Whatever possibly suicidal updating

By exaggerating their vulnerability to humiliation and physical attack, she justifies a maternal posture of excessive protectiveness.

This is not an act of dehumanization but the opposite. There is a horrible piety to Jude, named for the patron saint of lost causes; he has been force-fed sentimentality. When the author is not doling out this smothering sort of love through her male characters Willem, for instance , she is enacting it at the level of her own narration.

Charlie is a technician who takes care of mouse embryos at an influenza lab in Zone Fifteen. After Charlie is raped by two boys her age — the only rape in this whole book, if you can believe it — her grandfather Charles desperately tries to ensure her safety by marrying her off to a homosexual like himself. But it is with Charlie, who longs for her husband to touch her even as she knows he never will, that the sublimation of romantic love will finally slouch into despair. When Charlie follows him to a gay haven in the West Village, having discovered notes from his lover, she is heartbroken.

There is no paradise for Charlie. The odd and tuneless phrase to paradise provides a destination but withholds any promise of arrival. Doom shadows every character who decides to abandon one apocryphal heaven on earth for another: the plutocratic Northeast for the homophobic West, the colonized state of Hawaii for a delusional kingdom on the beach, totalitarian America for the unknown New Britain. Every paradise is a gossamer curtain; behind it lies a pit of squalor, disease, torture, madness, and tyranny.

Freedom is a lie, safety is a lie, struggle is a lie; even the luxuries Yanagihara has spent her career recording are nothing in the end. For paradise, insofar as it means heaven, also means death.

Her fantasies of suffering and illness are designed only to produce a very specific kind of love, and this love is not curative but palliative — it results, sooner or later, in the death of the thing.

The same phrase appears in The People in the Trees, where it describes the bleak vegetative state that befalls the islanders whose disease has stretched out their life spans. These are difficult words to read for those of us who have passed through suicidal ideation and emerged, if not happy to be alive, then relieved not to be dead.

A Little Life, like life itself, goes on and on. Hundreds of pages into the novel, Jude openly wonders why he is still alive, the beloved of a lonely god. For that is the meaning of suffering: to make love possible. Want more stories like this one? Subscribe now to support our journalism and get unlimited access to our coverage. If you prefer to read in print, you can also find this article in the January 17, , issue of New York Magazine. Already a subscriber? Log in or link your magazine subscription.

Account Profile. Sign Out. Photo: Amanda Demme. Tags: vulture homepage lede book review reviews essays books close reads one great story More. For the patient population as a whole, there is reasonable evidence that antidepressants are able to reduce suicidal ideations and suicidal behavior in depressed patients [ 1 ] and benefits of antidepressants appear to be greater than risks from suicidal ideations and attempts [ 28 ].

Nevertheless, regulatory agency warnings have had a notable impact upon antidepressant prescribing patterns. In the United States from to , diagnosis of depression in pediatric patients increased from 3 to 5 per , but after the FDA advisory the rate decreased back to levels.

The proportion of patients receiving no antidepressants increased to three times the rate predicted by the preadvisory trend [ 61 ]. Decreases in antidepressant prescribing have been associated with increases in rates of suicidality in children and adolescents [ 62 ]. Pediatric policies appear to have had an adverse effect on adult prescribing with the rate of diagnosed depression 7. The apparent impact on prescribing patterns has resulted in some arguing that the FDA overreacted to the analysis of the pediatric antidepressant trials with resultant unintended consequences [ 64 ].

Not all studies have demonstrated a negative impact, however. An ecological study of young people in the UK [ 65 ] concluded that the noticeable reduction in antidepressant prescribing following regulatory action in to restrict the use of SSRIs in persons under age 18 did not seem to have been associated with changes, either favorable or unfavorable, in suicidal behavior in that population.

A decrease in antidepressant prescribing under these conditions may be a reason for concern because a valuable modality for the treatment of depression may be in danger of underutilization. But clearly, clinicians should not stop prescribing antidepressants when they are indicated. What precautions then should be taken to prevent complications in the rare patient who might exhibit suicidal behavior as a result of antidepressant treatment?

One of the first mandates for physicians is primum no nocere —first do no harm. Before initiating treatment with an antidepressant, clinicians should carefully review the patient's past psychiatric history and assess any family history of mental illness, including mood disorders and any suicide attempts among relatives.

Past suicidal behavior by the patient, particularly any behavior representing adverse events that may have occurred as a result of previous antidepressant treatment, should be assessed.

Patients should also be screened to determine whether they might have unrecognized bipolar disorder. Before prescribing an antidepressant, clinicians should educate patients and their families or other caregivers to watch for signs of worsening depression or suicidality, and be instructed to report such symptoms immediately if they occur [ 6 ].

When antidepressant treatment is initiated it is important to monitor patients, especially at the beginning of treatment or when the dose is increased or decreased. The FDA initially recommended that pediatric and adolescent patients have visits once a week during the first month of treatment, every 2 weeks during the second month, and a visit at 3 months [ 67 ], but later modified its recommendations to make them less specifically prescriptive of weekly in person visits.

Additional studies need to be conducted to provide detailed guidelines for all patients. Regardless, careful monitoring should be considered.

Particular attention should be given to patients with abrupt changes in symptoms and those developing symptoms that were not part of their presentation prior to the initiation of treatment. It is important to remember that worsening symptoms could be due to the underlying disease or might be a result of drug treatment, and that activating symptoms e.

If there appears to be a risk of suicide, hospitalization should be seriously considered. In some instances the dose of an antidepressant may need to be decreased or the medication discontinued; this should be determined on an individual basis for each case. If antidepressants are to be stopped, some authorities recommend tapering instead of abrupt discontinuation [ 6 ]. Starting a different antidepressant is also a case by case decision, and when done would obviously require careful monitoring.

In conclusion, the benefits of antidepressants outweigh their risks and the judicious use of these medications can serve to effectively treat and actually protect depressed patients from suicide [ 68 ]. However, appropriate precautions and monitoring must be exercised to avoid the increased risk of suicide in an apparently small, but real, number of patients.

National Center for Biotechnology Information , U. CNS Neurosci Ther. Published online Jun Roy R. Reeves 1 , 2 and Mark E.

Ladner 1 , 2. Mark E. Author information Copyright and License information Disclaimer. Correspondence Roy R. Reeves, D. This article has been cited by other articles in PMC.

Abstract Evidence suggests that antidepressant treatment may in some cases result in worsening depression and increased risk of suicidality in pediatric and adolescent patients. Introduction Depression is a common, often serious, disorder and one of the most common reasons for suicide.

Conflict of Interest The authors have no conflict of interest. References 1. Moller HJ. Evidence for beneficial effects of antidepressants on suicidality in depressed patients: A systemic review.

Eur Arch Psychiatry Clin Neurosci ; — PLoS Med ; 5 — Isn't the efficacy of antidepressants clinically relevant? A critical comment on the results of the metaanalysis by Kirch et al.

Arch Gen Psychiatry ; 66 — Antidepressants and the risk of suicidal behaviors. JAMA ; — South Med J ; — Serious suicide attempt with duloxetine treatment letter. South Med J ; Akiskal HS, Mallya G.

Psychopharmacol Bull ; 23 — Paradoxical worsening of depressive symptomatology caused by antidepressants. J Clin Psychopharmacol ; 8 — Emergence of intense suicidal preoccupation during fluoxetine treatment. Am J Psychiatry ; — Suicidal ideation related to fluoxetine treatment. N Engl J Med ; Arch Gen Psychiatry ; 49 — Suicide attempts in clinical trials with paroxetine randominized against placebo. BMC Psychiatry ; 3 Healy D. Emergence of antidepressant induced suicidality.

Prim Care Psychiatry ; 6 — BMJ ; — Simon GE, Savarino J. Suicide attempts among patients starting depression treatment with medications or psychotherapy.

Suicide risk during antidepressant treatment. Tiihonen J, Lonnqvist J, Wahlbeck K, et al Antidepressants and the risk of suicide, attempted suicide, and overall mortality in a nationwide cohort.

Arch Gen Psychiatry ; 63 — J Clin Psychopharmacol ; 26 — Int J Neuropsychopharmacol ; 12 — Suicidality in pediatric patients treated with antidepressant drugs.

The risk of suicide with selective serotonin reuptake inhibitors in the elderly. Fergusson D, Doucette S, Glass KC, et al Association between suicide attempts and selective serotonin reuptake inhibitors: Systematic review of randomized controlled trials.

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