10.1 Suicide

I. WHY THIS TOPIC?

The motivation for this article came from an article in the Chicago Tribune that cited the following 1997 statistic: more people die of self inflicted gunshot wounds that those who are killed by others with firearms. 17,566 suicides compare with 13,522 homicides reported in 1997 according to the National Vital Statistics Report. Thirty thousand succeed at suicide every year in the United States. Half a million more make an attempt medically serious enough to require emergency room treatment.

As I write this, I am still gripped by the news of a mother of a Columbine shooting victim-both of whom seemed on the way to recovery. She loaded a handgun in a gun shop and shot herself. I'm still shocked by this event.

One aspect of gun-related deaths is encouraging: the homicide rate is down sharply since the early 1990s.

Why include this topic in medical anthropology? Suicide varies cross-culturally, is differential by age, sex, and temperament. It is really no different from any of the other health hazards that we meet in this course. It differs, of course, because here is an intentional fatal blow against life itself. In this article I treat this cause of death the same as alcoholism, cancer or infectious disease. In the context of this course, our attitudes about suicide and its incidence are embedded in human culture.

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Suicide is the third leading cause of death among young people in the United States and the second leading cause of death among college students.

Kay Redfield Jamison's new book Night Falls Fast Understanding Suicide follows her earlier, best seller An Unquiet Mind. It was the first new authoritative book on the subject in 25 years. Jamison's writing is intensely personal: she has struggled with manic-depression and suicide much of her life. This summary for you is based on her newest book, just a click away on amazon.com.

I have deliberately omitted 'methods' and there is only a brief mention of another current debate, assisted suicide / right to die.

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II. OVERVIEW

Cultures have varied in their notions of self-inflicted death. Attitudes have changed over time.

• The Eskimo, Norse, Samoan, and Crow Indian accepted (and even encouraged) self-sacrifice among the elderly and the sick.
• There are no early cultural or religious sanctions attached to suicide in the Old Testament. Jewish custom forbids funeral orations for suicide victims. In Islam, it is as grave a crime as homicide.
• Most European countries have formally decriminalized suicide in the eighteenth and nineteenth centuries. Ireland did not do so until 1993.
• In the United States, women are more likely to attempt suicide; however, men are much more likely to succeed at it.
• Depressive illness is far more common in women that men (in major Western countries surveyed). Manic-depression is the same in men and women.

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Worldwide, for persons 15-44, an abbreviated summary of cause of death for 1998 is shown below:

-WOMEN

1. Tuberculosis 9.4%

2. Suicide 7.1%

6. HIV/AIDS 3.4%

-MEN

1. Traffic Accidents 10.9%

2. Tuberculosis 9.0%

3. Violence 8.8%

4. Suicide 6.6%

7. HIV/AIDS 2.9%

Take a look at these figures, folks. Look at the figures for suicide. Which is greater? Which gets the most attention in the news?

Before you declare fatigue from statistics, just two more. Surveys have shown that one in ten adults has considered it at some point in their lives. Figures for college students are similar or higher. For high school students it is as high as one in five.

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II. THE PSYCHOLOGY OF SUICIDE

Each way to it is intensely private, unknowable, and terrible. What about the notes they leave behind? In fact, only one person in four leaves a note. Jamison reports that they have a stereotypic quality to them.

Hostility, when it occurs can be an eye-opener. One man whose wife was having an affair with his brother wrote " . . . I die hating you and my brother too." Many are specific about property distribution and insurance policies.

The overwhelming majority of suicides are linked to psychiatric illnesses. Thus, the notes and records left behind reflect the misery, cumulative despair, and hopelessness of these conditions.

(My note: Life isn't fair. We can do our best and yet get caught up in financial ruin, betrayal by others, disease that isn't our fault. Sometimes, some folks just can't take it any more.).....

III. RISK

The single most powerful predictors of subsequent suicide is a previous serious attempt. Coming in second, third, and fourth are depression, manic-depression, and substance abuse with opiates. Medical illnesses are all much lower than any of these.

One of the highest-risk periods for suicide is when patients are actually recovering from depression.

Suicide is more common in highly creative or successful writers, artists, scientists and businessmen. In these folks most are related to depression, manic-depression, or alcoholism.

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IV. DOES IT RUN IN FAMILIES?

There have been more than thirty family studies of suicide. Violent suicide tends to be likely in families with a strong history of suicide.

Particularly interesting are the Amish. They call it "the abominable sin" or "that awful deed." Also, they keep extensive medical records that can go back thirty generations.

Three fourths were in just four families. They were clustered in families with mood disorders. Most who did it were married, with children, and in the prime years of life.

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What about twins? In a major Veterans Administration study of twins, this was found:

1) Of 129 identical twin pairs, a second twin also did it 17 times.

2) Of 270 nonidentical twin pairs, a second twin also did it only two times.

Thus, the findings from the twin studies suggest a genetic component. Since they usually share similar upbringing, education, and life experience, the social aspect cannot be ignored.

Based on many other studies of body physiology, it is safe to say that much is determined by our biology. The causes of suicide lie in a person's predisposing temperament and genetic vulnerabilities, psychiatric illness, and acute psychological stress.

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V. DO ANIMALS DO IT?

Self-injury "self aggression" is widely reported for some animals under conditions of acute stress-isolation, overcrowding, confinement, or alteration in habitat. It has been reported in zoo animals including a variety of primate species.

The most severe forms of self-injury in animals seem to occur when a confined animal or an animal reared in isolation encounters acute stress. When these animals encounter acute stress, they can't cope. They become agitated, aggressive, or frustrated. (My note: The classic studies are by Harry Harlow.) Human prisoners have amputated toes, fingers, and genitals.

I have deliberately omitted the lemmings.

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VI. OTHER CORRELATIONS

1) Acute psychiatric illness is the single most common and dangerous trigger of suicide. Sleep loss tends to provoke mania in the manic-depressive.

2) Gender matters. Males are more likely to do it in most countries, BUT females predominate in Malta, Egypt, Papua New Guinea, western Ethiopia and China. Culture is clearly a factor.

3) Age matters. It is rare before the age of twelve. There is a sharp upturn at age 15.

4) Time of day matters. Most occur between 7:00 a.m. and 4:00 p.m. In a hospital, they usually occur between 5:00 a.m. and 7:00 a.m.

5) Seasonal variation is one of the most consistent findings in the literature. It isn't what you would expect. In sixty studies, the peak months were in late spring and early summer; the lowest are always found in the winter months. There is greater seasonality in rural areas than in urban ones.

6) Electroconvulsive therapy (ECT) has been used for decades to treat severely suicidal patients. Short-term improvement is well documented; however, long-term improvement remains to be confirmed.

7) Lithium is more effective than other antidepressant. Experts report that when antidepressants are found in the bloodstream, they are usually at too low a level to be clinically effective.

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VII. THOSE LEFT BEHIND

Suicide is a death like no other and those who are left behind to struggle with it must confront a pain like no other. Guilt is a usual and corrosive presence after suicide; survivors are left to ruminate on unintended slights, arguments, a call left unreturned.

Fathers of children talk about lost futures; mothers talk of present time as lost. Siblings feel terrible pain, but studies suggest that relatively few have long-term adverse psychological consequences.

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VIII. EPILOGUE

Look to the living, love them, and hold on.

Douglas Dunn's "Disenchantments"

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IX. ASSISTED SUICIDE AND THE RIGHT TO DIE

• As I prepare this article, only one state (Oregon) permits doctor assisted suicide. Efforts are pending in Washington to override the law with federal legislation..
• The Northern Territory in Australia provoked a heated debate with its law on assisted suicide; that law was overridden by national legislation.
• The Netherlands has had it for a long time.
• The Hemlock Society and the Right to Die Societies have published a book on assisted suicide. Its author, Derek Humphrey is in the news from time to time. Interestingly he lives in. . .Oregon. The book Final Exit drew protests but enjoyed good sales.

..... CJ'99

Resource

"Guns result in more suicides than homicides" Chicago Tribune October 17, 1999.

Jamison, K. Night Falls Fast Understanding Suicide New York: Alfred A. Knopf, 1999.

Humphrey, D. Final Exit Eugene, Oregon by The Hemlock Society, 1991.