By the time Andrew Potgieter learned why he had been so sick for so many years, he had become an invalid.
In 2005, the native of South Africa had come to New Jersey and was working as a day-laborer and gardener.
One day, while working in Monmouth County, he came home covered in ticks. Lyme disease is rare in South Africa, so Potgieter did not think about the potential danger.
It wasn't until 2014, after years of misdiagnoses and deteriorating mental and physical health, that he finally got his first dose of antibiotics targeting the bacteria coursing through his body.
What came next was worse — a series of extreme flu-like symptoms, known as a Jarisch-Herxheimer reaction, that spike when the bacteria begin to die.
"Everything was painful," said Mark Sluscavage, Potgieter's fiance and a resident of West Milford, N.J. "And it was unrelenting."
So was the anxiety.
"It gave him anxiety he never had," Sluscavage said. "He had all sorts of social anxieties and intrusive memories."
On Aug. 22, 2015, Potgieter put an end to his suffering. He committed suicide at the age of 41.
His suicide is emblematic of a trend in Lyme disease cases that often is overlooked, according to a recent paper authored by a New Jersey psychiatrist.
The report, published last month in the peer-reviewed journal Neuropsychiatric Disease and Treatment, suggests that suicidal thoughts in patients with Lyme and other associated diseases may provide context for the thousands of unexplained suicides in the United States each year.
More than 44,000 people took their own lives in 2015, the most recent year for which data from the Centers for Disease Control and Prevention are available. The rate of 13.3 suicides per 100,000 people was the highest since 1986.
The paper's author, New Jersey-based psychiatrist Dr. Robert Bransfield, estimates that as many as 1,200 of those suicides — as well as more than 14,000 incidents of self-harm and 31,000 suicide attempts — may be attributed to Lyme and associated diseases each year.
"It’s a constant action that comes up and isn’t adequately addressed in the scientific literature," Bransfield said. "... Failure to adequately diagnose, failure to adequately treat and the progression of the disease over a span of many years often leads to suicide."
Bransfield suggests the risk is greater among veterans and outdoor workers who are more likely to be exposed to ticks.
Dr. Brian Fallon, a psychiatrist who was not involved in the study and is the director of the Lyme and Tick-borne Diseases Research Center at Columbia University, said patients with Lyme disease are known to suffer from depression, a well-established indicator of suicidal thoughts.
He said that while the idea that Lyme and suicide could be linked may not be novel, "it certainly is important for clinicians to recognize that some of their patients, particularly those who are depressed, might be having suicidal thoughts."
Fallon raised questions about Bransfield's estimates of the number of cases. Bransfield, who has frequently spoken and written about Lyme, based his calculations on reviews of his own patients, many of whom have battled the disease.
Since no comparison group was used as a control, Fallon said, Bransfield's patient group could result in a biased sample.
"What we need is a high quality, epidemiological, random-sampling study to address this question," Fallon said, "using standardized psychiatric measures and a standardized way of diagnosing Lyme disease."
Lee Vickson, a 65-year-old resident of Marina Valley, California, said he lived with Lyme for decades after a tick-bite left him with a rash in 1982. Not surprisingly, few if any doctors had heard of Lyme since that was the same year a medical entomologist named Willy Burgdorfer first identified the spirochete bacteria that now bears his name.
Furthermore, Lyme cases in California are rare compared to the Northeast and upper Midwest. It would be decades before Vickson was formally diagnosed.
Before his physical and mental capabilities began to deteriorate, Vickson was a martial arts instructor and a cost analyst with the U.S. Air Force. Things became so bad, Vickson said, that his duties were reduced to playing dead on a runway during military exercises.
About a year after he got sick, Vickson said he went AWOL and woke up on a beach in Mexico, not knowing how he had arrived there. Lying next to him was a bottle of Scotch and a .357 Magnum. The night before, he had suffered night terrors, sweating and no sleep.
"It appears that I clocked out mentally," Vickson said. "So in my view, the bottle of Scotch saved my life because I fell asleep before I could kill myself with my .357 Magnum."
Bransfield's paper also addresses the controversial issue of chronic Lyme. He found the same psychiatric patterns in people who met the strict criteria used by the CDC to count Lyme cases and in people who were diagnosed with Lyme by doctors, regardless if they met the criteria.
"There was no significant difference in the psychiatric symptoms," Bransfield said. "Even if someone believes chronic Lyme disease is an invalid concept, there is still a valid statistical correlation that Lyme disease causes suicide."
Dr. Daniela Stokes, a Poughkeepsie-based infectious disease specialist, said there is a strong association between neuroborreliosis — a manifestation of Lyme in brain tissue — and suicide.
"Definitely, the neuroborreliosis — the late Lyme — is now considered one of the triggers for psychiatric illness, if there is a genetic predisposition," Stokes said. "It can be dormant for many years. So it's a very interesting subject. There is a lot of research needed."
Sluscavage said he hopes his fiance's story will draw attention to the issue.
"He suffered horribly with this for so many years, and had no idea," Sluscavage said. "He blamed himself."
John Ferro: 845-437-4816, firstname.lastname@example.org, Twitter: @PoJoEnviro
At a glance
Lyme disease statistics for 2015.
28,453: Confirmed cases in the United States
300,000: Estimated cases (The CDC says that Lyme disease suffers from underreporting.)
Source: Centers for Disease Control and Prevention, State Health Department