Could there be more evidence that something is very wrong with someone than an unexpected premature death? Or worse, the person contributes to the death either committing suicide or because of a repetitive high-risk behavior? 

A few years ago, probably in 2001, I spent a week in Zurich, Switzerland, seriously considering a position in a major epilepsy center there. It was one of those decisions one has to make once in a lifetime. I was almost 50, had children and a well organized life in Curitiba, so a change, even if to one of the best places in the world, would have to be pragmatically considered.

Settled in a hotel in the city centre, I followed an everyday routine from one Sunday to the following one. I watched the local TV at night in several languages, slept, woke up at a regular time, watched the news over breakfast and headed to work, always taking a slightly different route on my way back either on foot or by taxi when it was very cold. At the hospital, I had lunch in the cafeteria while reading local newspapers.

One fact was evident: there were no unexpected or violent deaths or suicides in all Switzerland that week. Nothing. I was so surprised that I checked it in details with the help of a secretary the hospital had placed at my service to help with renting a home, finding schools for the children and so on. Nor there were any traffic accidents with injuries, being it of a ski, train, bus, car, plane, cart, truck or horse nature, all means of transport fully used in Switzerland.

Over the 5 years I lived in London back in the 70s and 80s and until today throughout the United Kingdom any unexpected violent deaths make the headlines in newspapers, TVs and, nowadays, Internet.

Needless say how little life is worth in Brazil, Latin America, or Africa where people die with much greater ease and in much greater number than in the developed countries due to, for example, car accidents and violence of which more people die in Brazil than in the wars in Iraq or Vietnam.

I’d like to draw attention to, yet, another fact. In Curitiba, over the last 2 years, there were 6 sudden deaths or suicides, all of which I was acquainted with either socially or professionally. A rate of one every 3-4 months. A rough estimative of my professional and social scope shows these deaths took place among a total of no more than 20 thousand people. Had we been in Switzerland, with its 7.5 million people, we would have to have 375 times more deaths, i.e., instead of one in every 90 days, 4 per day. As no deaths took place in a week, we can come to the conclusion that there are at least 30 times more unexpected deaths and suicides in the upper middle class in Curitiba than in Switzerland. This is not what the World Health Organization Report (Wikipedia in English) says. According to them, Brazil is in the 73^rd position with 4 suicides and Switzerland in the 19^th with 17.4 suicides per 100,000 inhabitants per year. In the same report, the worst rate is in Lithuania with 40 deaths per 100,000 inhabitants per year. Taking into account only the 6 deaths I am acquainted with, our number would be 4 per year per 20 thousand inhabitants, meaning 20 per 100,000 inhabitants, what would set us in 16^th position.

A point to be made is that the people I was acquainted with really died under the conditions stated. I know of at least 2 other people who committed suicide during the same two years from the same social group in the same city, however, I have no further information. And, most certainly, I do not know all in this social class. And, not taking into consideration cases out of Curitiba. Suicides are notoriously well-hidden and under-reported in Latin, Catholic, developing countries. Among Jewish, suicides are totally denied. There are known cases of Jews arrested by the Brazilian Army that had to be buried in special places in Jewish cemeteries because their deaths were related to suicide.

All the cases in Curitiba that I have details of were being treated with benzodiazepines and/or antidepressants, none of them by me. The last suicide amidst my clientele took place well over 5 years ago. In our clinic, we used to have an average of one suicide every 2 years, however, they stopped when I decreased drastically antidepressants. At that time, international literature indicated that most, if not all, serious depression and psychotic disorders were associated with bipolar syndrome. In this perspective both antidepressants and benzodiazepines may lead to an increase in suicides because they stimulate repetitive behaviors. These are obsessive ideas that are compulsively spinning and turning in a person's head, until accomplished.

The problem is that the patient demands antidepressants and often demands benzodiazepines, a phenomenon that seems to be associated with health insurances and can be best understood through a rough, even harsh, analogy: if a woman goes to an oncologist to treat a breast cancer, especially if the health insurance is paying for all treatment, she does what she’s been sent to do. Part of the breast is removed, followed by radiotherapy that burns the skin and then comes chemotherapy with its horrible side effects. Dosages are not discussed, relatives can even discuss whether the health insurance will pay or not, but other details are considered irrelevant.

When people seek treatment for depression, they want to present solutions. They say that only they understand their own brain. They come in for the first appointment saying they suffer from depression and they want to take fluoxetine or perhaps alprazolam clonazepam. They come for a prescription. I usually tell them that I am a doctor, not a "prescription-maker". Our service is appointments, not prescriptions. According to the Brazilian Code of Law, the prescription is the result of a medical act and cannot be given without an appointment. Even if a fortune is paid for a private appointment, many want to state their diagnosis and treatment. When they come for treatment in very dramatic conditions, for example, after an accident, injuries from fights or attempted suicide, they tend to stop the treatment once a certain routine is established. For them, one doctor is too expensive, the other is very boring and authoritarian and so on. Then, they go elsewhere, where they can take care of their brain the way they see fit.

The problem is that a breast or a pancreas, a liver, even the heart or the kidneys, are of a brutal simplicity when compared to the brain and its billions of neurons and synapses arranged in many different organs. There are the hippocampus, the tonsils, several basal ganglia, the ascending reticular substance, the limbic system, the frontal lobe system, the memory, the verbal function. There are so many parts in the brain that there are different comprehensive ways to divide it. It may be divided into various organs, anatomically, or in various systems, a functional division that is always being improved. Much more complicated than an abdomen, with bowel, liver, pancreas, stomach, spleen, kidney and adrenal glands, bladder and urethra. 

It is worse than being naive to believe that anyone can fix the problems of the brain. It can only be considered psychotic the idea that a layman can deal with brain problems, whether their own or somebody else’s. If that was possible, they could treat all diseases, as there is no doubt about the much higher complexity of the brain. 

For example, a man with prostate cancer could feel that because the prostate is his, he should choose the doctor he goes to, decides whether to undergo a surgery or endoscopy, brachytherapy or stereotactic radiotherapy, conformal or traditional radiotherapy, whether to do chemotherapy or not, whether to take hormones or not and the dosage of hormones and each of the chemotherapy components. There is no reason a person should feel more like the owner of their own brain than of a breast, prostate, thyroid, stomach or a callus on the foot.

The next problem to be emphasized is the 'clutch mechanic phenomenon’. Doctors are technicians, they do what they know. When you take your car to a mechanic to fix the clutch, the mechanic fixes only the clutch, even if the tires and the engine are in dreadful conditions. If a person with dizziness goes to a doctor who treats labyrinthitis, the person will be treated for labyrinthitis. Increasingly, this is true because health insurances pay much more for medical procedures, tests and treatments than for appointments. A doctor’s opinion, the diagnosis, these are worth almost nothing. It amounts to as much as a plumber or a computer technician’s opinion. I believe there is no need to state the differences in training. To understand how a patient with a health insurance in Curitiba thinks, just picture a doctor stating the diagnosis in shorts, sandals, unshaved and with earrings, two days too late as computer technicians do. This is the reality, I blame neither individuals nor entities, I am only pointing out what happens.

The next problem has to do with patients' rights. Increasingly, because of the information available in the Internet, even well-informed patients come to the doctor aware of their rights as a consumer. However, in behavioral and mental disorders, there is a clear conflict of boundaries everybody has. In life, when we step over boundaries we get fines, get arrested, lose jobs, friends, colleagues and so on. So it seems that the price we pay for stepping over our mental and behavioral boundaries may be very expensive: life itself.

I had the opportunity to witness one extreme situation a few years ago, when some mothers killed several of their children in the USA. I remember it was in Houston, Texas. Coincidently, I was in front of the TV, watching CNN, when Larry King interviewed 3 men who had been husbands to these women. All 3 said the same thing: the women had postpartum depression and were taking a combination of 2 or 3 antidepressants. At the time, it was believed these women suffered from a depression refractory to treatment, so the doctors increasingly prescribed more antidepressants. Nowadays, scientific evidence points out that psychotic depressive behavior worsens with antidepressants and benzodiazepines. This needs to become common knowledge, known by all.

Prof. Dr. Paulo Rogério M de Bittencourt