They added that Cornell was a recovering addict with a prescription for the anti-anxiety medication Ativan and that he may have taken a bigger than recommended dosage. "The family believes that if Chris took his life, he did not know what he was doing, and that drugs or other substances may have affected his actions," they wrote, with Pasich adding that some medical literature indicates that "Ativan can cause paranoid or suicidal thoughts, slurred speech and impaired judgment."
Billboard spoke to a panel of mental health experts about suicide, depression and the dangers of taking increased doses of prescription medication and/or mixing them with other drugs. [Editor's note: due to professional ethical rules, all of the experts spoke in general terms about these subjects with no first-hand knowledge of the Cornell case.]
"Ativan is a sedative in the benzodiazepine family, like drugs such as Xanax or Valium. It's something that in the same way we talk about people with alcohol who can have a social drink and it's never associated with anything bad, but situationally alcohol can completely disinhibit someone and lead them to do things and mixed with other substances it can be lethal," said Dr. Praveen R. Kambam, a clinical assistant professor at UCLA Department of Psychiatry who has an addiction medicine certification and a focus in forensic psychiatry. "People often die with alcohol or benzos in their system and if you mix them with the wrong thing it can lead to confusion and delirious symptoms."
Kambam told Billboard that an overdose of a benzo such as Ativan can lead to cardiac issues and cause a patient to stop breathing. "Let's say you were delirious from medication and not fully aware of what you were doing or the consequences that could happen?" he said, noting that in his work with children there is sometimes a "paradoxical reaction" to certain benzo drugs where the patient can get very agitated and hurt themselves or get disinhibited in another way that clouds their judgment or conjures dark impulses they are unable to control.
On Friday (May 19), Men's Health magazine resurfaced an 11-year-old interview with Cornell in which the singer discussed his long struggles with depression and dark thoughts. "I was depressed for a long time. If you're depressed long enough, it's almost a comfort, a state of mind that you've made peace with because you've been in it so long. It's a very selfish world," he told the magazine.
“For me, I always had one foot in this very dark, lonely, isolated world. Then about eight years ago [he was 42 at the time of this interview] I got very dark and there was a ton of isolation," Cornell said. "I had to do a lot of things I didn’t want to do. Like I had to admit that I made all the mistakes I assumed I would never make. I changed pretty much everything you can change. The city that I lived in, every person that I spent time with. I got a divorce, but then fell in love in a way that I didn’t know I was capable of, and then felt loved in a way I didn’t know I was capable of. I quit drinking, quit smoking. And suddenly I had all this energy."
Just as we don't ask why celebrities get cancer or lose their eyesight, forensic psychiatrist Dr. Vasilis K. Pozios told Billboard that "suicide doesn't discriminate." Pozios said the typical increased risk factors for suicide include a history of previous suicide attempts, mental disorders (particularly depression), substance abuse, family history of suicide, feelings of hopelessness and access to lethal means.
"Under the facade of fame, celebrities may be suffering inside," he said. "We might forget that the causes of suicide -- most often depression -- are rooted in a biological disorder of the brain. We also might not realize how common mental illnesses are: over half of Americans will experience a diagnosable mental disorder at some point in their lives." The problem, he said, is that suicide is notoriously difficult to predict.
Sometimes suicidal actions are preceded by warning signs he described including "depressive symptoms characterized by feelings of hopelessness or an inability to experience pleasure, changes in sleep and appetite, loss of interest in typically enjoyable activities (often resulting in social withdrawal), excessive guilt or shame, low energy, and, of course, increased thoughts of death and dying." People who are depressed may also turn to drugs and alcohol to self-medicate those symptoms.
Unfortunately, suicide often occurs because of our capacity to put on masks that hide any or all of those symptoms, according to Dr. Lloyd Sederer, Chief Medical Officer for the New York State Office of Mental Health and an adjunct professor at the Columbia/Mailman School of Public Health. "Someone like [late actor] Philip Seymour Hoffman on the surface looked like everything was fine and performers are even better at putting on a mask and portraying everything as okay but inside they could be in profound turmoil," Sederer told Billboard. While sympathizing with a family trying to sort out the shock of a loved one who died by hanging themselves, Sederer said the act is "quite a complex intentional one" and without a note it is difficult to know whether there were antecedent events or if it was an impulsive act.
"If you look at the literature, people who survive suicide may have been considering it but they reached a tipping point and acted within five or ten minutes, so it can be brewing but then something happens or their emotions take over," he said. "I see suicide as the endpoint of a great deal of psychic pain and a profound sense that there is no hope and no one to turn to." Choosing a method such as a gun, jumping off a building or a noose makes the likelihood of fatality much higher than if one were to cut their wrist or take pills, he added.
Kambam said one of the most difficult legacies of suicide is the people left behind who have to cope with a mixture of anger, compassion and guilt, plus the cognitive dissonance of asking "how could you leave us here?" while reconciling that with feelings of love for a good person who might have left children and a spouse behind. "Suicide notes are left somewhere between an quarter and under half of the time," he said, urging anyone who is worried about a loved one who might be contemplating suicide to look for warning signs and reach out immediately.
"In practicality, once someone has decided that they will die from suicide there is sometimes a sense of peace, which can also be a warning sign. Especially if they were depressed and all of a sudden they seem to be at peace and they are giving away their things and seem very happy," he said.
The good news, Pozios said, is that there are treatments for depression (and other mental illnesses) that work and if you think you or someone you know might be at risk for suicide you can call the National Suicide Prevention Lifeline at (800) 273-TALK.