Why People Die By Suicide Read online

  to a teacher or parent connected with Malachi’s preschool who might

  approach me and say, “Malachi’s been telling the other children about

  people killing themselves.” I prepared for what I would do if Malachi

  became worried or upset about this (might his own dad kill him-

  self?) or had bad dreams. None of this occurred, but it worried me,

  and so I understand why people lie about suicide, though the disad-

  vantages far outweigh the advantages.

  Every now and then Malachi will surprise me with a comment or a

  question related to my dad’s death. Perhaps the one that touched me

  the most occurred about a week after our first conversation. We were

  about to go outside to play when he abruptly turned and said, “When

  you were a little boy, I was your dad.” More than just the timing of the comment, there was something in his expression and tone that made

  me see that he understood that it was painful that my dad was gone,

  and he wanted somehow to lessen the pain. He did.

  When he was four or five, he asked me how my dad died by sui-

  cide, to which I replied that he cut himself. In another conversation

  when he was six, in which I mentioned the specific cause of my dad’s

  death, Malachi pointed out, in a somewhat playful tone he uses when

  he believes he’s discovered something that I didn’t want him to know,

  that earlier I had only said my dad cut himself—I had never been

  more specific. Had I lied altogether, Malachi eventually would have

  caught me in my lies.

  Allow me to emphasize that approximately one millionth of the

  conversations between us are about my dad’s death. The topic ranks

  far, far behind topics like school, friends, various sports, the antics of

  his charismatic little brother Zekey, science, nature, his mother’s abil-

  ity to do magic tricks, and things like fish that can taste with their

  skin. But I have been open about it with him, as I will be with Zekey,

  and I have not regretted it at all. And now, when I talk about the

  topic with others, it’s really very easy; if I can tell the three-year-old

  that I love most in this world (along with his brother and mother), I

  can tell anyone.

  Prologue: Losing My Dad ● 9

  The idea that suicide is a shameful act of weakness nagged at me in

  the years following my dad’s death. My dad was not weak in any

  sense of the word. On the contrary, he had a stoic toughness about

  him that seemed to inure him to physical pain. The anecdotes are

  numerous—and I’m confident that there are more I never knew

  about or have forgotten. When he was three, he tried to balance by

  standing on an upright milk bottle, which broke and severely cut his

  Achilles tendon (and which the babysitter packed with chimney soot

  and wrapped). As an adult, he was a Marine sergeant. When I was

  seven, my dad took our family skiing. I’m not sure, but I think it was

  the first time he had ever skied. He broke his leg. A few years later he

  was jogging with our family dog Jupiter. Jupiter cut in front of my

  dad, who tripped and ruptured his Achilles tendon. Still later, he was

  badly injured in a boating accident.

  The idea that suicide requires a kind of courage or strength has

  implications not only for the causes of suicide—a focus of this

  book—but also for the public view of those who die by suicide. The

  truth about suicide may prove unsettling—it is not about weakness,

  it is about the fearless endurance of a certain type of pain. Perhaps

  this view will demystify and destigmatize suicide and perhaps even

  the mental disorders associated with suicide, like mood disorders.

  There is no question but that my dad had a mood disorder, and

  one of relatively long duration. I remember being puzzled as a young

  child that my dad spent most of the day in bed once, but wasn’t phys-

  ically sick. Later, I imagined that he may have had too much to

  drink the night before. But that didn’t fit. I never knew him to drink

  to excess. I now understand that he was in the middle of a depressive

  episode.

  Near the end of his life, he seemed to have even more obvious de-

  pressive episodes, especially around the Christmas holidays. When I

  would come home from college for the holidays, my dad would

  sometimes pick me up from the airport, and his depression was often

  palpable the moment I saw him. On the drive home from the airport,

  10 ● WHY PEOPLE DIE BY SUICIDE

  I would think of whatever I could to draw him out, but would get

  only monosyllabic replies. Though I’d keep trying, I was relieved

  when the twenty-minute drive was over. And I was glad—no, saved is

  more like it—by the relief provided by seeing my old friends from

  home.

  My dad and I often watched sports together when I was a child.

  Some of my earliest and fondest memories of him are when he and I

  would lie next to each other on a sofa watching football or basketball

  games. He’d have to pull the sofa out from the wall so we would both

  be able to see. We’d be under the same dark red wool blanket, with a

  Bulldog on it and georgia underneath the Bulldog in big block let-

  ters. Years later, home from college for the holidays, I’d often arrange

  for or be given tickets by friends and family to various sporting

  events. I’d invite my dad, again in an attempt to draw him out, and

  again with no success. The twenty-minute ride from the airport be-

  came the three-hour stay at a football game.

  He also had what I now see as frequent episodes of what is called

  hypomania, a milder form of what is known as a full-blown manic

  episode. Manic episodes are discrete periods of symptoms; the epi-

  sodes are phasic—they come and go—and they include grandiose,

  often delusional ideas, expansive planning, elated mood, and bound-

  less energy (e.g., going without sleep for days). The sleep symptom

  in bipolar disorder is notable. People experiencing manic episodes

  are too busy to sleep. Irritability also can characterize manic epi-

  sodes. The combination of severe manic phases and severe depres-

  sive phases is known as bipolar I disorder in the psychiatric nomen-

  clature.

  My dad never had frank manic phases, but he did experience epi-

  sodes of hypomania, which can be viewed as an attenuated form of

  mania. Someone with hypomania may sleep every night (but for a

  shorter time than usual), may express quite positive self-views (but

  not seem frankly grandiose), and may have a noticeably upbeat mood

  Prologue: Losing My Dad ● 11

  (but not seem extremely elated). The combination of hypomania

  and severe depressive phases is known as bipolar II disorder in the

  psychiatric nomenclature, and I now see that this was what my dad

  had. Bipolar II disorder is a serious condition; approximately as

  many people with bipolar II die by suicide as those with bipolar I.

  Some estimate that up to 10 percent of those with bipolar disorder of

  either type die by suicide.

  I believe most of my dad’s hypomanic episodes occurred in the

  spring, which is one of the most common times
for manic or hypo-

  manic phases to occur. The clearest example was from the spring of

  1989—about fifteen months before his death by suicide—when

  my dad visited me, somewhat unexpectedly, in Austin, Texas. I ac-

  companied him all day as he met with various officials of state and

  local government to discuss things related to real estate, taxes, and

  the like. These busy people all saw my dad on very short notice—a

  testimony, I now know, to his truly considerable talents and ingenu-

  ity. To a person, they were also perplexed about just what my dad was

  talking about (not to mention why his long-haired son in high-top

  basketball shoes was accompanying him)—evidence, I now see, of

  his hypomania.

  On this trip, my dad also saw the hovel that my friend and I were

  living in. It was truly bad, but the rent was incredibly low and I didn’t

  mind. I figured my dad wouldn’t mind it too much either. He didn’t

  seem to; all he said was something like, “don’t tell your mother.” But

  it occurred to me later that this may have been a real disappointment

  to him; he may not have understood that even the best of graduate

  students live in such places and may have wondered what had be-

  come of his Princeton-educated son. It haunts me to imagine that he

  counted my circumstances as his failure. It is agonizing that he can’t

  see how and with whom I live now.

  During all the years my dad had these symptoms, he was not

  treated until within a year or so of his death. Partly this was because

  12 ● WHY PEOPLE DIE BY SUICIDE

  my dad was extremely capable and accomplished. For example, he

  finished second in his law school class at the University of Georgia—

  in fact, he finished a close second to his best friend at the time, a

  friend with whom he later lost touch. As another example of my

  dad’s ability, he blazed trails in the field of business software during

  the early 1970s, at a time when few people had even heard the term

  “software.” He was a talented person, able to function even when

  symptomatic. That was one reason he was not treated until near the

  end of his life. Another reason had less to do with my dad and more

  to do with the state of mood disorder science at the time. Treatments,

  the treatment climate, and the societal view of mood disorders be-

  tween the 1950s and 1980s were not such as to encourage accessing

  care. When my dad finally did access care in 1989, he received rea-

  sonable treatments (e.g., an SSRI medicine and a mood stabilizer).

  The problem was not really the type of treatments, but rather, their

  timing. By that point his mood disorder had taken a forty-year toll,

  and his treatment came too late.

  I mentioned earlier that my dad sustained a lot of physical inju-

  ries, some of which occurred in boating accidents. In one such boat-

  ing incident, he sustained a minor injury, yet his life and the lives of

  others in the boat (me and our dog Jupiter) may have been threat-

  ened more than in the other instances. My dad loved to fish, and he

  liked for me to go with him. At times I liked to go, but conditions

  could get extreme for a young boy—leaving before dawn in a rela-

  tively small boat in rough surf, going out a mile or two, staying all

  day in the sun, and coming back at dusk, often empty-handed. In the

  most memorable instance, as we were fishing as usual, huge waves

  suddenly rose, seemingly out of nowhere. I guess our boat was about

  twenty-five feet long; from crest to base, these waves were bigger, be-

  cause our boat would not clear a crest until a moment or two after it

  cleared a base. My dad was struggling with the steering wheel to keep

  our boat at a ninety-degree angle to these waves; if we got sideways,

  Prologue: Losing My Dad ● 13

  we’d be in real trouble. As the boat mounted a wave, our dog Jupiter

  would slide helplessly to the back of the boat, along with a lot of

  fishing poles and tackle and such. The same process occurred in re-

  verse as we slid down the back of the wave. My dad was winning the

  struggle of keeping the boat at the right angle when the steering

  wheel broke off and shattered in his hands. He had to steer with the

  base of the steering wheel, which he gripped like he was trying to

  choke it. Within a few minutes, we were in calmer waters, and I

  pointed out to my dad that the steering wheel had cut one of his

  hands pretty badly; I’m sure that he had not noticed until then.

  This story displays the kind of stoicism and toughness of mind

  and body my dad possessed. As I will explain later in the book, past

  experience with bodily injuries may be important in later suicide

  risk. My dad was calm in the face of pain; he hardly batted an eye as

  he steered our boat through a very dangerous situation, clutching the

  stub of the steering wheel with a bleeding hand.

  There is also a touch of recklessness implicit in the story. I don’t

  recall my dad ever checking weather reports before we went out.

  Spending fifteen-hour days in a small boat on the open ocean is not

  something that I would attempt with Malachi or Zekey. My dad was

  not a generally reckless character; he was not impulsive, not prone to

  substance abuse, not prone to fits of anger. But there was recklessness

  of a sort, and various kinds of recklessness may predispose people to

  suicide precisely because it leaves them open to injury and danger.

  Repeated exposure to injury and danger, in turn, makes people fear-

  less about a lot of things, including serious self-injury.

  Despite my dad’s substantial history of injury and a definite sto-

  icism and fearlessness, when it came to producing his own death, he

  seemingly needed to work up to the act. He died by piercing his

  heart, but first, he worked up to that by cutting other areas of his

  body. This fact about my dad’s suicide—still painful to write about

  after many years—is, I think, important. In one way or another, ev-

  14 ● WHY PEOPLE DIE BY SUICIDE

  eryone who dies by suicide has to work up to the act, certainly over

  the long-term (through getting used to pain) and sometimes over

  the short-term, by trying out the means of death in a milder, non-

  lethal way.

  A day or two after my dad’s funeral, my Uncle Jim and I went to

  retrieve some of my dad’s belongings and papers from the Atlanta

  morgue. The attendant was a true idiot and seemed irritable about

  just what it was we were doing there. My Uncle Jim was a very gentle

  soul, but his reaction to the attendant was a perfect blend of force

  and rage. The attendant was transformed—he would have tried a

  back flip then and there if asked.

  Among my dad’s things that we picked up at the morgue was

  his watch—a gift from my mother, a 1970s waterproof Rolex. My

  dad wore it always on his left wrist, with the face of the watch on the

  inside of his wrist. When asked why he wore it like that, he’d say,

  “So I can see what time it is without spilling my coffee.” I still have

  the watch, and it is evident that he wore it everywhere, given how

>   scratched it is. I tried it on a while after he died, but it was too small.

  Recently, my wife wanted her wedding ring updated. I planned a

  special ceremony to present it to her exactly as I did the first time,

  but this time around with Malachi and Zekey as our witnesses. When

  I picked up my wife’s updated ring, I had the thought that the jeweler

  could repair the face and enlarge the band of my dad’s watch for me.

  So many of my experiences and memories subsequent to my dad’s

  death are tinged like this, sometimes in a deeply painful way (for ex-

  ample, he will never meet my wife or sons) and sometimes, like the

  episode at the jeweler’s, with a kind of wistfulness that stitches his life and even his death into the lives of my family and me.

  There is such a well of sadness in me even to this day. But it’s be-

  come more general now—less about my dad and more about how

  heartsick I am that tomorrow around eighty families in the United

  States will lose a loved one to suicide, just like my family did. Im-

  Prologue: Losing My Dad ● 15

  provements in science and clinical work can save lives and reduce the

  number of bereaved families.

  I share with survivors the pain of losing a loved one to suicide. But

  I share with clinicians the challenges of treating suicidal behavior,

  and I share with scientists the daunting task of unraveling suicide’s

  mysteries. I want to acknowledge this shared legacy and future, use

  them to pose various pressing questions about suicide, and employ

  them as context for my explanation of why people die by suicide.

  WHAT WE KNOW

  AND

  DON’T KNOW

  ABOUT SUICIDE

  1

  The last compelling theory of suicide appeared approximately fifteen

  years ago. The number of other prominent and coherent theories in

  the decades or even centuries before that can be tallied on one hand.

  This is a strange state of affairs for a phenomenon that kills millions.

  A new theory is needed that builds on existing models and pro-

  vides a deeper account of suicidal behavior to explain more suicide-

  related phenomena. This is a very tall order, because the extent and

  diversity of facts related to suicide are intimidating and baffling. For

  example, suicide is far more common in men than in women . . . ex-

  cept in China. In the United States, there has been a recent increase