INTRODUCTION

Razors pain you;
Rivers are damp;
Acids stain you;
And drugs cause cramp;
Guns aren't lawful;
Nooses give;
Gas smells awful;
You might as well live.

---Dorothy Parker, Resume --1926

This book describes, in sometimes-gory detail: (1) methods people use to commit suicide; (2) the medical consequences of suicide attempts; (3) how to carry out a safe suicidal gesture; (4) how to commit suicide as non-traumatically as possible.^(1f)

You may find parts of it disturbing. But the consequences of ignorance are more disturbing: botched suicides, accidental deaths and maimed survivors, slow and painful deaths,

Every 18 minutes someone in the United States kills himself.^(2f) A few are younger than ten years old; others over ninety. Between seven-and-a-half and sixteen percent take more than a day to die.⁽³⁾ An estimated 300,000 to 600,000 survive suicide attempts, but suffer varying degrees of injury. Nineteen thousand are permanently disabled each year.⁽⁴⁾

Only about one in ten or twenty suicide attempts is fatal. Given the easy availability of highly-lethal methods, it seems that most suicide attempters don't want to die.

Yet some people who didn't intend to die kill themselves. Many lack knowledge of drugs and may unknowingly take a lethal overdose. Some expect rescuers to save them. Others, who are really trying to die, live through their attempts. Many survive five-story jumps or head-in-the-oven gassing. Few have an accurate idea of how dangerous their chosen method is, or the consequences of its failure. Throughout the book, I try to provide evidence of the medical effects of each suicide method so that you can make more realistic decisions, whether you're thinking about killing yourself or hoping to get help and attention. I also cite my information sources so that you can look at the original data unfiltered through my interpretations, biases, or errors.

Statistics, though informative, diminish the impact and reality of death. While this book is filled with figures and abstractions, behind each of the numbers is a real person, with a history, personality, and pain that is both particular to each and common to us all. They are not just numbers; these are our friends, and neighbors, and families, and selves. I include some of their words to give a sense of the quality of their lives, and the thinking that led to their choice of suicide.

Karen, sixteen:

"I was really upset and depressed. My life just seemed to be in total chaos. My boyfriend just dumped me flat, and he said he loved the other girl and didn't love me at all. My parents and I also just got into another fight again about some really dumb things, so I just went into my room and closed the door. There was this bottle of sleeping pills my mother was using, and I had them with me. I sat and stared at it for a long time, weighing out the good and the bad things in my life. The bad things came out ahead. I poured some of the pills in my hand, and figured ten or fifteen ought to be enough to do it. Those pills...they all looked so innocent and peaceful, like they couldn't do much to hurt anyone. Well, I put them in my mouth and held them there for a long time, wondering if I should or shouldn't. I took a glass of water and swallowed. At first nothing happened, and then they all hit me at once. The room started to blur and spin, small sounds were going on in my head. The last thing I remembered was trying to move and not being able to. I woke up in the hospital. They were pumping out my stomach, one of the worst things you can have done to you. My mother came into the room, and she apologized for the fight we had."⁽⁵⁾

The material here is intended both for those who want a quick and relatively painless death, and for those who want to carry out a suicidal gesture as safely and non-injuriously as possible. If it convinces some potential suicides to seek other solutions---suicide should be an absolutely last resort and mistakes may leave you crippled---so much the better. But the fact remains: there is no way to limit this knowledge to those whose aims we agree with.

To make my premises explicit: (1) Decisions concerning your death should be, ultimately, yours to make; (2) Most--but not all--decisions to commit suicide are due to temporary problems, and are mistakes.

My position comes from two principles: (1) self-determination and (2) mercy. The more fundamental, self-determination, says that each competent person may decide and act on (subject to non-interference with the rights of others) his or her own views of what constitutes a good life and death.

In practice, I think that temporary suicide intervention is appropriate when there is other reason to believe that someone's thinking is impaired (e.g. by depression), though both the nature (reversible) and timecourse (brief) of the intervention should be limited.

The principle of mercy holds that no one (or thing) should be made to suffer unnecessarily. This is necessarily the subordinate principle; one may choose to suffer for some perceived higher good. While mentioned in this book, these ethical and philosophical issues are treated in much greater detail elsewhere. (See suggested readings.)

For those who are religiously, philosophically, or ethically opposed to suicide under any circumstance, this publication will be of little comfort; those who believe that it is each person's right to decide, insofar as possible, when to die may find some answers to their questions and fears.

"Just as I shall select my ship when I am about to go on a voyage, or my house when I propose to take a residence, so I shall choose my death when I am about to depart from life. "

--Seneca, Epistulae Morales

I place suicide attempters in one of four groups: (1) Rational people facing an insoluble problem, generally a fatal or debilitating illness; (2) Impulsive people, frequently young, truly but temporarily miserable, sometimes drunk, who wouldn't even consider suicide six months later; (3) Irrational people, often alcoholic, schizophrenic, or depressed; (4) People trying to make a safe gesture as a "cry for help" or to get someone's attention.

The first group---and most of us will eventually be in it---has, in my view, the right to decide the time, place, and manner of their death. It is clear that a competent person who really wants to kill himself can usually do so. However, seriously ill or physically impaired people often have both the greatest interest in, and least ability to carry out, suicide. They ought to have medical help to die peacefully and without pain, but this, while sometimes surreptitiously done, cannot at present be relied on.

Many of us have known people who have suffered long, agonizing deaths because they became too ill to kill themselves and their physicians were unwilling to act on their request. I will not mince words by calling it "euthanasia" or "self-deliverance": if you're terminally ill, I hope to provide you with information that will help you determine the best way to kill yourself, if that's your well-considered decision.

What about the young and impulsive, particularly teenagers? At the moment, they seem to have the worst of all worlds, where: (1) lethal and not-so-lethal suicide methods are readily available; (2) neither they, their parents, nor their teachers are likely to know how dangerous particular methods are; (3) personal ("Are you thinking about...?) or practical ("How would you go about...?) discussion of suicide is largely taboo.

While many schools now teach about AIDS and its transmission, more teenagers will attempt or commit suicide next year than will become HIV-infected. The ignorance, stigma, and fear about suicide would decrease if that topic were added to the curriculum and treated honestly.

A case will be made that people shouldn't commit suicide and that, therefore, a manual telling them how to go about it is pernicious.^(6f) This is like one of the arguments against sex education: "If they know how, they'll do it." Well, they do it anyway. Thirty thousand suicide deaths a year in the U.S. should make this clear. In the absence of knowledge about suicide methods---and the consequences of failed attempts---people will continue to act in desperation and ignorance, as they have throughout recorded history, with gun, rope, blade, poison, and anything else available.^(7f) That is the reality. And the methods people use all too often leave them neither dead nor fully recovered, but maimed and permanently injured: paralyzed from jumps, brain-damaged from gunshots, comatose from drugs.

But for anyone considering suicide (or even "safe" suicidal gestures; nothing is 100 percent reliable), I urge you to try every alternative first---and then try them again. These include a variety of anti-depressant drug therapies, various flavors of psychotherapy, electroshock, and "reality therapy"---helping people worse off than you. Each of these will work for some; no single solution will work for everyone. That's why it's vital not to give up if one or two or three don't do much to decrease your pain. How do you know that suicide is the best solution if you haven't tried everything else first? You can always kill yourself later.

"Every person's fight with death is lost before it begins. What makes the struggle worthwhile, therefore, cannot lie in the outcome. It lies in the dignity with which the fight is waged and the way it finds an end." ---Joseph Fletcher

I've known several people who have killed themselves, and others who intended to, but waited too long. Three have been significant influences in writing this book:

One man had a series of small strokes and specified that if he had a major one he did not want so-called "heroic" measures used. Soon afterwards, he did suffer a massive stroke and was reduced to a vegetative state, kept alive contrary to his written instructions. His son, a physician himself, was appalled by the contravention of his father's instructions in a medically hopeless situation. Nevertheless it took weeks of argument and delay before the hospital agreed to act in accordance with their wishes.

Another man, 80 years old, entered a hospital intending to kill himself (he said) if he didn't get better. After four months and a series of operations, he became too weak and disoriented to act on his intention. He "lived" another four months in the hospital, progressively deteriorating both physically and mentally.

One young woman took a drug overdose, expecting that her housemates would return soon. They were delayed. I would like to believe that, had she known about less lethal methods, she would be alive today.

Chapter one: A brief overview of suicide.

"Most people, in committing a suicidal act, are just as muddled as when they do anything important under emotional stress. Carefully planned acts of suicide are as rare as carefully planned acts of homicide." --Erwin Stengel⁽⁸⁾

"Dying
is an art, like everything else.
I do it exceptionally well."

--Sylvia Plath, Lady Lazarus

"It seemed like a good idea...at the time."---Anon

Overview

Throughout the world, about 2000 people kill themselves each day. That's about 80 per hour, three quarters of a million a year.⁽⁹⁾ In the U.S., there are more than 80 deaths from suicide every day, 30,000 every year.⁽¹⁰⁾ This is the equivalent of a fully loaded jumbo jet crash every fifth day. From another perspective, you are more likely to kill yourself than be killed by someone else.^(11f)

Another estimated 300,000 (or more) Americans a year survive a suicide attempt.^(12f) A majority have injuries minor enough to need no more than emergency room treatment. However, about 116,000 are hospitalized, of whom 110,000 are eventually discharged alive. Their average hospital stay is 10 days; the average cost is $15,000.⁽¹³⁾

"...without knowledge of proper dosages and methods, suicide attempts are often bungled, leaving the victim worse off than before. Many intended suicides by gunshot leave the person alive but brain-damaged; drug overdoses that are not fatal may have the same effect. One eighty-three-year-old woman obtained an insufficient number of pills and lost consciousness but did not die; her daughter ended up smothering her with a plastic bag."⁽¹⁴⁾

Seventeen percent, some 19,000, of these people are permanently disabled---restricted in their ability to work---each year, at a cost of $127,000 per person.⁽¹⁵⁾ Such injury is tragic, either if someone were trying to kill herself and failed, or, perhaps even sadder, if the suicide attempt was intended as a "cry for help".

About 1.4% of Americans end their lives by suicide.⁽¹⁶⁾ This is the eighth leading cause of death in the U.S., and ranks fourth in years of lost life. The largest increase in the last 30 years has been among people between 15-24 years old, but the highest rates are still among the elderly. Men kill themselves at about four times the rate for women (19.8/100,000 vs 4.5/100,000 in 1994).^(17f) Around 3% of adults make one or more suicide attempts.⁽¹⁸⁾

There are more suicides than the official numbers show,^(19f) but there is no general agreement as to how many more. Estimates of under-reporting range from around 1% to 300%.⁽²⁰⁾ Reasons for under-reporting include:

(1) families or family physicians may hide evidence due to the stigma of suicide. For example, "Physicians and surviving relatives have told me in confidence of many deaths which were suicides, but which had been certified as natural or accidental deaths by a physician, either through error, misinformation, or deliberate falsehood....My own estimate is that there were an additional 10,000 deaths yearly [in the U.S.] which would have been certified as suicides if there had been complete and impartial investigations."⁽²¹⁾

(2) the determination of cause-of-death is judged by local standards, which vary widely. In one egregious instance, a coroner would cite suicide only in deaths where a suicide note was found---and suicide notes are only found in around one quarter of known suicides.⁽²²⁾

(3) there are lots of ambiguous situations, some of which are suicides, but which almost always end up classified as "accidental" or "undetermined" :⁽²³⁾ the single-car "accident"^(24f) with no skid marks; the "fall" off the night ferry; the "stumble" in front of the train; the "inadvertent" overdose; the gun-cleaning "mishap".^(25f)

(4) compared to the "accidental" or "undetermined" motive categories, there is a much larger number of deaths officially classified as "ill-defined and unknown causes of mortality,"^(26f) where even the actual cause of death is uncertain, and some of which are undoubtedly suicides.

(5) the frequency of physician-assisted suicide for the terminally ill is unknown, but, based on anecdotal evidence, is probably both substantial and increasing. More on this in "Assisted Suicide and Terminal Illness".

On the other side of the ledger, some doubtful cases are classified as suicides. These usually occur in institutions, such as prisons, hospitals, religious orders, and the military, which control their populations more-or-less completely. For such institutions a verdict of suicide is likely to be the least embarrassing (after "natural") cause of death: homicides must be investigated and a murderer sought; accidents may be the basis of negligence lawsuits.⁽²⁷⁾(28f)

The number of suicide attempts is also subject to dispute. Based on a range of studies, there are probably between 10-20 attempts for every suicide,⁽²⁹⁾ or roughly 300,000-600,000 attempts per year in the U.S. Yet more than half of suiciders kill themselves on their first try.⁽³⁰⁾ The overall 3-or-4-to-1 male-to-female suicide ratio in the U.S. is reversed for suicide attempts. Between 70% and 90% (studies differ) of suicide attempts are by medicine/drug overdoses, roughly 15% by wrist cuts.⁽³¹⁾

For adolescents, the attempt-to-fatality ratio may be 50:1;⁽³²⁾ but this average masks the fact that the death rate for boys is a hundred times higher than for girls: around 10 percent and 0.1 percent, respectively. About 11% of high school students have made at least one suicide attempt.⁽³³⁾ Ninety percent of adolescents' suicide attempts occur at home, and parents are home 70% of the time.⁽³⁴⁾

What is Suicide?

The numbers above refer to acts formally classified as suicides, but the more one thinks about it, the less clear the boundaries become. Should we include refusing medical treatment in a terminal illness? What about a suicidal gesture gone awry? How about martyrdom? And what of the "little suicides": the high-speed drag race, the drunk drive, the picking of a quarrel in a bar?^(35f) Among adolescents the combination of reckless (and inexperienced) driving with alcohol/drug use may be more dangerous than overt suicide attempts.⁽³⁶⁾

In Man Against Himself Karl Menninger compiled some 400 pages of self-destructive behavior, ranging from war to nail-biting. He divided these into three groups: "chronic" suicide includes alcoholism, martyrdom, psychiatric illness, and antisocial actions; "focal" suicide targets specific parts of the body, as in self-mutilation, or deliberate "accidents"; and "organic" suicide, where people supposedly lose their will to live and die of illness and disease that they would otherwise overcome. His list, and subsequent additions to it, has been called "slow suicide" or "suicide on the installment plan".⁽³⁷⁾

And there is the daily suicide of depression and apathy:

"A thousand people are `officially' dead of suicide every day, but they are not the only ones who are faced with the constant choice between life and death. We all are....We might lack the nerve to commit the final act, and we might not recognize our `sinful' tendencies for what they are, but day in and day out we confront the problem of our innate attraction to self-destruction. We live in a world that encourages the small daily acts of negation that prepare us for the great one. There are meanings of suicide that neither the courts nor the dictionaries admit, but that make it impossible for us to regard those thousand people a day who do themselves in as very different from us. They are not necessarily `sick' or `sinners', but simply our sisters and brothers. And who are we? We are the resigned housewives, the compulsive playboys, the despairing priests, the addicted teenagers, the reckless drivers, the bored bureaucrats, the lonely salesmen, the smiling stewardesses, the restless drifters, the walking wounded....It may be nothing more than the steadfast commitment to sameness. The simplest form of suicide is the act of refusing the adventures and challenges that offer themselves to us every day. `No, thanks,' we say. `I prefer not to,' we murmur, like Melville's Bartleby, preferring to stare at the wall outside the window. Preferring, as I do on especially bad days, to stay in bed." --James Carroll⁽³⁸⁾

If you play Russian roulette with a six-shooter, your odds of dying are one in six; if you climb Mt. Everest they're also about one in six.⁽³⁹⁾ The former is a generally-condemned form of suicide; what, then, is the latter?

Yet, "Life is impoverished, it loses in interest, when the highest stake in the game of living, life itself, may not be risked. It becomes as shallow and empty as, let us say, an American flirtation." --Sigmund Freud⁽⁴⁰⁾

As you can see, the topic of suicide is almost boundless.

Chapter 2 HISTORY

Death is before me today

Like the recovery of a sick man...

Like the longing of a man to see his home again

After many years of captivity...

---Man Disputing over Suicide with his Soul Egypt, ca. 2100 bc

The oldest known reference to suicide is Egyptian; a fragment is quoted above.⁽⁴¹⁾ There are seven suicides in the Old Testament;^(42f) none of them are criticized in that document. In the New Testament, the suicide of Judas seems to be implicitly condoned---it's mentioned without comment in Matthew 27:3---as a sign of his repentance; not until much later did the church claim that Judas' suicide was a greater sin than was his betrayal of Christ.

Early Christianity was strongly attracted towards suicide, perhaps because the act was often indistinguishable from martyrdom, and,

"...even the death of Jesus was regarded by Tertullian, one of the most fiery of the early Fathers, as a kind of suicide. He pointed out, and Origen^(43f) [another major early Christian theologian] agreed, that He voluntarily gave up the ghost, since it was unthinkable that the Godhead should be at the mercy of the flesh."⁽⁴⁴⁾

While early Christianity accepted suicide, it condemned killing of others, including warfare, self-defense, and capital punishment. After all, Jesus had taught non-violence: "Do not resist one who is evil. But if anyone strikes you on the right cheek, turn to him the other also....I say to you, Love your enemies and pray for those who persecute you."⁽⁴⁵⁾ This was taken seriously by the early Church Fathers, for example, Tertullian, who asked, "Can it be lawful to handle the sword, when the Lord himself has declared that he who uses the sword shall perish by it?"⁽⁴⁶⁾

However, as Christianity became the dominant religion in the Roman empire, its views on suicide gradually changed, until suicide became a religious sin and a secular crime in the sixth century. In 533, Christian burial (a requirement for getting into heaven) was forbidden to suicides who killed themselves while accused of a crime. In 562 this was extended to all suicides, regardless of the reason or circumstances. In 693 even attempting suicide became an ecclesiastical crime punishable by excommunication, with civil consequences to follow.

St. Augustine, in the fifth-century book The City of God, was the first Christian to make a blanket condemnation of suicide. His only biblical justification for the change was a novel interpretation of the sixth commandment, "Thou shalt not kill"; his other reasons were, as Rousseau noted, taken from Plato's Phaedra.^(47f)(48f)

Ironically, this well-intentioned and humanitarian opposition to suicide eventually degenerated into "...legalized and sanctified atrocities, by which the body of the suicide was degraded, his memory defamed, his family persecuted."⁽⁴⁹⁾ Suicides were buried at crossroads with a stake through their bodies,^(50f) and their property confiscated by the State. Perhaps the ultimate irony was the execution of people for the crime of attempting to commit suicide. A Russian exile in England, Nicholas Ogarev, wrote,

"A man was hanged who had cut his throat, but who had been brought back to life. They hanged him for suicide. The doctor had warned them that it was impossible to hang him as the throat would burst open and he would breathe through the aperture. They did not listen to his advice and hanged their man. The wound in the neck immediately opened and the man came back to life again although he was hanged. It took time to convoke the aldermen to decide the question of what was to be done. At length the aldermen assembled and bound up the neck below the wound until he died. Oh my Mary, what a crazy society and what a stupid civilization."^(51f)

We have progressed far beyond such barbarism, and no longer condemn failed suicides. Now, for example, if a death-row criminal attempts suicide, every effort is made to save him (or, rarely, her), so that a civilized, state-approved execution can be carried out.

Non-Christian societies had a wide range of views about suicide. Buddhist, Confucian, and Shintoist ethics accepted suicide and euthanasia in cases of incurable illness. The Vikings felt that Valhalla, with its perpetual Feast of Heroes and Gods, was reserved for warriors who died in battle. Suicides were second-best and might get to sit below the salt; people who died in bed could eat with the kitchen help and sleep in the barn.^(52f)

Similarly, the Scythians considered it an honor to commit suicide when they could no longer keep up on their nomadic travels, while "death, passively awaited, is a dishonor to life."⁽⁵³⁾

Various Greek philosophical schools of thought rejected (Pythagoreans, Aristotle), conditionally accepted (Plato, Epicureans) or approved of (Stoics, Zeno) suicide. The Romans followed the Greek lead in these matters, particularly that of the Stoics. "To the Romans of every class, death itself was unimportant. But the way of dying---decently, rationally, with dignity and at the right time---mattered intensely."⁽⁵⁴⁾

The early Christians agreed that death was unimportant, but for entirely different reasons: they wanted to go to the glory of heaven and saw no good reason on earth to wait. Life was a gateway, filled with sins, snares, and temptations, all leading to eternal damnation. Thus they often invited persecution as a path to martyrdom, which automatically wiped the slate of any old sins, prevented new ones, and guaranteed a seat in paradise. This was carried to its logical conclusion by a sect known as the Donatists, of whom St Augustine said, "...to kill themselves out of respect for martyrdom is their daily sport."⁽⁵⁵⁾ They were noted for jumping from cliffs, and also burned themselves to death in large numbers. They are probably best known for their practice of stopping travelers and either paying them or threatening them with death to encourage them to kill the, presumably, heaven-bound martyr. The Donatists were eventually declared heretics and suppressed with a notable lack of Christian charity.^(56f)

Much later, the thirteenth-century Albigensian (aka Catharist) heretics in southern France were slaughtered with incredible savagery, also, in part, because they sought martyrdom. This sin compounded their damnation for other theological errors---for example, they had the temerity to believe that religious orders should actually practice their vows of poverty. Not until the late renaissance---a thousand years after Augustine---did people again dare, very cautiously, to argue the case for suicide in Christian Europe.

By the sixteenth century Roman and Greek philosophy had been rediscovered and the unconditional condemnation of suicide was being questioned. In Holland, Erasmus wrote In Praise of Folly (1509), in which he defended suicide which was committed to escape an unendurable life. Soon afterwards Sir Thomas More, in his fictional Utopia (1516), proposed suicide for the purpose of euthanasia:

"They console the incurably ill by sitting and talking with them and by alleviating whatever pain they can. Should life become unbearable for these incurables the magistrates and priests do not hesitate to prescribe euthanasia....When the sick have been persuaded of this, they end their lives willingly either by starvation or drugs, that dissolve their lives without any sensation of death. Still the Utopians do not do away with anyone without his permission, nor lessen any of their duties to him."⁽⁵⁷⁾

Shakespeare (1564-1616), always theatrically pragmatic, portrayed fourteen suicides in his eight tragedies without condemning them, asking instead, "Then is it sin / To rush into the secret house of death / Ere death dare come to us?"⁽⁵⁸⁾

John Donne wrote the first English defense of suicide, Biathanatos, in 1608, but had second thoughts (as well as a job, Dean of St. Paul's, that required staying on good terms with the Church) and found it expedient to wait until after his death to have it published, in 1644. Other justifications of suicide followed.

In the eighteenth century, the "Age of Reason", traditional beliefs were re-examined from a rational, empirical, and skeptical perspective. Theological arguments against suicide were challenged, suicide was claimed to be a human right, and the subject became a secular matter as much as a religious one.

Of course, the traditional views had many defenders. For example, the renowned religious leader John Wesley (1703-1791) said, with dubious logic, that failed suicide attempters should be hanged. Similarly, the eminent legal authority William Blackstone (1723-1780) asserted that suicide was a crime against both God and King. And the illustrious philosopher Immanuel Kant, whose writings remain unsurpassed in incomprehensibility, used suicide as an example of moral error that could be demonstrated with his logical rapier, the categorical imperative.⁽⁵⁹⁾

During this time, the brutal treatment of suicidal people eased in some parts of Europe. For example, the laws against suicide were relaxed in France at the time of the French Revolution; and the Prussian penal code of 1794 (influenced earlier by the "liberal" monarch, Frederick the Great, and then by the French Revolution) did not punish attempted suicide. In England, however, trying to kill oneself remained a felony until 1961 (and was only de-criminalized to encourage people to seek treatment), and anyone aiding, abetting, or counseling a suicide or attempted suicide is still subject to 14 years imprisonment.⁽⁶⁰⁾

The Romantics of the late eighteenth and early nineteenth centuries (Byron, Keats, and Shelley in England, Lermontov in Russia, Chateaubriand and Lamartine in France, Novalis and Goethe in Germany^(61f)) went further, and glorified suicide as the heroic last act of a free man.

Thus, from antiquity into the 19th century, suicide was mostly a philosophical, ethical, religious, and legal issue; the concern was: under what circumstances might it be forbidden, acceptable, or even desirable? Starting in the early 1800s, it gradually became a sociological/statistical inquiry and a psychological one: who killed themselves and why they did so.^(62f) The focus changed from philosophy and theology to the social conditions and personality traits associated with suicide.

More recently, with the advent of "anti-psychosis" drugs, such as Thorazine, in the 1950s, the concept of a biochemical basis for behavior has become increasingly persuasive.

One of the effects of these changes has been to largely remove suicide from the category of "moral crime." Instead, the fault has been shifted onto society, mental illness, or biochemical imbalance, things for which an individual can hardly be blamed.^(63f)

Thus, if suicide is involuntary and beyond an individual's control, rational or moral arguments against it will be useless. The only moral question, then, will be that of intervention, abstention, or assistance by individuals or society-at-large.

While today most people still consider suicide an abnormal, destructive behavior^(64f) that should be prevented (except, perhaps, with the terminally ill), its failure is no longer punished---or is it rewarded?---by death. And so we progress.^(65f)

Chapter 3: Three ways to study suicide

Sociology, Psychiatry, and Biology^(66f) offer three different lenses currently used to study suicide-as-a-pathology.

Sociology

The sociological perspective looks at society's influence on its members; how do various social conditions (and their changes) affect suicide rates. Examples of such social variables are income, unemployment rate, birth order, gun ownership, divorce, and immigration. As its most eminent early proponent, Emile Durkheim, said, "social facts must be studied as things, as realities external to the individual."[Suicide, pp37-8]

The sociological/statistical study of suicide actually began in the 1820's with research by Jean-Pierre Falret in France, and Johann Casper in Germany. Durkheim organized the earlier work and integrated it into a theoretical framework in the late 1800s. His ground-breaking book Suicide: A Study in Sociology was published in 1897.

Durkheim felt that the Industrial Revolution had massively disrupted Western communities. As a result, people who didn't have the structure of ties to family or religion became particularly susceptible to suicidal urges. He called suicide due to such social disintegration "anomic".

In other societies the individual is so highly integrated into the community that his life and behavior are tightly governed by the community's customs. In these circumstances, most suicide occurs because it is expected---almost required---rather than from personal sorrow or guilt.

Examples of such "altruistic" suicide include the Indian custom of suttee where widows (but not widowers) burn themselves to death; Japanese seppuku or hara-kiri where ritual disembowelment (sometimes followed by coup-de-grace decapitation) prevents, or atones for, dishonor. Among military officers in nineteenth-century Europe, suicide-by-pistol was the expected response to inability to pay gambling debts. Suicide by groups seeing themselves as persecuted also falls into this category; the Branch Davidians (Waco, Texas, 1993) for example, or the members of the People's Temple at Jonestown (Guyana, 1978), who held suicide "rehearsals".⁽⁶⁷⁾

Durkheim's third category, "egoistic" suicide, describes individuals who lack involvement with their reasonably stable societies. Such people are often "misfits" or "criminals". A prototypic example might be an unemployed, isolated, man or woman living alone in a rooming house.

Sociology's forte is the statistics of suicide. Its self-acknowledged limitation is that it doesn't tell us anything about why one person kills himself while another person, in similar circumstances, doesn't.

One other weakness of this method was that it offers no good explanation of cultural and national differences. For example, if, as frequently claimed, Catholic countries have lower suicide rates than Protestant ones because Catholicism is the more cohesive religion, why does Catholic Hungary usually have the highest suicide rate in Europe, and, often, in the world?

The suicide rate in Hungary, for various age groups, [see Table V-4, Website Appendix]
is anywhere between 5 and 25 times the corresponding rate in nearby Greece. And, the suicide rate of countries bordering Hungary is highest in the regions near Hungary, and those with large Hungarian populations.^(68f)(69)

Sometimes there are extraordinary or temporary circumstances that lead to a high suicide rate. In the 1990s Sri Lanka, in the midst of a protracted civil war, has had unusually high rates. However, Greenland (127 per 100,000 population in 1987) has the highest rate in the world.⁽⁷⁰⁾ This has been attributed to the cultural and social disintegration of the native Inuit population in the face of well-meaning Danish paternalism.

Psychology and Psychiatry

The psychological/psychiatric approach rose to prominence a bit later than the sociological one, at the end of the nineteenth and beginning of the twentieth centuries. It emphasizes and examines the individual, and the conflicts within a particular mind leading to self-destructive behavior.

"When we learn that the most densely populated parts of the world have the highest incidence of suicide, and that suicides cluster in certain months of the year, do we thereby learn a single adequate, explanatory motive?" asked psychoanalyst Alfred Adler in 1910. "No, we learn only that the phenomenon of suicide is also subject to the laws of great numbers, and that it is related to other social phenomena. Suicide can be understood only individually, even if it has social preconditions and social consequences."⁽⁷¹⁾

While people with diagnoses of "depression" or "schizophrenia" or "psychosis" have suicide rates five to fifteen times that of the general population, the vast majority of those so-diagnosed do not attempt suicide. One limitation of the psychological strategy is the inability of experts to reliably predict who will carry out suicides and suicide attempts, even among the highest-risk groups.

"Robert Litman...believes that suicide-vulnerable individuals move in and out of periods of suicidal risk---sometimes for brief periods, sometimes for moderate or long periods---as their life circumstances fluctuate. But of all those people who enter that zone, very few actually kill themselves. "For every hundred people at high risk," he says, "only three or four will actually commit suicide over the next couple of years....It's like a slot machine....You can win a million dollars on a slot machine in Las Vegas, but to do that, six sevens have to line up on your machine. That happens only once in a million times. In a sense it's the same with suicide." Those spinning sevens represent all the biological, sociological, psychological, and existential variables that are associated with suicide---broken family, locus of control, decreased serotonin [a chemical found in the brain], triggering event, and so on. "In order to commit suicide, a lot of things have to fall together at once, and a lot of other things have to not happen at once," says Litman. "There's a certain random element determining the specific time of any suicide and, often, whether it happens or not....It's as if you need to have six strikes against you...and we're all walking around with one or two or three strikes. Then you have a big crisis and you have four strikes. But to get all six really takes some bad luck." "⁽⁷²⁾

Hopelessness about the future seems to be a better predictor for suicide than is depression.⁽⁷³⁾ For example, in one group of 207 suicidal patients, 89 were ranked high on a widely used "hopelessness" scale. Thirteen of fourteen suicides within the next five years came from this subgroup, even though only half of them had a diagnosis of depression.⁽⁷⁴⁾ Nevertheless 76 of these 89 did not kill themselves, underscoring the difficulty in predicting suicidal behavior, even the highest-risk groups.

Indeed, in one study a computer program was better at identifying people who would attempt suicide than was a group of experienced clinicians. To add insult to injury, half of the patients preferred "talking" with the computer to talking with the human interviewers.⁽⁷⁵⁾

Another issue is that there is dispute as to what extent, if any, various schools of psychological therapy are effective. For example, in one study psychotherapy was found to be counterproductive with those who had attempted suicide.^(76f)(77) Other studies have been equivocal. Current expert opinion seems to be that psychotherapy is about as effective as drug therapy for mild to moderate depression, but significantly less so for more severe cases.⁽⁷⁸⁾

Biology

(3) The biological view sees physical disorders, often a biochemical imbalance, as the "cause" of suicide and other psycho-pathological problems, like schizophrenia. This concept was articulated by Emil Kraepelin, a German contemporary of Freud's. It didn't gain wide acceptance for a half century, largely because the biochemical tools for testing it were lacking.

In suicide, the biochemical problem often seems to be associated with a low level of the chemical nerve-impulse transmitter, serotonin, in the brain. Treatment consists of repairing or overcoming the original neurochemical imbalance. Some drugs increase serotonin levels and are used as anti-depressants with moderate, but increasing, effectiveness.

Some evidence for, and limitations of, the biological model are:

(a) Studies on twins provide the most persuasive evidence of a biological basis for suicide. In two investigations of suicide among twins, the identical twin of a suicide also killed himself in 19 percent of the cases (22 out of 118), while there were no instances (0 out of 254) where the fraternal [non-identical] twin of a suicide had done so.⁽⁷⁹⁾

(b) Suicide tends to run in biological families. Adoption data show a significantly greater frequency of suicide among the biological relatives of suicides than among adoptive relatives. In a study of Danish adoptees diagnosed with depression, there were 15 suicides among 387 biologic relatives while only one suicide occurred in 180 adoptive relatives. Similarly, there were 12 suicides among 269 blood relatives of 57 adoptees who had killed themselves; there were no suicides among their 150 adoptive relatives.⁽⁸⁰⁾

This is not to say that there is a "suicide gene". But there are statistical associations between depression, aggression, and suicide, and depression clearly has a genetic component: for example, in 57% of identical twins studied, if one twin had major depression, so did the other.⁽⁸¹⁾

This evidence for a biological tendency to suicide is convincing. Yet even among identical twins, in more than four out of five instances the suicide of one twin was not followed by the suicide of the other. Tendency is not fate.

(c) Studies on brain tissue and cerebro-spinal fluid (CSF) show that many people who kill themselves, especially those who use violent methods, have low levels of a brain tissue chemical neurotransmitter, serotonin, and its metabolic breakdown product, 5-hydroxyindoleacetic acid (5HIAA). "Lower levels of 5-HIAA in CSF have been found to predict a 10-20 times higher mortality from suicide within 1 year after discharge from the hospital."⁽⁸²⁾ Especially interesting is the fact that whether the psychiatric diagnosis was depression, alcoholism, schizophrenia, or personality disorder, low 5HIAA was associated with significantly more of the suicides and suicide attempts, as well as other violent or impulsive behavior. In this model, lower CNS serotonin levels makes people more aggressive and impulsive, and thus increases the effects of stress, depression, and psychosis.

Moreover, the types of anti-depressant drugs that increase serotonin levels are generally more effective in decreasing both suicidal thoughts and suicide attempts, than are other anti-depressants that work by different mechanisms.⁽⁸³⁾

There are also animal data that link aggression with low serotonin levels. For instance, blocking the formation of serotonin causes tame house-cats to become ferocious, and nursing rats to bite their pups to death.⁽⁸⁴⁾

The 5HIAA hypothesis is not universally accepted. There are methodological criticisms.⁽⁸⁵⁾ Some studies have failed to find any connection between suicide and 5HIAA; and most have found little or no correlation of 5HIAA levels with non-violent suicide. This murky picture should not be entirely surprising, since "suicide" lumps together groups as diverse as depressed teenagers, prisoners, alcoholic adults, political protesters, and the terminally ill. Most suicide is probably due to the interaction of multiple factors. Even if 5-HIAA is one of them, it may be overcome or augmented by others. Finally, it's not clear that even if there is a relationship between low 5HIAA and suicide, violence, or impulsiveness, whether the low 5HIAA level is a cause of the behaviors, an effect of the behaviors, or is the result of some other yet-undiscovered factor.

One supposed problem with the serotonin model is that there are a number of places, like Denmark, Switzerland, and Japan, that have low rates of outwardly-directed violence (e.g. homicide) along with high rates of suicide. A possible explanation for this is that there are cultural factors that influence whether violent impulses manifest themselves as suicide or as homicide. An alternative view, that suicide is associated with prosperity, is discussed later.

A more significant weakness of the biological model as the prime mover in suicide is its difficulty in explaining the sometimes-large changes in suicide rates seen over short periods of time. For example from 1958 to 1978 the suicide rate for Americans 15-24 years old went from about 4 per 100,00 to about 14 per 100,000, an increase of roughly 250 per cent.

The suicide rate in Norway was an almost constant 7 per 100,000 from 1876, when central records were first collected, until about 1966.⁽⁸⁶⁾ It then increased 112 percent (from 7.3 to 15.5 per 100,00 between 1960-4 and 1990), while that of England decreased by 36 percent (11.7 to 7.5 per 100,000 between 1960-4 and 1991) and Ireland increased 170 percent (from 2.7 to 7.4 per 100,000 between 1971 and 1988). A convincing biological explanation is not obvious.

An interestingly different perspective is provided by some evolutionary biologists, who note the persistence of suicide (about 1 percent of all deaths) across culture and time. While such behavior may seem counter-productive in a simple Darwinian sense---if you're dead, you probably won't be passing on too many more genes---they argue that this may represent (like altruism), a trait that has evolutionary benefits.

They suggest that suicide may be the sometimes-inappropriate expression of an instinct for self-sacrifice for the good of surviving relatives, who do pass on the deceased's genes. We see other forms of this in, say, parents perishing to save their children from danger, or old people killing themselves to leave more resources for their families.

Consistent with this, psychiatrists have noted that many people who are considering suicide think of it in altruistic terms, as the best thing for their family and friends.

"If you talk to people immediately after they made a serious suicide attempt, they'll have a very altruistic explanation for what they did," says Dr. David C. Clark. "They believed it was the wise, clever and thoughtful thing to do."⁽⁸⁷⁾

An alternate view is that the tendency for depression, rather than "suicide", is the behavior selected for. In this picture, depression is useful because it forces people to contemplate and, presumably, learn from their mistakes. Suicide is, in this model, due to an excess of that process. Unfortunately (for the model), most patients with "major depression" never attempt suicide, and suicide rates for people with other diagnoses (e.g. schizophrenia, or substance abuse) are comparable to those with major depression.

Other researchers claim that traumatic or premature births are highly correlated with later suicide⁽⁸⁸⁾ and even with the suicide method employed.⁽⁸⁹⁾ There is both human and other animal evidence for each of these views, but they are not more convincing than other explanations.^(90f)

While it simplifies the picture, it may be counter-productive to limit one's understanding of suicide to "biology" or to "sociology" or to "psychiatry". There have been attempts to integrate some of these ideas under the label "suicidology." For example, Jack Douglas, in The Social Meanings of Suicide, argues that how the individual sees and interprets sociological situations determines their effects on her; a biologist might tack on a biochemically-caused tendency toward impulsivity or violence. But, for the most part, we're still in the same position as the apocryphal blind men each describing a different part of an elephant: each discipline tends to see suicide through its own filters and biases, and there is, as yet, no adequate synthesis.

Chapter 4: Why people attempt suicide

"Let them think what they liked, but I didn't mean to drown myself. I meant to swim till I sank---but that's not the same thing." --Joseph Conrad

"In a real dark night of the soul it is always three o'clock in the morning." ---F. Scott Fitzgerald

"To be or not to be: that is the question."---William Shakespeare

Thousands of books have tried to answer the question of why people kill themselves. To summarize them in three words: to stop pain. Sometimes this pain is physical, as in chronic or terminal illness; more often it is emotional, caused by a myriad of problems. In any case, suicide is not a random or senseless act, but an effective, if extreme, solution.

A slightly more elaborate list of some reasons people commit or attempt suicide follows. The categories are arbitrary and overlap to some degree. However, this is just an outline, and there is no lack of books that discuss suicidal motivation in much more detail and from many different perspectives.

(1) Altruistic/Heroic suicide. This is where someone (more-or-less) voluntarily dies for the good of the group. Examples include the Greeks at Thermopolae; the Japanese kamikaze pilots^(91f) at the end of WWII; the Buddhist monks and others who, starting in 1963, burned themselves to death trying to stop the Viet-Nam war;^(92f) elderly Inuit (Eskimos) killing themselves to leave more food for their families; some Communists who confessed to invented (and often impossible) crimes during the Purge Trials of the late 1930s and early 1950s. Gandhi's tactic of hunger strikes, called "satyagraha" or "soul force", would have fallen into this category, had the British authorities failed to respond to his demands.^(93f)

(2) Philosophical suicide. Various philosophical schools, such as stoics and existentialists, have advocated suicide under some circumstances.⁽⁹⁴⁾

(3) Religious suicide. There is a long history of religious suicide, usually in the form of martyrdom. This was widespread in the early years of Christianity and was also commonly seen in the various "heresies" uprooted before and during the Reformation, Counter-Reformation, and Inquisition. More recent examples may include members of the Solar Temple in Switzerland, France, and Canada, the San Diego Hale-Boppers in March, 1997, the Branch Davidians in Waco, Texas, and some of the people at Jonestown, Guyana.

(4) Escape from an unbearable situation. This may be persecution, a terminal illness, or chronic misery. There is no lack of historical examples:

Epidemics of suicide were frequent among Jews in medieval Europe; (sometimes they were given a choice between converting to Christianity and death).^(95f) Later, both Indian and black slaves in the New World committed mass suicide to escape brutal treatment. One slave owner supposedly stopped such desertion among his slaves by threatening to kill himself and follow them into the next world, and impose worse repression there.⁽⁹⁶⁾

There were large numbers of suicides during times of pestilence in medieval Europe. More recently, AIDS has generated a similar response among many of its victims.

There was also a wave of suicides among priests and their wives around 1075, after Pope Gregory VII imposed celibacy on the clergy, who had previously been allowed to marry.⁽⁹⁷⁾ Marriage had been only slightly more popular than damnation with the Church ("It is better to marry than to burn."), but had been accepted for its first thousand years.

A significant number of killers commit suicide. Four percent of 621 consecutive murderers later killed themselves;⁽⁹⁸⁾ and about 1.5 percent of suicides follow murders.⁽⁹⁹⁾

All of these situations can be readily seen as more-or-less "unbearable". However, sometimes "unbearable" means failing an exam, or missing a free throw in the big game. As George Colt notes,

"Most adolescent depression is caused by a reaction to an event---a poor grade, the loss of a relationship---rather than a biochemical imbalance....Feeling blue after not getting into one's first-choice college is as appropriate as feeling happy after scoring a winning touchdown. But many adolescents who experience depression for the first time don't realize that it won't last forever."⁽¹⁰¹⁾

Or, as an anonymous teenager said, "It sounds crazy, but I think it's true---kids end up committing suicide to get out of taking their finals."⁽¹⁰²⁾

(5) Excess alcohol and other drug use. The observed high correspondence between alcohol and suicide^(103f)(104) can be explained in several ways, including: (a) Alcoholism can cause loss of friends, family, and job, leading to social isolation. (This may be a chicken-and-egg question; it's equally plausible that family or job problems induce the excess alcohol use. In its later stages, the fact and consequences of alcoholism dominate the picture and are often blamed for everything.); (b) Alcohol and suicide may both be attempts to deal with depression and misery; (c) Alcohol will increase the effects of other sedative drugs, frequently used in suicide attempts; (d) Alcohol may increase impulsive actions.

The significance of the last two points is emphasized by findings that alcoholic suicide attempters who used highly lethal methods scored relatively low on suicidal-intent tests. The correlation between lethal intent and method was found only among non-alcoholics.⁽¹⁰⁵⁾

Thus, to claim that alcoholism "causes" suicide is simplistic; while the association of alcohol excess with suicide is clear, a causal relationship is not. Both alcoholism and suicide may be responses to the same pain. "A man may drown his sorrows in alcohol for years before he decides to drown himself."⁽¹⁰⁶⁾

(6) Romantic suicide. "My life is not worth living without him". This is most celebrated among the young, as in Romeo & Juliet, but is probably most frequent among people who have lived together for many years, when one of them dies.

Suicide pacts (dual suicide) constitute about 1% of suicides in western Europe.⁽¹⁰⁷⁾ Most often, their participants are over 51 years old---except in Japan, where 75% of dual suicides are "lovers' pacts."⁽¹⁰⁸⁾

(7) "Anniversary" suicide is characterized by use of the same method or date as a dead loved one, usually a family member. "Imitative" suicide is similar to anniversary suicide in its focus on the dead, but uses a different date and method.

(8) "Contagion" suicide.⁽¹⁰⁹⁾ This is where one suicide seems to be the trigger for others, and includes "cluster" and "copycat" suicides, most often among adolescents.⁽¹¹⁰⁾ For example, on April 8, 1986, Yukiko Okada, 18, jumped to her death from the seventh floor of her recording studio. She had recently received an award as Japan's best new singer. Media attention was intense. 33 young people, one nine years old, killed themselves in the next 16 days, 21 by jumping from buildings.⁽¹¹¹⁾

There are comparable examples from many parts of the world. The highly publicized suicide of a Hungarian beauty queen was followed by a epidemic of suicides by young women who used the same method.⁽¹¹²⁾

Similarly, there was a spate of ethylene glycol (automobile antifreeze) intentional poisonings in Sweden following two accidental fatalities and "spectacular attention in the Swedish mass media."⁽¹¹³⁾

In the U.S. there have been clusters of suicides, most often (or most often reported) among high school students, but not necessarily using identical methods.⁽¹¹⁴⁾ Even fictional accounts may be enough, as in a claimed spurt of "Russian roulette" deaths shortly after the release of the film The Deer Hunter, with its powerful and nihilistic Russian roulette scene.⁽¹¹⁵⁾

On the other hand, other studies found no linkage between most newspaper reports and suicides.⁽¹¹⁶⁾ Nor do copy-cat suicides occur consistently. For example, the 1994 death of Nirvana lead singer Kurt Cobain was not followed by a cluster of suicides.⁽¹¹⁷⁾ In the seven weeks following his death there were 24 other suicides in the Seattle area, compared with 31 in the corresponding weeks of the previous year.

(9) An attempt to manipulate others. "If you don't do what I want, I'll kill myself," is the basic theme here. However, the word "manipulative" does not "...imply that a suicide attempt is not serious....fatal suicide attempts are often made by people who are hoping to influence or manipulate the feelings of other people even though they will not be around to witness the success or failure of their efforts."⁽¹¹⁸⁾ Nevertheless, while people sometimes die or are maimed from their attempts, the intention in this case is to generate guilt in the other person, and the practitioner generally intends a non-fatal result.

(10) Seek help or send a distress signal. This is similar to "manipulative" suicide except that there may be no specific thing being explicitly sought; it's the expression of too much pain and misery. This may occur at any age, but it is more frequent in the young. However, "Parents may minimize or deny the attempt. One study found that only 38 percent of treatment referrals after an adolescent attempt were acted on. Another found only 41 percent of families came for further therapy following an initial session. `It's often difficult to get parents to acknowledge the problem because they are the problem,' says Peter Saltzman, a child psychiatrist."⁽¹¹⁹⁾

(11) "Magical thinking" and punishment. This is associated with a feeling of power and complete control. It's a "You'll be sorry when I'm dead" fantasy. An illustration is the old Japanese custom of killing oneself on the doorstep of someone who has caused insult or humiliation. This is similar to "manipulative suicide", but a fatal result is intended. It's sometimes called "aggressive suicide." In a power struggle, if you can't win you can at least get in the last word by killing yourself.

(12) Cultural approval. Japanese (like Roman) society has traditionally accepted or encouraged suicide where matters of honor were concerned. Thus, the president of a Japanese company whose food product had accidentally poisoned some people killed himself as an acknowledgment of responsibility for his company's mistake.

It's almost unheard-of to find an American CEO who has voluntarily resigned on account of his company's misdeeds, let alone one who has committed suicide because of them. In Japan, 275 company directors killed themselves in a single year, 1986 (albeit for a variety of reasons).⁽¹²⁰⁾

(13) Lack of an outside source to blame for one's misery. J.F. Henry and A.F. Short present evidence that when there is an external cause of one's unhappiness, the extreme response is rage and homicide; in the absence of an external source, the extreme response tends to be depression and suicide.⁽¹²¹⁾ Thus, while marriage and children are associated with a lower suicide rate, they are also correlated with a higher homicide rate.

Henry and Short also suggest that, as economic quality-of-life improves, homicide should decrease and suicide increase. Long-time suicide researcher David Lester found such a correlation when comparing 43 countries;⁽¹²²⁾ and also when comparing American states.⁽¹²³⁾

However, national data are contradictory: it's easy to find countries with low suicide and low homicide rates (e.g. Great Britain and Greece); or high rates of both (e.g. Finland and Hungary). Furthermore, recent multi-national increases in suicide rates are roughly matched by similar increases in homicide.

In addition, there are high rates of both suicide and homicide in prison. Most jail (short-term) and prison (longer-term) suicide rates have been reported between 50 and 200 per 100,000 per year, while the age-matched male rate in the general population was around 25. Jail suicide is more frequent than prison suicide.⁽¹²⁴⁾

Still, the Henry-Short hypothesis can be used to explain some counter-intuitive facts, such as the low suicide rate among Nazi concentration camp inmates,^(125f)(126) among African-Americans,^(127f) and during wartime; though, as Erwin Stengel observed, "It is a melancholy thought that marriage and the family should be such effective substitutes for conditions of war..."⁽¹²⁸⁾

(14) Other. Most suicides have multiple causes.⁽¹²⁹⁾

Consider, for example, an existentialist with a serious illness who is devastated by a recent divorce and consequently suffering from "clinical major depression". He has a prescription for anti-depressant medication which makes him feel well enough to go out of the house. He goes to a bar, gets drunk, comes back and shoots himself with a loaded gun he kept in the bedroom. None of his neighbors responds to the noise and he bleeds to death. What "caused" his death: physical illness, philosophy, divorce, depression, medication, alcohol, availability of a gun, or social isolation? Or, perhaps, none of the above: from a slightly different perspective, none of these factors caused the suicide; rather it is the pain associated with them (along with the unwillingness to bear it) that precipitates suicide.⁽¹³⁰⁾

"Reasons" cited for suicide change with the times. Dr. Forbes Winslow wrote in 1840 that the increase in suicide was due to socialism, and particularly, Tom Paine's Age of Reason. Additional causes he cited were "atmospheric moisture" and masturbation, "a certain secret vice which, we are afraid, is practised to an enormous extent in our public schools." He recommended cold showers and laxatives.⁽¹³¹⁾

The question of intent in suicide attempts

"The survivor of a suicide attempt act is regarded by the public as either having bungled his suicide or not being sincere in his suicide attempt intention. He is looked upon with sympathy mixed with slight contempt, as unsuccessful in an heroic undertaking. It is taken for granted that the sole aim of the genuine attempt is self destruction, and therefore the dead are successful and the survivors unsuccessful."---Erwin Stengel⁽¹³²⁾

People who carry out acts lumped together as "suicide attempts" actually have a variety of motives, and combining various intents masks important differences. According to Louis Dublin, a respected statistician, almost a third fully intend to kill themselves; fewer than half of these succeed. Those that fail generally do so because of unexpected rescue, or, more often, mistakes in planning or knowledge. These people tend to use generally-lethal methods (guns, hanging, drowning, jumping) and are disproportionately older and male.⁽¹³³⁾

Another third clearly do not want to die. Their suicide attempt, more aptly called a "suicidal gesture", is a cry for help or attention. They're trying to change their circumstances or to influence important people in their lives, usually parents, spouse, or lover. They make every effort to be saved, often scheduling the attempt to coincide with the expected return of a would-be rescuer.

Of course, rescuers are sometimes delayed--or uninterested. Forensic texts provide some charming examples. In one case a woman took an overdose of barbiturates and pinned a note to herself saying, "If you love me, wake me up." Her husband came home around 10 p.m., saw the note, tossed it into the trash, and went out to a bar. When he returned early next morning, she was dead. The official cause of death was suicide. Criminal charges of homicide were considered, but not filed.⁽¹³⁴⁾

These suicide "attempters" are more likely to be younger and female, and use less lethal means than the first group, most frequently drug overdoses and wrist cutting. Note that a "failed" suicide attempt in this group is one in which the person dies, which is the opposite of failure in the previous group.

The last third are people tossing the dice. They are in such emotional pain, rage, or frustration that they don't much care if they live or die, as long as the pain stops. They tend to be impulsive, not plan carefully (if at all), and leave their survival to chance.⁽¹³⁵⁾ In another study, of 500 suicide attempts, only 4% were described as "well-planned"---but only 7% turned out to be more-or-less harmless.⁽¹³⁶⁾

The relationship between the seriousness of someone's intent to kill herself and the lethality of the attempt is controversial. While it would seem intuitively plausible that the more seriously one intended to die the more lethal the resulting suicide attempt would be, numerous studies have reached contradictory conclusions: some have found an association, others have not.⁽¹³⁷⁾

The debate is more than academic. If the connection between serious intent and lethality of attempt is real, it implies that suicide prevention strategies that focus on decreasing the availability of lethal methods (e.g. gun-control laws) will fail, because people wanting to die will simply switch to other, similarly lethal, methods such as hanging.

If, on the other hand, there is no good correlation between intent and lethality, then a decrease in the availability of lethal methods will be effective in decreasing suicides, because serious (but not fully rational) attempters will tend to switch to methods of lesser lethality.

Other evidence suggests a third possibility, that impulsivity or depression might have the best correlation with use of lethal methods; and that these in turn, are associated with neuro-chemical imbalance.⁽¹³⁸⁾

And we find ourselves back to the biological issues raised in chapter 3.

Chapter 5: Youth Suicide

"I want to kill myself, but I don't want to be dead."

--a 15 year old

"Most things, except agriculture, can wait."

--Jawaharlal Nehru

Teenagers attempt suicide roughly 10 times more frequently than adults, although their fatality rate of 11.1 per 100,000 people is about the same as adults'. This is the third leading cause of death among 15-19 year-olds. For this age group, there were 5,174 motor-vehicle deaths in 1994, compared to 1,948 suicides.

According to U.S. national data released in September 1991, about one million teens (out of about 25 million) attempt suicide each year, of which an estimated 276,000 sustained injuries serious enough to require medical treatment.⁽¹³⁹⁾

Some other estimates (these are total, not per-year) are considerably higher: 3% of elementary-school, 11% of high-school, and 17% of college students. However, "Most were low-lethality attempts for which medical or other attention was not sought. Accordingly, the vast majority of [these] suicide attempts will not be uncovered by investigations dealing solely with clinical or medically identified populations."⁽¹⁴⁰⁾ Thus, estimates or calculations of teenage suicide-attempt rates are particularly unreliable.

About four times more girls than boys make suicide attempts, but boys are much more likely to die: about 11% of (reported) males' attempts were fatal, compared to 0.1% of females', a ratio of more than 100:1.⁽¹⁴¹⁾ This also gives a ballpark average of about 50 attempts for every fatality in this age group.

This low fatality rate might be taken to mean that most of these adolescents don't want to kill themselves (true) and that there is generally one or more "warning" attempts before a lethal one (not true). In a study from Finland, only 30 percent of male, and 68 percent of female suicides 13 to 22 years old had made a previous (known) suicide bid.⁽¹⁴²⁾ This suggests that many of these lethal first-time-attempters intended to die.

Compared to those of older people, adolescents' suicide-attempt statistics show two significant differences. First the fatality rate for boys is a hundred times that of girls, a much greater gender difference than with any other age group. The immediate reason is clear enough: most teenage girls use relatively low-lethality methods like drugs and wrist cuts, while a substantial number of boys use guns and hanging. The reasons behind these choices are not known.

Second, the fatality rate among adolescents, less than 2%, is much lower than that among the elderly, variously reported to be between 25% and 50%. This may be because the young, however miserable, usually have more reason for optimism about the future than do the old, who are too often without friends, family, job, and health.

Nevertheless, their suicide rate is increasing, and approaching the national average. U.S. suicide rates for 15-19 year-olds and over-65 year olds are shown in Table 5-1 (more complete tables in Website Appendix).

Table 5-1: U.S. suicide rate for selected age groups

Rate per 100,000 population, not age-adjusted

Year	U.S. Rate	15-19 year-old rate	over 65 year-old rate
1970	11.6	5.9	20.8
1980	11.8	8.5	17.6
1981	12.0	8.6	17.0
1982	12.2	8.7	18.3
1983	12.1	8.6	19.2
1984	12.3	8.9	20.0
1985	12.5	9.9	21.0
1986	12.8	10.1	21.6
1987	12.7	10.2	21.7
1988	12.4	11.1	20.9
1989	12.2	11.1	20.1
1990	12.4	11.1	20.6
1991	12.2	11.0	19.7
1992	12.0	10.8	19.0
1993	12.1	10.9	19.0
1994	12.0	11.0	18.2

This corresponds to about 2000 suicides among 15-19 year-olds per year. While it's true that the suicide rate is substantially higher among old people, suicide is a relatively more frequent cause of death in the young, who have few deaths from illness. That's why it's the third leading cause of death among 15-24 year-olds, but ranks ninth or tenth for those 55-74.⁽¹⁴³⁾

These numbers show that overall U.S. suicide rates have been essentially unchanged between 1980-94, while 15-19 year-old rates have risen significantly and elderly rates held steady.

Among children between the ages of 10 and 14, the suicide rate increased 110 percent (from 0.8 per 100,000 to 1.7 per 100,000) between 1980 and 1994.⁽¹⁴⁴⁾

There are also claims of an epidemic of youth suicide, with increases on the order of 300% between the early 1950s and late 1980s.⁽¹⁴⁵⁾ In 1950 the official rate for adolescent suicides was 2.7 per 100,000; by 1980 it had increased to 8.5 per 100,000. However, there is dispute about the magnitude of this "epidemic" in part because (1) the base rate chosen was the lowest in this century; (2) there is a greater willingness to admit to teen suicides now than in the 1950s.⁽¹⁴⁶⁾

The reasons for this rise are also in dispute. Besides the usual social rationales (e.g. higher divorce rates), "Some statistics indicate that suicide attempts among younger persons have not increased, but the methods and means they are using are more lethal, making the attempts more successful," says CDC's [Centers for Disease Control] Dr. Alexander E. Crosby.⁽¹⁴⁷⁾

According to Crosby, in 1992 firearm-related deaths accounted for 64.9 percent of suicides among people under 25. Among those aged 15 through 19, firearm-related suicides accounted for 81 percent of the increase in the overall rate from 1980 to 1992.

International Data

Data from around the world [Table, Website Appendix] show no consistent suicide pattern.^(148f) 20 of 27 national rates rose between 1970 and 1980; so did 22 of 27 youth rates [Table V-3, Website Appendix]. The male youth-suicide rate generally increased more than the female rate. In most countries, the youth suicide rate is around one half of the adult rate, but in Chile, Venezuela, and Thailand, the youth rate is somewhat higher than the overall adult rates. The reasons are uncertain; and youth suicide rates show fewer correlations with social variables, such as income or national birth rate, than do adult rates.⁽¹⁴⁹⁾

In terms of methods, a 16-country survey found suicide rates from 1960 to 1980 increased for motor vehicle exhaust (carbon monoxide), guns, and hanging; decreased for domestic gas; were stable for solid and liquid poisons, drowning, and cuts/stabs.⁽¹⁵⁰⁾

Suicidal adolescents are so caught up in their own misery, that they can't see they have choices. Most have had little experience dealing with problems. They often can't or won't talk with their parents and may have no other trusted adults in their lives. Frequently they have withdrawn from their friends. This isolation further decreases their contact with other ideas and views.

Death may seem like the only solution to teenagers grieving over a major loss in their lives. In the bleak words of one fourteen-year-old girl, "If I died, I wouldn't hurt as much as I do now."

`But if you could say to them, "Don't commit suicide because I can get you away from the pain without dying," says psychiatrist Michael Peck, they'd likely be ready to do it.'⁽¹⁵¹⁾

One counselor's description of a session with a suicidal college student follows: the student was highly religious, single, and pregnant. Overcome by guilt, she wanted to kill herself. The counselor tried to show her that there were other possible solutions:

"I did several things. For one, I took out a single sheet of paper and began to "widen her blinders." Our conversation went something on these general lines: "Now, let's see: You could have an abortion here locally." ("I couldn't do that.") ...."You could go away and have an abortion." ("I couldn't do that.") "You could bring the baby to term and keep the baby." ("I couldn't do that.") "You could have the baby and adopt it out." ("I couldn't do that.") "We could get in touch with the young man involved." ("I couldn't do that.") "We could involve the help of your parents." ("I couldn't do that.") "You can always commit suicide, but there is obviously no need to do that today." (No response.) "Now, let's look at this list and rank them in order of your preference, keeping in mind that none of them is perfect."

"The very making of this list, my non-hortatory and non-judgmental approach, had already had a calming influence on her. Within a few minutes her lethality had begun to de-escalate. She actually ranked the list, commenting negatively on each item. What was of critical importance was that suicide was now no longer first or second. We were then simply "haggling" about life---a perfectly viable solution."⁽¹⁵²⁾

Sometimes the triggering event is astonishingly trivial: George Colt mentions,

"...the fourteen-year-old boy who, according to his parents, shot himself because he was upset about getting braces for his teeth that afternoon; the girl who killed herself moments after her father refused to let her watch "Camelot" on television....Such incidents are often misinterpreted as the "reason" for a suicide, but they are usually the culmination of a long series of difficulties..."⁽¹⁵³⁾

Even so, there may be qualitative differences between suicidal adolescents and older people. "When young people are suicidal, they're not necessarily thinking about death being preferable, they're thinking about life being intolerable," says Sally Casper, former director of a suicide prevention agency in Lawrence, Massachusetts. "They're not thinking of where they're going, they're thinking of what they're escaping from. Recently, a fifteen-year-old girl came in here. In one pocket she had a bottle of sleeping pills, and in the other pocket she had a bottle of ipecac, a liquid that makes you vomit. She said, `I want to kill myself, but I don't want to be dead. I mean, I want to be dead, but I don't want to be dead forever, I only want to be dead until my eighteenth birthday.' "⁽¹⁵⁴⁾

The fact that more than 95% of adolescents who live through their suicide attempt do not go on to kill themselves suggests that their problems are not as permanent or serious as their attempted solution. Feeling miserable and hopeless, these adolescents choose an irrevocable solution to temporary problems and, "...reject not just a last few bitter moments, but life, all of it and at once, with all its myriad possibilities...'"⁽¹⁵⁵⁾

This is what make youth suicide especially heartbreaking.

Chapter 6: Suicide in the Elderly and Other Groups

"Lord save us all from old age and broken health and a hope tree that has lost the faculty of putting out blossoms." ---Mark Twain

"When an old person attempts suicide he almost fully intends to die."⁽¹⁵⁶⁾

Statistics

The elderly (defined as those over 65 years old) have, historically and currently, the highest suicide rates in most---but certainly not all---countries of the world. [See table, Website Appendix.]

The death rate in adolescent suicide attempts is roughly 2%; among men over 45 years old, R. W. Maris found 88% of first-time attempts are fatal.⁽¹⁵⁷⁾ Other estimates are lower, but still on the order of 25-50%,⁽¹⁵⁸⁾ though psychiatrist Herbert Hendin, questioning these numbers, points out that there seem to be many more elderly survivors of suicide attempts than there are suicide deaths in this age group.

Despite recent decreases in old-age suicide frequency and increases in youth suicide, the suicide rate for the elderly in the U.S. is still more than 50% higher than that of 15-24 year-olds.

26 percent of the population is over 50 years old; 39% of suicides are from this group, a rate 1.5 times the national average. White males over 50 years old are about 10 percent of the population, but 33 percent of the suicides in the U.S.⁽¹⁵⁹⁾ Elderly white males have a suicide rate 5 times the national average.⁽¹⁶⁰⁾

Among people over 65 years old (12% of the population), the suicide rate was about 22 per 100,000 (21% of suicides) in 1986, or almost twice the national average.⁽¹⁶¹⁾ The actual rate for the elderly is probably a good deal higher, since, "Many deaths from suicide are never investigated and are reported mistakenly as accidents or deaths from natural causes, particularly when the victim was old."⁽¹⁶²⁾

The annual suicide rate for elderly women (6.7/100,000) is lower than that for middle-aged women (7.9/100,000), and about one sixth that of elderly men (around 40/100,000); however the rate for women is relatively under-reported, since they tend to use methods (e.g. overdose) that leave room for other verdicts.⁽¹⁶³⁾ Since American men most often use guns, these deaths are harder to attribute to "natural causes".

Nevertheless, the fact that American male suicide rates peak in old age while female rates are at their maximum during middle age is difficult to explain. The unpleasant realities of old age---increasingly poor health, death of a husband or wife, relegation to a nursing home---fall more frequently on women than men, due to the former's greater longevity. On the other hand, women are generally better than men at maintaining social and family contacts. And men, due to the higher status and more competitive nature of their activities (e.g., business, sports, war) lose more social standing to the infirmities of old age than do women, who generally have lower rank and thus less distance to fall.

Reasons for these high rates seem to include:

(1) social isolation and loneliness, especially among widowers.

(2) physical isolation: because many old people live alone, a suicide attempt may not be discovered soon enough to survive it.

(3) the accumulation of losses, such as friends, physical and mental abilities, social status, and health.

(4) the elderly use more lethal methods than do younger people.^(164f)

(5) old people are less likely to survive any given level of injury than are younger, healthier, ones.

Some specific reasons were identified among elderly suicides from the Miami area [Table V-5, Website Appendix]. The single most-cited cause was "physical health concerns", which were more frequent than the next two reasons ("depression" and "unknown") combined.

Such health concerns are not necessarily accurate. In one study of 248 suicides, more people (8) killed themselves in the mistaken belief that they had cancer than the number of suicides who, in fact, had terminal cancer.⁽¹⁶⁵⁾

The real rates are probably a good deal higher than the official ones. This is because many drug overdoses have no witnesses, no wounds, and look like a natural death. Since serious pre-existing illness is common in the elderly, such deaths are particularly likely to be misdiagnosed as "natural." In one study, 15,000 autopsies in apparently-natural deaths were reviewed. 764 (5.1%) bodies contained enough poison to account for death.⁽¹⁶⁶⁾

About half of the elderly who commit suicide are "depressed", but depression is common amongst old people. Both psychiatric and physical illness are more common in elderly suicides than in younger ones, whose deaths are more often precipitated by relationship, school, job, or jail problems.⁽¹⁶⁷⁾ Between 60 and 85 percent of elderly suicides had significant health problems and in four out of every five cases this was a contributing factor to their decision.⁽¹⁶⁸⁾ On the other hand, non-suicidal elderly had similar rates of physical illness as the suicidal.⁽¹⁶⁹⁾

Does depression affect willingness to accept treatment for other medical problems? In one study, depressed patients were less inclined than non-depressed ones to want medical treatment when the likelihood for improvement in some physical disease was good, but there was no difference between the two groups when the prognosis was poor. It seems that both groups were equally realistic about a poor prognosis, but that the lower quality-of-life and hopes-for-the-future among depressed patients decreased their willingness to seek or accept help when the probability of improvement was good.⁽¹⁷⁰⁾

This is consistent with other data. For example, a survey of elderly (60-100 years-old) visitors to senior centers in Indiana found that depression, low self-esteem, and loneliness were not associated with a decision to end their lives if faced with terminal, or debilitating chronic, illness.⁽¹⁷¹⁾ Again, both the depressed and non-depressed elderly were similarly pragmatic about their options under these circumstances.

However, when the severity of the depression is taken into account, differences appear. Elderly patients who were hospitalized for major depression were asked, before and after anti-depressant medication, whether they wanted life-sustaining treatment for their current physical health problems and for two hypothetical physical illnesses. In the relatively "mild" to "moderate" cases, remission of their depression did not increase their willingness to accept medical intervention; however in the most severely depressed people, it did. This suggests that people in the midst of severe depression should probably not make life-and-death decisions, because their views are likely to change after anti-depressant treatment.⁽¹⁷²⁾

Poverty is not a good suicide predictor. Sweden and Denmark both have high per-capita income as well as comprehensive social welfare for the aged. They also both have high suicide rates among the elderly, as well as in the general population. Greece and Mexico, which have a far lower (economic) standard-of-living than Sweden and Denmark, have particularly low rates, though higher in the elderly than in the general population. Interestingly, during times of economic prosperity, the elderly suicide rate goes down while the suicide rate of younger adults goes up in the U.S.⁽¹⁷³⁾

A final observation: suicide notes left by the elderly tend to show a desire to end their suffering, rather than dwell on interpersonal relationships, introspection, or punishing themselves or others, which are common themes in younger suicides.⁽¹⁷⁴⁾

Are there groups that have particularly high or low suicide rates?

Yes. Native Americans have the highest "racial" rate (16.2/100,000 [1991-3, age-adjusted] while the White rate was 11.1/100,000 [1992, age-adjusted]). Among Native Americans, the pattern of suicide resembles that of Black Americans: a male peak in early twenties, and decreasing thereafter. This pattern differs from that of White Americans, where elderly White males have the highest rates.⁽¹⁷⁵⁾

Black Americans have reported suicide rates substantially lower than those of Whites---except among males 24-35 years old, whose rates are similar. The overall rate for Blacks (6.2/100,000 in 1980; 7.0/100,000 in 1994) is roughly half that of Whites, a ratio which has been consistent over many years. There is, however, some evidence that a small part of the difference is due to more under-reporting of Black suicide than White.⁽¹⁷⁶⁾

The best single socio-economic predictor appears to be religious affiliation. Suicide is infrequent in Moslem populations, typically reported as less than 1 per 100,000 per year. It also is uncommon in many Catholic countries, with rates of 2 to 8 per 100,000 per year. On the other hand, Catholic Austria and Hungary have rates of 23 and 39 per 100,000 per year, respectively. Protestant, Hindu, and Buddhist regions have, with a few exceptions, higher reported suicide rates than Moslem or Catholic ones.

However, there is substantial skepticism about the accuracy of suicide statistics, particularly from societies in which suicide is most condemned. Psychiatrist Erwin Stengel observes, "In Roman Catholic and Moslem countries a verdict of suicide is such a disgrace for the deceased and his family that it is to be avoided wherever possible."⁽¹⁷⁷⁾

The suicide rate is not reliably correlated with such factors as income, education, and health care availability. The effect of unemployment is in dispute. For example, while some studies have found an association between unemployment and suicide, in England there was a 35 percent decrease in the suicide rate between 1963 and 1975, the same period that showed a 50 percent increase in unemployment.⁽¹⁷⁸⁾

While there is no good correlation with wealth or poverty and suicide, certain professions have especially high rates: psychiatrists, physicians, lawyers, and retired military officers.

However, (to combine some risk factors for suicide) the highest suicide likelihood would probably be found in a depressed, ill, elderly white Protestant male immigrant, widowed, divorced or unmarried, who sleeps more than 9 hours a day, has more than three drinks a day, smokes, and keeps a gun in the house.

Chapter 7: Some Frequently-asked Questions About Suicide

Are suicidal people crazy?^(179f)

Yes, no, not necessarily, and so what. Certainly, people with a diagnosis of "schizophrenia" have a high lifetime risk of suicide (10%)⁽¹⁸⁰⁾ as do people with severe depression (15%)⁽¹⁸¹⁾ and/or alcoholism (2-11%).⁽¹⁸²⁾ But so do people with medical illness (18% to 85%---studies are all over the map---of suicides had a physical illness; for 11% to 69% this was an "important contributing cause"; however, only around 5% were terminally ill.⁽¹⁸³⁾

In addition, the association of suicide with mental illness or alcoholism does not mean that suicide cannot be rational: chronically depressed, alcoholic, or schizophrenic persons may decide that it is better to be dead than to continue living as they are.

And to insist that suicide is irrational and attribute it to depression or mental illness "...is absurd and infuriating to those who have spent time at the bedside of dying patients who are suffering severely with no good choices."⁽¹⁸⁴⁾ Besides, "Who wouldn't be depressed with such severe limitations to a meaningful life as incontinence, inability to speak, heavy curtailment of the ability to move and loss of dignity?"⁽¹⁸⁵⁾

Moreover, one doesn't need to be terminally ill to decide that one's physical, mental, or emotional limitations have become unacceptable, and that it's pointless to go on living. As an 84 year old woman said to her, son, a professor of health policy:

"Let me put this in terms you should understand, David. My "quality of life" -- isn't that what you call it? -- has dropped below zero. I know there is nothing fatally wrong with me and that I could live on for many years. With a colostomy and some luck, I might even be able to recover a bit of my former lifestyle, for a while. But do we have to do that just because it is possible? Is the meaning of life defined by its duration? Or does life have a purpose so large that it doesn't have to be prolonged at any cost to preserve its meaning?

"I've lived a wonderful life, but it has to end sometime and this is the right time for me. My decision is not about whether I'm going to die -- we will all die sooner or later. My decision is about when and how. I don't want to spoil the wonder of my life by dragging it out in years of decay. I want to go now, while the good memories are still fresh. Help me find a way."⁽¹⁸⁶⁾

Studies have claimed to find among suicides about three times the rate of mental disorders as people with non-suicidal natural deaths (77% versus 25%).⁽¹⁸⁷⁾

Other studies have found similar,⁽¹⁸⁸⁾ higher,⁽¹⁸⁹⁾ and lower⁽¹⁹⁰⁾ rates. However, some of these investigations have had the benefit of hindsight:⁽¹⁹¹⁾

"...the highest estimate of mental illness when a sample had been diagnosed before suicide was 22 percent. Afterward the highest estimate was 90 percent."^(192f)(193)

After-the-fact diagnosis is rightly criticized⁽¹⁹⁴⁾ for lack of objectivity: when a psychiatrist knows that someone died a suicide, his conclusion will be influenced by that knowledge, particularly if the psychiatrist believes that people who kill themselves must be crazy.^(195f)

The diagnosis of mental illness is especially suspect when it comes to self-destruction. "The argument connecting suicide and mental illness is tautologically based upon our cultural bias against suicide....We say, in essence, `All people who attempt suicide are mentally ill.' If someone asks, `How do you know they are mentally ill?', the implied answer is, `Because only mentally ill persons would try to commit suicide.' "---Z. Stelmachers⁽¹⁹⁶⁾

But there is a wide range of opinions, even within the psychiatric community:

"Is every suicide mentally ill and in need of hospitalization as [interventionist] Eli Robins believes?⁽¹⁹⁷⁾....Or is he simply called mentally ill for the purpose of controlling his behavior, as [radical Thomas] Szasz believes?⁽¹⁹⁸⁾ Or does he have the right to kill himself whether or not he is mentally ill as [libertarian Eliot] Slater advocates?⁽¹⁹⁹⁾ These views reflect the diversity of psychiatric thought with regard to suicide. My own view is that each of these positions contains some truth and that no one of them is an adequate guide for social policy. Most suicide can be diagnosed under present clinical standards as mentally ill; many diagnoses are influenced by the concern with suicide and the desire to prevent it through hospitalization; and the diagnosis of mental illness is not only insufficient to explain suicide but does not by itself justify taking away an individual's rights....[But] Surely confinement for a limited period for the purpose of evaluation with a view to providing help is indicated."⁽²⁰⁰⁾

I would agree that it is better to err on the side of temporary intervention. People sometimes regret things they do; suicide is hard to regret. You can usually kill yourself later, but you can't bring yourself back to life. On the other hand, it remains all too possible to turn "temporary" into permanent; to subject people to conditions that worsen their state; to drug them into submission, or to lock them up indefinitely. There need to be clear limits to both the duration and nature of any intervention; and if someone is persistent in wanting to end their life, that, however distressing, must---and ultimately will---be their decision to make.

"You don't have to be `crazy' to commit suicide. You just have to be desperate, and in need of attention and care." --Emilinda, 15⁽²⁰¹⁾

The notion that suicidal people are crazy also tends to isolate those who are feeling suicidal. Because of the stigma associated with mental illness, they may not be willing to seek help, even in a crisis.

Thus, one of the ironies of suicide is that a suicide attempt--if survived--is probably the most dramatic and convincing way to draw attention to a problem and get help. Often family, psychiatric, and social service resources become suddenly available. A survey of Swiss survivors found that a majority felt that their actions had positive consequences for them.⁽²⁰²⁾ In Erwin Stengel's words, "The suicidal attempt is a highly effective though hazardous way of influencing others and its effects are as a rule...lasting."⁽²⁰³⁾

Optimists may derive comfort from the fact that only about 1% of suicide survivors kill themselves within one year;⁽²⁰⁴⁾ of 886 suicide survivors in another study, only 3.84% killed themselves within five years;⁽²⁰⁵⁾ or that a Swedish study with 35 year follow-up found 10.9% died by suicide.⁽²⁰⁶⁾

A pessimist might note that about half of the people who make a suicide attempt will make a subsequent one;⁽²⁰⁷⁾ the one-year suicide rate of 1% is 50 times the rate of non-attempters; and 10-15 percent will eventually kill themselves, a rate 10-15 times that of the general population.⁽²⁰⁸⁾

How would I know if someone close to me was considering suicide?

There are two general strategies, that overlap to some degree: awareness of (1) sociological or biological risk factors and (2) individual signals. Risk factors are discussed in Chapter 3 and elsewhere. The generally more familiar method consists of sensitivity to various verbal and behavioral signs; but the fact is, while many people consider, mention, or threaten suicide, far fewer make a suicide attempt. Probably the closest we can get to knowing is to ask---usually not a comfortable question to think about, let alone ask.

The most important suicide warning signs are:

(1) A previous suicide attempt. Between 20-80 percent of suicides (studies vary wildly) have made one or more prior attempts.⁽²⁰⁹⁾ Whatever the actual number, this is the single most significant flag.

(2) A major change in behavior or personality. A normally cheerful person may become quiet and withdrawn, and stop formerly-pleasurable activities. Insomnia, or more often an excess of sleep, may be seen. Giving away prized possessions is sometimes a sign that a decision for suicide has been made. However, in all of these and other changes, alternative reasons for the behavior are entirely possible.

(3) Reckless behavior. "I don't care" or "leave it to chance" actions are close to out-and-out suicidal behavior. An example of this is "Russian roulette".

(4) Severe depression. Some of the components of depression are hopelessness, inability to concentrate, sleep disturbances, feelings of worthlessness, loneliness, and sadness. Such a person might say things like, "You would be better off without me," or "Everything I touch turns into ashes." However, some people are so depressed that they don't have the energy to kill themselves. These folks are actually at higher risk when they're just starting to feel a little better.

As one suicidal woman noted,

"It takes a tremendous amount of energy to figure out how you're going to kill yourself....I wanted something that was final and wasn't going to be messy. I didn't want to jump off the roof; I might end up only half dead, and I wouldn't like that. I didn't want to blow my head off---I didn't happen to feel that physical disembodiment would be a particularly pleasant thing for everybody....I kept thinking about what would be easiest for everyone else. Of course the easiest thing would have been if I'd lived."⁽²¹⁰⁾

Since thought disturbances and hopelessness are generally associated with depression, severely depressed people may not recognize the serious nature of their problem, or, if they do, lack the will to try to get help.

"Their thought processes often seem tailored to narrow possibilities, for their rigidity often makes them unable to see alternative solutions, while depression alters their judgement about possibilities for the future."⁽²¹¹⁾

"When I was nineteen, I had my first deep depression. I was terrified. Everything---the way I walked, the way I talked---slowed to a crawl. I felt empty, like everything inside me had been cut up and pulled out. It was as if something had died inside me and was disintegrating. I couldn't concentrate. Reading a book, I'd find myself skimming the same passage over and over until I'd realize I had read the same paragraph sixteen times. After eight months I began to wonder whether my depression would ever lift. I envisioned spending my whole life like that. The feeling that it was never going to end is what made me think of suicide."---Anne-Grace Scheinin⁽²¹²⁾

She made six suicide attempts in the two years before being diagnosed as manic-depressive and being treated with lithium. There were no suicide attempts in the following 10 years.^(213f)(214)

(5) Talking, or dropping clues, about committing suicide. This is usually an indirect, but unmistakable, plea for help, and shouldn't be ignored. Adolescents, in particular, generally place high value on independence, privacy, and self-reliance. If they're asking for help, they're probably in serious pain.

The idea that people who talk about suicide won't carry it out is dead wrong. Erwin Stengel estimates that three fourths of the people who either commit suicide or make an attempt give clear warning of their intent; perhaps some act because they were not taken seriously.

On the other hand, depression is often hidden ("The mass of men lead lives of quiet desperation." --Thoreau) or unnoticed. Thus, as discussed later, physicians often don't recognize depression in their patients.

Risk Factors for Suicide

The second identification strategy takes a statistical look at the social, biological, and psychiatric components associated with suicide: are there characteristics that suicidal people tend to share? One small study looked at a few such risk factors among New York teenagers:⁽²¹⁵⁾

In Table 7-1 below, column 2, the "odds ratio", shows the relative likelihood of someone with a particular risk factor killing themselves, compared to similar persons without that trait. In this study, the greatest risk factor was a prior attempt, 22.5 times t