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Death´s uncertain hour – a psychiatrist´s reflection on uncertainty


If anything is certain, it is the fact that our physical and mental reality is surrounded by layers of uncertainty. Just think about the chaos and upredictability of the physical world, from faraway planets exploding and asteroids and comets nearly hitting earth, all the way down to the apparently random behaviour of cells multiplying out of control and causing cancers. I live in Iceland and from kitchen windows in Reykjavik one can see volanic eruptions go off every few weeks, with an unpredictability that even the technical jargon and explanations of geologists can´t mask. This is a great reminder of the chaos (or at least seeming chaos, when one doesn´t understand things well enough to be able to predict them correctly) of nature, only further emphasised by the regular earthquakes shaking the foundations of my house. News of environmental disasters, pollution and global warming just adds to the uncertainty.

The seeming randomness of war and conflict, the unpredictability of politics, the ever increasing speed of technological progress, best exemplified by doomsday predictions of how artificial intelligence will take over, „Matrix“ style and how our children are turning into social media zombies. All of this adds to the brew and as I sit here in my chair by the window on a Saturday in March 2024, it is hard not to feel empathetic towards my most anxious patients, when they feel paralysed by uncertainty.

Yes, it is easy to sympathize with the effects uncertainty in both our natural and man-made environment has on peoples´ mental state. In my clinical work I have usually looked after people suffering from schizophrenia. For the last year however, I have worked in an emergency room and outpatients clinic where the majority of patients suffer from anxiety and depression. I have been taken back by the prevalence of these problems and how intractable and debilitating these so called „minor“ mental illnesses in fact are. There is certainly nothing minor about someone with agoraphobia not leaving their house for years out of anxiety and fear.

But there are more layers to the anxiety that surrounds us. As anyone who has spent more than a few months in the field of mental health realises, the field of psychiatry itself has to deal with a plethora of internal uncertainty.

Partly this is simply the uncertainty innate to the field of medicine. Physicians of all specialties are trained to make decisions quickly, often based on inadequate information and then adapt their diagnosis and interventions as more evidence becomes available. It is really about moving onwards through the uncertainty of illness and cure and through that process shaping more certain outcomes.

There is also the uncertainty of both diagnosis and prognosis within psychiatry. The illnesses we most commonly deal with lack the pathophysiological underpinnings of many common diseases in other specialities. This can lead to uncertainty about which treatments are most effective and of prognosis. Not that prognosis is necessarily that certain or helpful in other brands of medicine, when dealing with individual patients. Although a certain cancer has let´s say an 40% chance of causing death within five years, for each individual the chance is either 100% or 0%, as you are either alive or not.

Yet another level of uncertainty is the question that most vexes and taxes many of us – how to predict the risk of suicide in patients under our care. To predict the future is not possible, although certain strands of information can help us, if we have access to it. This includes the current mental state of the person, past history and current social circumstances – but even when we have all this information to hand, prediction is hard and we are often wrong. The making of lists and questionnaires can´t hide that fact or remove the need for a careful formulation, as so well discussed by Oxford based suicide prevention researcher and psychiatrist Keith Hawton in an editorial in The Lancet two years ago (Hawton K et al. 2022) and the importance of evidence based interventions (Rozek DC et al. 2022). These may help influence what happens next, but even so, we never know for sure, which is hard, when we care and want to make correct predictions, as peoples´ lives and freedom are at stake.

Again, another uncertainty surrounds risk assessments psychiatrists are often called upon to conduct. Similar strands of information help, as so well outlined in the HCR-20 questionnaire (Challinor A et al. 2021). Past history best predicts what will happen in the future, current mental state helps too, and the plan on how to dispose of people may help – the risk assessment is different in a supported, secure environment compared to unsupervised and unsupported in the community. At the end of the day though, gazing into the future is not for the faint of heart, as we are so often wrong about what will happen next.

So how do we cope with the layers of uncertainty that surround us, like layers of a large onion, blocking our view? Well we advise our patients well, through numerous interventions aimed at reducing their anxiety; putting their fear into perspective, avoiding black and white thinking, facing their fears. At the same time though, we can´t hide the fact that nearly the only thing that´s certain in our life is that death will come one day – but even the timing of death we can´t be sure of. Some people seek solace in the certainty of religion. Perhaps others simply have to accept that they don´t know it all, accept, even embrace the freedom that comes with the fact that nothing is certain. – Or as the dreaded artificial intelligence machine chat-GPT said so sagely when I put the following question to it; „discuss in one paragraph in a scholarly manner how best to handle the uncertainty of life and death.“

„Navigating the uncertainty inherent in life and death requires a multifaceted approach blending philosophical contemplation, practical preparation, and emotional resilience. Philosophically, embracing existential uncertainties by acknowledging the impermanence of life can foster a deeper appreciation for the present moment and mitigate anxiety about the unknown. … Emotionally, fostering resilience through mindfulness practices, supportive relationships, and engaging in activities that bring joy can help individuals cope with the inevitability of mortality and find meaning amidst uncertainty. Recognizing the interconnectedness of these approaches can empower individuals to navigate life's uncertainties with greater equanimity and acceptance.“

I could not have put it better myself!

P.S. This same evening one type of uncertainty in my life disappeared, as our local volcano once again erupted.

A photo taken by my wife of the latest volcanic eruption, across the bay.
A photo taken by my wife of the latest volcanic eruption, across the bay.

References by request

  • Challinor A, Ogundalu A, McIntyre JC, Bramwell V, Nathan R. The empirical evidence base for the use of the HCR-20: A narrative review of study designs and transferability of results to clinical practice. Int J Law Psychiatry. 2021 Sep-Oct;78:101729. doi: 10.1016/j.ijlp.2021.101729. Epub 2021 Aug 20. PMID: 34425379.

  • Hawton K, Lascelles K, Pitman A, Gilbert S, Silverman M. Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management. Lancet Psychiatry. 2022 Nov;9(11):922-928. doi: 10.1016/S2215-0366(22)00232-2. Epub 2022 Aug 8. PMID: 35952701.

  • Rozek DC, Tyler H, Fina BA, Baker SN, Moring JC, Smith NB, Baker JC, Bryan AO, Bryan CJ, Dondanville KA. Suicide Intervention Practices: What Is Being Used by Mental Health Clinicians and Mental Health Allies? Arch Suicide Res. 2023 Jul-Sep;27(3):1034-1046. doi: 10.1080/13811118.2022.2106923. Epub 2022 Aug 9. PMID: 35943133; PMCID: PMC9908767.


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