to load her father's gun. Aged 28, she attempted suicide with a drugs overdose. Having survived, she devoted herself as a young academic to a clinical investigation of mental illness and suicide: as lion tamers learn about their animals' moods, she decided to learn about "the moods of death".

She finally went public about her manic depression in 1995. "I got a tremendous amount of exceedingly vitriolic letters from the Christian right. They said, 'You turned your back on God', which I hadn't done, and 'You got what you deserved'. The level of hatred of mental illness is I unattractive."

But most of her academic colleagues were sympathetic. The chairman of her department encouraged her to write and speak from her experience, saying that this was an extension of her teaching. But she has not found it easy. "Nobody likes talking about their private life. It's uncomfortable."

As an undergraduate in the late 1960s, Jamison spent her junior year abroad studying biology at St Andrews University, Scotland. She returns to St Andrews annually as honorary professor of English, a tribute to her books An Unquiet Mind and Night Falls Fast: Understanding Suicide. She gives formal lectures while in Scotland, but in common with everyone who speaks publicly about their psychiatric illness, she is sought out by people who want to confide their own mental anguish.

Her tone is surprisingly dispassionate, with flashes of wry wit, but she is insistent in her message. Suicide accounts for nearly 2 per cent of deaths worldwide and it is the second biggest killer of students in the United States, after accidents/ injuries. Most suicides stem from psychiatric illness. "Postmortems are consistent in finding at least 90 per cent of suicides were suffering from psychiatric disorders," she says.

"One of the most common misconceptions is that because people don't talk about depressive illness, it doesn't exist. As soon as society starts talking about mental illness the way it does about any other illness, I think suicide rates will go down."

She has received hundreds of letters from students and staff who are terrified by the thought of being open about their mental illness. Depression may now be discussed a little more openly, but not manic depression or schizophrenia, because of their psychotic component: "The potential for irrationality is frightening to people." But one in five women and one in ten men will suffer from at least one major episode of mental illness over their lifetime. And this differs from many other diseases in that it disproportionately affects young people. The average age of the onset of manic depression is 17, and 19 for schizophrenia. Students are therefore in the highest risk group for both mental illness and suicide. "In 1996 in the US, it killed more teens and young adults than cancer, heart disease, Aids and lung disease combined."

Jamison says there is clearly a strong genetic component in psychiatric illness, but two things in particular are likely triggers - alcohol and disrupted sleep - neither of which "is unassociated with college life". American surveys have found one in ten students admitting that they seriously contemplated suicide in the previous year, while almost as many have attempted suicide. Jamison warns that this must never be dismissed. "Suicide is 40 times more likely if there has been a previous attempt."

There have been huge advances in the understanding of suicide and depression over the past five years, she says. But there is a discrepancy between what is known and what universities do about it. "There's a suicide, everybody is concerned for a while, but there's no systematic plan for prevention. Students get information about everything else, but they don't get quality controlled information about what we know about depression and where they can go for help."

She has worked with Harvard students who, frustrated with managerial foot-dragging, set up a website and support groups, and badgered the authorities to improve counselling facilities.

Practical measures can help. In the past decade, the US air force has launched a radical suicide prevention strategy, raising awareness of symptoms. "They took on a systematic programme of getting chaplains, sergeants and physicians involved. They made the entire community look out for one another and if someone was disturbed, encouraged them to get into treatment. They made drinking socially unacceptable and said the courageous thing to do was to get treatment."

The air force has succeeded in reducing the suicide rate effectively to zero, while suicide remains the second biggest killer in the army, navy and marines.

Jamison would like to see higher education follow the US air force's example. She feels the student website is a good idea, because students suffering from depression often feel isolated. She has been working with the surgeon general's office to produce a CD-Rom for young people, which they can look at in private.

Research has consistently shown that the best treatment is a combination of medication and psychotherapy, rather than one or the other alone, Jamison says. "I'm a great believer in psychotherapy. There's been a tendency to say you can take a pill and get better. A lot of people can't."

But drugs are undoubtedly effective. There is solid evidence that lithium leads to a dramatic drop in suicides and attempted suicides. In use since 1949, it has proved to be remarkably safe, with only the occasional patient suffering kidney problems.

Jamison believes that mental illness can and should be dealt with. But in response to her attackers who argue she should not be allowed to teach, she says: "The question is, are you competent to do the job? If you got rid of everybody with mental illness, you wouldn't have much of a teaching force left."