Suicide-2
‘Dr G, there might be another book here in the comments.’
My MS-Selfie Newsletter on ‘Suicide and Suicidal Ideation (22-April-2026)’ hit a nerve with a large and frank discussion on the topic that seems to be independent of me as an HCP. I find this very reassuring and validates MS-Selfie as a self-help platform. I start the discussion, and you, the people with MS, get on with it and help each other.
Tom A, an MS-Selfie subscriber and commentator, said: ‘Dr G, there might be another book here in the comments.’ Maybe not a book, but at least another look at the subject. I have therefore tried to extract some of the learnings from the comments for further debate. The comments provide a deep and arguably multifaceted look into how people living with MS (pwMS) view suicidal ideation, mental health, and assisted dying.
Suicide as a rational decision vs. a mental health disorder
A significant thread throughout the comments is the belief that contemplating suicide is a logical, rational response to the relentless physical decline caused by MS, rather than a psychiatric illness.
Rational planning: Ian describes suicide as “sensible planning” to avoid the end-stage reality of becoming a “totally helpless bed patient.” He argues that treating this as a mental health issue is merely a “smokescreen” and an “excuse to dish out a pill”.
Logical choice: Bottomley echoes this sentiment, asserting that deciding to end a life that has become a “hard daily struggle with absolutely no prospect of anything getting better” is a “factual and straightforward, even logical decision,” and absolutely not a mental health issue.
Situational distress: Other commenters point out that suicidal thoughts are often a direct result of their horrific circumstances. “Italien” emphasises that the natural sadness accompanying a degrading quality of life and social isolation should not be conflated with clinical depression. Others note that severe, unmanageable symptoms—such as bowel incontinence—or severe social failures like homelessness are the root causes of their suicidal thoughts.
Conversely, there is pushback against dismissing the clinical reality of mental health disorders in MS:
Validating mental illness: Jenny Powell firmly objects to the notion that mental health issues are a “smokescreen,” noting that her own severe depression and anxiety are effectively managed with medication and are incredibly real.
Biological basis: I reinforced that depression in MS is not simply a psychological “reaction” to having the disease. It has a biological basis driven by neuroinflammatory and neuroendocrine mechanisms, and may also be due to specific lesion locations in the brain.
Proactive treatment: Another commenter notes that treating MS early and aggressively can reduce both physical disability and the underlying biological disease that causes clinical depression.
Arguments for assisted suicide
Those advocating for the right to assisted dying focus primarily on bodily autonomy and the prevention of extreme suffering.
Fear of end-stage MS: Several commenters express a deep fear of the late stages of MS, detailing the horrors of being bed-bound, entirely reliant on carers for feeding and washing, and suffering from repeated bouts of aspiration pneumonia.
Autonomy and dignity: Commenters express a strong desire for control over their end of life. Ian states, “I alone will decide when the quality of my life is so poor that I want to end it,” expressing a wish for a local dignified method (like a pill or injection) rather than having to travel to Dignitas in Switzerland or use “messy” methods at home.
Arguments against assisted suicide and alternative views
Arguments against legalising assisted dying focus on fears of systemic healthcare degradation, coercion, and procedural concerns.
Healthcare degradation and “mission creep”: Mark strongly argues that legalising assisted suicide could have severe unintended consequences. He fears that busy doctors might refer high-demand patients to assisted dying services rather than aggressively treating their depression, leading to the defunding of neurology departments and a halt in MS cure research. He also warns of “mission creep,” where the criteria for assisted suicide expand dangerously over time.
Adaptation to disability: Mark points out that published evidence suggests a person’s tolerance for disability often changes as their condition worsens, meaning a patient’s current fear of future disability might not match their reality when it arrives.
Procedural horrors: Luke notes he is conflicted about legalisation because he has read that assisted dying procedures can sometimes cause a patient’s lungs to fill with fluid, leading to an “excruciating sense of drowning for an extended period”.
Existing legal alternatives: Some commenters note that individuals already have the legal right to bodily autonomy without changing the law. Patients can legally refuse a feeding tube or voluntarily stop eating and drinking, which commentators describe as a painless way to die that does not require a doctor to administer poison.
Defining the role of the healthcare system and/or HCP
When looking at the literature, the proposed medical framework focuses entirely on preventing suicide by identifying and treating underlying distress, rather than providing policies to guide pwMS toward assisted suicide. Most articles state that suicide in MS is not inevitable and emphasise aggressive treatment of the drivers of suicidal ideation.
However, it is clear that the patient community, or at least part of it, highlights a desperate need for policies that allow for open, non-judgmental dialogue about end-of-life fears without pwMS immediately losing their autonomy.
There are, therefore, learnings and policies that could be implemented to identify and support these individuals:
Policies for systematic screening and identification
To accurately identify who is experiencing suicidal ideation, HCPs must stop relying on pwMS to spontaneously volunteer this information.
Mandatory routine screening: Clinics must embed a validated screening tool, such as the Patient Health Questionnaire-9 (PHQ-9), into routine MS reviews.
Targeted screening at critical junctures: Screenings should occur at least annually and, crucially, at major transition points. These include diagnosis, relapses, major disability milestones (like losing the ability to walk or drive), or when transitioning to secondary progressive MS.
Structured follow-up questions: If a pwMS screens positive for suicidal ideation, policies must dictate specific follow-up questions to assess imminent risk. Clinicians must ask whether the pwMS has a plan, access to the means, or has made any preparations for suicide.
Immediate action protocols: The presence of a plan, access to means, or preparatory behaviour must trigger an urgent, ideally same-day, psychiatric referral.
Policies for intervention and support
Once identified, the healthcare system must have pathways to address the physical, psychological, and social drivers of the pwMS’s distress.
Aggressive treatment of comorbidities: Clinics must reject the dogma that depression is just a “normal” reaction to having MS. Policies should encourage the proactive use of SSRIs, talking therapies, mindfulness, and cognitive behavioural therapy (CBT), which have a good evidence base in MS.
Holistic symptom management: Because physical symptoms directly drive suicidal ideation, treating pain, fatigue, sleep disturbances, and bladder/bowel/sexual issues must be viewed as an active suicide prevention strategy.
Mandatory safety planning: For at-risk pwMS, HCPs must collaboratively develop a written safety plan (such as the Stanley-Brown Safety Plan) that outlines warning signs, coping strategies, and crisis contacts.
Embedded mental health professionals: At a systemic level, it should be a minimum standard—not a luxury—to have a clinical psychologist or neuropsychologist embedded directly within the MS care service.
Policies for managing “rational” end-of-life discussions
While the clinical framework aims to prevent suicide, pwMS advocate for policies that allow them to discuss the realities of severe disability safely.
Destigmatising the conversation: HCPs should be trained to initiate calm, kindly, and reassuring discussions about general mental health shortly after diagnosis. They should normalise the fact that pwMS may experience fears about mortality or even abstract thoughts of suicide when facing severe disability.
Protecting patient agency: Policies should ensure that when pwMS express fears about their future or end-of-life scenarios, the medical system does not immediately “swoop in” with aggressive interventions that strip the pwMS of their voice and agency.
Facilitating frank discussions: The NHS or other healthcare systems and MS support services should facilitate open discussions about life in the later stages of MS, including the associated problems, rather than treating it as a taboo subject. The latter must not be rose-tinted, but realistic.
Implementing these policies requires significant investment and a shift in how chronic illness is managed, ensuring mental health is treated with the same urgency as physical health. Given the clear need for better mental health integration, how do you think the NHS and other healthcare systems can overcome the financial and staffing barriers to embedding psychologists directly into standard MS clinics? Trying to prioritise MS care in a system that is failing feels like rearranging the deck chairs on the Titanic.
People with MS deserve better care. Do agree? Any thoughts on how we can get things changed?
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Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Queen Mary University of London or Barts Health NHS Trust. The advice is intended as general and should not be interpreted as personal clinical advice. If you have any problems, please tell your healthcare professional, who can help you.
Email comment: "V interesting reading the MS-Selfie article on suicide. Not surprised you got such a reaction. I did notice that one of the eight deaths across the fenebrutinib two trials was from suicide... all v sad."
Email: "There are few horrors to match the loss of physical ability, agency, and autonomy. I was Dx'ed with MS in 2020. Steady declines since then. Absolutely agree that each person has the right to determine their manner and means of living and dying. Appreciate these two articles very much! More to ponder; this conversation is essential. Thanks."