Last week Professor Bongani Mayosi died. By choice. His family released a honest and gracious statement, openly acknowledging his suicide, while asking for privacy and respect for their grieving.

I agree with all the people who say the way they did this was a good thing, possibly a ground-breaking thing. The medical fraternity (being very much a fraternity) still has trouble with its emotional side. Despite the intense suffering and not uncommon deaths-by-choice amongst its members, it would still rather mental illness only happened to other people (preferably called “patients”). I’ve read articles over the past week appealing to this community to understand mental illness as something biological, just as “legitimate” as diabetes or cancer. In order to break the stigma.

This is possibly where my agreement ends.

I have some experience in this area: firstly, because of my own long-term relationship with depression. Secondly, because the person who was my closest friend for more than 20 years chose to die four years ago.

When I was first diagnosed, a friend who is a psychiatric nurse (and a very wise person) asked me whether I was thinking about suicide. I said no, because it hadn’t really occurred to me. She said there are three different kinds of people with depression. For some, suicide just isn’t something they think about. Others will think about it, but only as one option among several. For the last group, it is the option, the thing they will go to when things get bad. Eventually, they will probably do it. I have mostly been in the first group, with only occasional visits to the second. My friend belonged firmly in the third.

Why? I don’t know. Not because we never spoke about it – we did, often. She wasn’t a morbid person, or a drama queen. She was however in intense pain, for increasing periods of her life. All the reasons that that led to her choice to die rather than carry on like this – I don’t even know where to start.

I used to think her condition must be worse than mine, because mine didn’t make me want to die. Later I realised it isn’t that simple: you don’t just reach a certain number on some scale of suffering and then a switch flips on your will to live. Our relationships with life, with death, with pain – they are personal, knotted up with so many things that in the end “wiring” might be the best shorthand. And I firmly believe it has nothing at all to do with strength or weakness.

At the same time, the choice to commit suicide isn’t necessarily a long-term consideration. The possible reasons, the contributing factors, are too many to count, and are probably unique to each person and situation. There are certainly patterns worth knowing about – for instance, a large number of suicide attempts happen when someone actually begins to feel better. At your lowest point, you are immobilised. When you come out of it, you can remember how completely horrific it was, and you don’t ever want to go back there. You also have the energy to do something about that. (This is possibly why some anti-depressants have been associated with increased suicide risk – because they actually work.)

Yes, I know that neurotransmitter imbalances are part of the picture. I’m just not sure that that’s all – or that finding life unbearable and the future unthinkable is madness. The world is mad. Reality is ugly. The internet, bless it, affords us a wide screen HD view of our own corruption and failure as a species. The people I know who bear a diagnosis of mental illness often seem to be the ones who see that most clearly. We used to think insanity was being out of touch with reality, but now perhaps the latter is necessary to stay “sane”.

Episodes of depression always remind me of the silver chair, in the Narnia books. The children in the story (Jill and Eustace, if I remember), meet a young man who seems quite ordinary and cheerful. But every night for an hour he slips into madness, and must be tied to a silver chair until it’s over. He warns them on no account to untie him, even if he begs them. The hour comes, and the young man changes – but instead of losing his senses, he seems to become more sane. He tells the children his real identity (a kidnapped prince) and explains the magic that keeps him forgetful during the other hours of the day. They must decide which is the madness, and which the truth.

When I’m in one of those holes, it feels completely true. Life is hard. Hope is often irrational. I’m not always sure what changes when I come out. And I don’t know why, in spite of it all, I still want at some very basic level to live.

This might all seem really unhelpful, but what I’m trying to get to is the danger of seeing mental illness, and the desire for death, as simply biological. I can’t tell you why Prof Mayosi chose to die. Did he just have an unfortunate chemical imbalance? From his family’s brief statement, it’s hard not to note the coincidence of his period of struggle with depression with his tenure as Dean of Health Sciences at UCT – during one of the toughest, maddest periods of its history. The things that made him who we need in this time – intelligence, dedication, integrity, passion, compassion – might well be the things that made it impossible for him to continue. In health care, it’s almost always the best workers that burn out: the ones that care the most, know the most, see the most.

We have to ask: what have we done? Have we made a community in which a man of this kind finds the future unfeasible? If we make this a straightforward biological issue, we reduce it to an individual event (albeit a tragic one) and ignore the bigger problems surrounding it. Which means it will happen again.

When someone commits suicide, people want to know why. This is not for the Mayosi family to try and explain, and perhaps the real reasons (if anyone can really know them) are none of our business. But it is something we need to make sense of as a community, as a society, because mental illness is certainly not a non-communicable disease.

Bertrand Russell said: “I should wish to die while still at work, knowing that others will carry on what I can no longer do and content in the thought that what was possible has been done.”

I don’t think this was the situation he had in mind, but all the same. Rest peacefully, Professor. It’s up to the rest of us now. DM

Kate Sherry is an occupational therapist, rural health activist and occasional travel writer. She has a PhD in Public Health from UCT and is a founding member of Rural Rehab South Africa (RuReSA) and the Rural Mental Health Campaign. She also has a (not unrelated) history of mental illness. She is currently manager at CREATE, an NGO working in disability-inclusive development in rural communities in KZN.