We present the case of a patient with anxiety who attempted suicide by self-removal of her permanent pacemaker (PPM). Self-harm involving a pacemaker is associated with significantly endangering patient well-being and often with greatly increased health care costs. It is an indication that the numbers of patients with a PPM who are clinically depressed and anxious has been underestimated. Early detection of depression, using a validated questionnaire, followed by ongoing care and shared decision making (SDM), a focus on psychosocial stressors, medication adherence, somatic complaints and attention to any adverse drug reactions, are likely to improve clinical outcomes.