Psychiatric Annals

Case Challenge Free

A 20-Year-Old Man with a Suicide Attempt Using Helium

Deepti Mughal, MD; M. Rehan Puri, MD, MPH

The patient was a 20-year-old man who was brought to our emergency department by emergency services after his father found him unresponsive in his apartment after attempting to commit suicide. The patient's father reported that he had received an email from the patient stating that he was going to commit suicide, which is why he rushed to the patient's residence. The patient was lying unconscious and had a helium tank connected to a face mask that he was wearing. The patient's father immediately called 911 when he found him.

The patient, his father, and his mother were all interviewed separately and the patient's medical records were reviewed as well to obtain his medical history.

The patient complained of chronic depressive symptoms for the past 7 years that had never been managed medically. His mother reported that he had been depressed since high school after a relationship with a girlfriend ended. He had first started talking about suicide then. At that point, he just received some school counseling but received no medications. After high school his main goal had been to enlist in the US Navy, but he was rejected because he had been diagnosed with mild cerebral palsy during his employment physical for Navy services. Since then he seemed devastated and did not know how to go on with his life. He had lost all the interest in life. He also reported that he felt empty and isolated. He reported sad mood, loss of appetite, low energy, anhedonia, insomnia, and indecisiveness since that event. He did not describe any feelings of excessive worry but believed that he suffered from occasional panic attacks. The patient denied any history of manic or psychotic symptoms, trauma, or seizures.

During the interview, the patient's affect was constricted and he maintained minimal eye contact. He was tearful at times and he talked minimally with encouragement. The patient reported having a depressed mood for the past 7 years, as well as having thoughts of committing suicide multiple times in the past. About 3 months prior to presentation, he stated that he had begun researching methods of suicide on the Internet. That is when he decided to use a helium tank and mask, because this method seemed an easy way to end his life.

The patient denied any current or past illicit drug or alcohol use. He had no records of previous inpatient or outpatient hospitalizations, and he had not been treated by any therapist or psychiatrist.

There was no history of mental illness, suicide attempts, or illicit drug or alcohol abuse within the patient's family. His biological parents had divorced by the time he was age 4 years. He had one older brother and three half-siblings. The patient reported that he had lived most of his life with his father, but he suffered physical and emotional abuse by a step-mother between ages 4 and 7 years. When his father learned about the abuse he ended the relationship with that woman. The patient also reported that his family and friends were supportive, but it seemed difficult for him to share his feelings openly with them.

Diagnosis

Major Depressive Disorder, Recurrent, Severe without Psychotic Features

After initial assessment of the patient, the following evaluations were made: major depression, recurrent severe without psychotic features. He also had educational problems, other psychosocial or environmental problems, problems related to social environment, and problems with primary support group. As the patient was at risk of hurting himself or others, he was admitted to the inpatient psychiatric unit on an involuntary basis. During his stay, he was educated about depression and he was prescribed the antidepressant medication escitalopram and psychotherapy. He was monitored for symptoms of depression and for safety within the unit, and he was encouraged to participate in group and individual therapy. The patient was compliant with treatment and therapy and was doing well at last check.

Discussion

Helium is a colorless, odorless, and tasteless monatomic gas. It is the second lightest element and it heads the noble gas group in the periodic table. It was first detected in 1868 by French astronomer, Jules Janssen, as an unknown yellow spectral line in sunlight during a solar eclipse.1

Helium has had many uses throughout the years after its discovery. It has been used in industries for leak detection, for lifting airships and balloons, and for minor commercial and recreational uses.2 In the 1930s, helium began being used medically to alleviate the symptoms of airway obstruction. It has also been used, along with oxygen and nitrogen, in breathing systems for deep-sea diving to reduce the risk of oxygen narcosis, decompression sickness, and oxygen toxicity.3 Helium is now widely available in refillable tanks to use in balloons, and this availability has contributed to the increasing incidence of suicide attempts using helium.

Suicide is the deliberate act of killing oneself.4 It is a major public health problem, and is now the 10th leading cause of death worldwide.5 The incidence rate for completed suicide varies between different countries, with the highest rates seen in Eastern European countries (Belarus, Estonia, Lithuania, and Russia) and the lowest mainly in Latin America (Columbia, Paraguay) and some Asian countries (Thailand, Philippines).6 Preferred methods of suicide vary at different ages, with accessibility, availability, lethality, and familiarity with devices being significant factors that determine the choice of each attempter.

Helium can cause or contribute to asphyxiation by displacing oxygen needed for normal respiration. Breathing pure helium can cause death by asphyxiation within minutes, and this fact is used in the design of suicide “bags” or “masks.” Inhaling helium directly from pressurized tanks can also lead to barotrauma because the high flow rate can result in rupture of the lung tissue.7 Given the availability of helium and the recent promotion of this method of suicide, it is becoming obvious that a new trend in suicide attempts is emerging.

Suicide by helium inhalation has been increasing in recent years as it has been discussed in the “right-to-die” literature and on Internet suicide forums as an effective and peaceful method of suicide for terminally ill patients. This raises a great concern within the medical community because helium balloon tanks can be easily and readily obtained by anyone, even from toy stores and welding supply stores.

Suicide by the use of inhaled helium was first discussed in a controversial book, the Supplement to Final Exit: The Latest How-To and Why of Euthanasia/Hastened Death8 that was published in 2000, and a separate video/digital video disc9 was already available to public at that time. In the year after publication of this book, the number of suicide attempts in New York City involving asphyxia by a plastic bag, as described in the book, increased notably.8,9 In 2002, the third edition of the book had a full chapter on helium asphyxia titled, “A Speedier Way: Inert Gases.”10 It appears that the inspiration for the rise of helium as a method for suicide started in November 1999 at a conference of the New Technology Self-Deliverance group.11 In 2008 one Swiss right-to-die organization, Dignitas, started researching helium as an alternative to phenobarbital.12 Several easily accessible suicide Internet forums also described this method as a successful and painless method of suicide.

The majority of the reported cases of persons who committed suicide with helium in the literature suffered from psychiatric and/or substance use disorders and were free from terminal illness.13 In this reported case, the patient was suffering from untreated major depressive disorder associated with biopsychosocial factors like social isolation, and occupational and financial issues. This, along with plethora of information on the Internet, from videos, and in Internet forums about the lethality of helium, motivated him to attempt suicide using helium asphyxiation.

Despite its lack of direct toxicity, helium's physical properties make it a dangerous substance. Inhaled helium quickly displaces the air gases, most importantly oxygen and carbon dioxide. The breathing reflex in humans is not triggered by the lack of oxygen, but rather by the excess of carbon dioxide. Because helium displaces carbon dioxide, the inspiratory reflex will be weak.14 Occupational Safety and Health Administration defines an oxygen-deficient atmosphere as one below 19.5% (normal air contains 21% oxygen).15 When there is a decline in oxygen concentration, the human body responds to a decline in oxygen sequentially. At an oxygen concentration of 12% to 16%, breathing rate increases and coordination is disturbed. At 10% to 14%, there is abnormal fatigue and disturbed respiration. At 6% to 10%, there may be nausea, vomiting, loss of free mobility, and loss of consciousness. Levels under 6% oxygen concentration can cause convulsions, gasping, loss of respiration, and cessation of heart activity after only a few minutes. When pure helium is inhaled, sudden exposure to a severely oxygen-deficient environment will cause unconsciousness within 5 to 10 seconds, and permanent brain injury with death within 2 minutes.16

Another major problem is that helium asphyxiation can be disguised, and it can be a method of concealing assisted suicide. Detection of helium by toxicological process is complex and cannot be detected using standard toxicological analysis of blood and urine samples.17 Therefore, special autopsy techniques and devices are needed for the collection of the gas from the lungs. The literature suggests that reported cases of helium-assisted suicides are only the tip of the iceberg, as right-to-die literature instructs people to remove the suicide apparatus from the scene.9,10,12 Because of the rapid fatality of helium asphyxiation and the diagnostic hurdles, it is crucial that the suicide scene is thoroughly investigated for situational evidence, particularly the helium tank, plastic bag or mask, guiding literature on a computer, and a suicide note.18

Conclusion

The public and clinicians, in particular psychiatrists and primary care physicians, need to be aware of helium inhalation as a highly lethal method of assisted suicide, and the purchase of helium gas tanks, in our view, should be better controlled. In this case, the easy availability of helium tanks and other equipment and instructional literature on the Internet and lack of psychiatric care were important factors. We hope this article encourages physicians and other professional to keep helium use in mind while screening people at risk of suicide. It is worth considering that regulatory bodies mandate reporting of suicide by helium to health departments and that a national database be maintained. It is time to recognize the lethality of helium, and we feel necessary steps should be taken for better regulations from the governing bodies to prevent the dissemination of this novel method of suicide.

References

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Authors

Deepti Mughal, MD, is a Transcranial Magnetic Stimulation Specialist, Nihalani Clinic (TMS of Jacksonville). M. Rehan Puri, MD, MPH, is a Child and Adolescent Psychiatric Fellow, Institute of Living, Hartford Hospital.

Address correspondence to Deepti Mughal, MD, 6011 Shadehill Road, Jacksonville, FL 32258; email: deeptimughal@live.com.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20160908-01

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