vendredi 17 octobre 2014

USA : Introspection "Ruban pourpre et turquoise, pour un débat public ?"

Ruban pourpre et turquoise, pour un débat public
Publié le 17/10/2014
On sait qu’il existe divers insignes montrant l’empathie de leurs porteurs pour certains malades, notamment le ruban rouge contre le SIDA et le ruban rose contre le cancer du sein. Mais qui connaît aux États-Unis (et ailleurs), s’interroge The American Journal of Psychiatry, l’existence d’un ruban similaire, « pourpre et turquoise », destiné à dénoncer un autre problème de société, « responsable de plus de morts que les accidents de voiture » ?
Prenant aux États-Unis chaque année « deux fois plus de vies que l’ensemble des meurtres » (statistique déjà effrayante dans un pays où la législation sur les armes est pour le moins laxiste !) et « plus de 800 000 vies annuellement dans le monde », le responsable de cette hécatombe planétaire est le suicide. Mais, demande l’auteur, « où est le large débat public que cette force de destruction massive devrait susciter ? » Indépendamment des raisons humanitaires pour combattre le suicide, les psychiatres devraient ajouter une dimension personnelle à leur engagement pour prévenir ce fléau : en effet, des études ont confirmé l’impact néfaste du suicide chez les psychiatres ayant traité ces patients ! Le tiers des psychiatres ayant perdu un malade par suicide éprouvent ainsi « des troubles de l’humeur ou du sommeil ou même un mal-être important. »[1],[2]. Des aspects égoïstes doivent donc rejoindre les motivations philanthropiques pour amplifier la prévention du suicide. Car les taux de suicide sont en augmentation et la souffrance des parents ou amis du suicidé se révèle « inconcevable. »
Il est donc temps de relancer le débat public à ce sujet et de rappeler avec insistance que le suicide s’apparente toujours à une « fausse note », mais ne constitue jamais, dans l’histoire de la personne concernée, une « bonne sortie » pour délaisser discrètement, comme par une porte dérobée ou latérale, une situation qu’on n’ose plus endurer frontalement. L’auteur se demande si les personnes vulnérables gagneraient à être plus conscientes de la vraie nature du suicide, « horrible et violente. » Un débat plus transparent en la matière permettrait-il d’épargner des vies ? En d’autres termes, « devrions-nous porter ces rubans pourpre et turquoise » pour afficher notre détermination plus marquée à combattre le suicide ?    
1) R Ruskin & coll.: Impact of patient suicide on psychiatrists and psychiatric trainees. Acad Psychiatry 2004; 28:104–110.
2) H. Hendin & coll.: Factors contributing to therapists’ distress after the suicide of a patient. Am J Psychiatry 2004; 161:1442–1446.

Dr Alain Cohen
Bremer J : Purple and turquoise ribbons. Am J Psychiatry, 2014; 171: 916–917. 
 l'article en question
Introspection   |    
Purple and Turquoise Ribbons
Jennifer Bremer, M.D.
Am J Psychiatry 2014;171:916-917. doi:10.1176/appi.ajp.2014.14060777
Copyright © 2014 by the American Psychiatric Association

Are all psychiatrists careful, having heard so many horrors that our patients have endured? Or is it just me? Near our South Side Chicago home, our family stays in after dark, takes certain roads, and avoids others. We’ve got a guard dog (actually a gentle, deaf dog, but we tried), antibacterial soap, organic everything, a carbon monoxide detector and fire and burglar alarms, and so on. No padded suits or football helmets on the kids, but I’ve thought about it. Why expose children to danger or to life’s dark side? Why not let kids be kids—for one sweet, fleeting-as-floating-dandelion-fluff childhood minute? Or at least, I tried.
On a weekend away in an idyllic town, my family soaked up peace, love, and joy. Remember this moment, kids, I wished, as we traipsed down a winding path. My husband and I held hands and walked a few steps ahead. Thank goodness.
We blocked the kids’ view, but our children heard the shatteringly loud thwack. My husband yelled, “Kids back!” as he and I surged toward the crumpled, aged form, neck at an odd angle. A man had swan-dived from the tall building next to the path, and almost onto my family. I knew better than to move him and ran on to security, “Ambulance! … Help!”
My husband shook violently. He saw and still sees the horror over and over, forged into his brain more permanently than our wedding day, because that’s how traumatic memories are stored. My kids will likely remember this most clearly of any childhood moments. Suicide is hideous and NOT solitary. Suicide looks nothing like its widespread portrayal in opera or other arts (1). No Ophelia was on that path. No Romeo and Juliet. Just my kids.
As a psychiatrist, I’ve seen how biologically rooted and ferocious suicidal impulses can be. While aggressively treating contributing psychiatric illnesses, I’ve repeated our all-important messages to those who are dangerously struggling—“stay in treatment,” “increase treatment,” “call 911,” “see a psychiatrist,” “call a therapist,” “walk into any emergency room,” “call the suicide hotline (1-800-273-8255),” “talk to loved ones,” “reach out”—again and again.
Despite our work, though, suicide remains a leading cause of death in America, taking tens of thousands of lives each year, more than the number of people killed by car accidents and double those murdered. Worldwide the number of suicides is, unthinkably, more than 800,000 yearly (2, 3).
The survivors, family and friends close to those who die by suicide, suffer unimaginably. And about half of psychiatrists lose a patient to suicide, with about a third of us subsequently experiencing mood and sleep disturbances, or even severe distress (4–7). Then there are the little-discussed random persons affected—bystanders like my family, medical students, residents, nurses, police, and so on. The security responder at our horrific scene trembled, held hands over her face, and said over and over, “I'm messed up.”
Yet where is the awareness of suicide's vast brutality? Many people have pink ribbon images on their jewelry, pens, or whatnots advocating for breast cancer awareness. But who has purple and turquoise suicide prevention ribbons? Who even knew the color of the ribbon? Who even knew there was a ribbon?
Where is the vast public conversation about this massive destructive force? I wonder if the discussion is muted partly due to meticulous attempts to follow the detailed NIMH media guidelines, intended to avoid glamorizing suicides and so avoid copycat suicides—tragic and well-documented phenomena. However, perhaps the muted reporting unintentionally also sometimes quiets crucial discussions about suicide’s gruesome reality and cost.
The only tiny news article I found about the suicide witnessed by my family read as neat and tidy as hospital corners. The man might as well have strolled out of the shiny life exit door, without a blemish on him or on anyone else. NOT what happened. His death, in my opinion, was romanticized by underreporting, with too little information shared.
Conversation around the ugliness and violence of suicide is inhibited by far more than guidelines and fear of copycats, though. There are numerous additional obstacles to forthright discussion, including profoundly troubling questions. How can we talk about suicide without offending heart-broken survivors? Without causing more pain to those currently suffering and suicidal? Without offending?
Yet, suicides in recent years increased (8). So perhaps it is time to reexamine our public conversation. And to make clear suicide is NEVER a spotless footnote. NEVER a clean exit. NEVER a sidebar.
In my practice, while some patients with suicidal inclinations were angry and longed to lash out, so many others were gentle souls who never purposefully would leave train wrecks behind. Would any such gentle souls reconsider, or at least pause, if they were made more aware of how hideous and violent suicide is? Could more truth buy any individuals precious, life-saving time? Should we wear purple and turquoise ribbons?
1Pridmore  SA;  Auchincloss  S;  Soh  NL;  Walter  GJ:  Four centuries of suicide in opera.  Med J Aust 2013; 199:783–786
[CrossRef] | [PubMed]
2 Centers for Disease Control: Suicide Facts at a Glance 2012.
3 World Health Organization: Mental Health: Suicide Prevention.
4Ruskin  R;  Sakinofsky  I;  Bagby  RM;  Dickens  S;  Sousa  G:  Impact of patient suicide on psychiatrists and psychiatric trainees.  Acad Psychiatry 2004; 28:104–110
[CrossRef] | [PubMed]
5Chemtob  CM;  Hamada  RS;  Bauer  G;  Kinney  B;  Torigoe  RY:  Patients’ suicides: frequency and impact on psychiatrists.  Am J Psychiatry 1988; 145:224–228
6 Waern  M:  One’s own patient suicide—a trauma for the physician.  Lakartidningen 2003; 100:2140–2143
7 Hendin  H;  Haas  AP;  Maltsberger  JT;  Szanto  K;  Rabinowicz  H:  Factors contributing to therapists’ distress after the suicide of a patient.  Am J Psychiatry 2004; 161:1442–1446
[CrossRef] | [PubMed]
8 National Institute of Mental Health: 1999–2007 Trends in Suicide Rate.

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