Why People Die By Suicide Read online

suicide in the past, but unlike Gayle, she had no history of repeated

  painful and provocative experiences through which she might have

  acquired the ability to enact lethal self-injury. She thus did not have

  the setting condition for serious suicidal behavior, even though, as it

  turns out, she did have the other factors important in the current

  theory. That is, she felt she was a burden on others and felt discon-

  nected from them. These feelings, combined with statements like,

  “I’d be better off dead” and with symptoms like sleep difficulty,

  clearly indicated a mood disorder, but her risk for suicide was slight.

  The thought never occurred to me that she should be hospitalized.

  Indeed, though she clearly had a mood disorder, it was of relatively

  moderate severity, and she remitted with less than two months of

  psychotherapy and stayed remitted for at least two years thereafter,

  which was the last time I contacted her.

  The cases of Gayle and Sharon, especially when viewed through

  the lens of this book’s theory on suicide, are informative regarding

  suicide risk assessment. Generally speaking, someone like Gayle is at

  chronically elevated risk, at least to some degree, because the capacity

  for serious self-injury already is in place. All that is needed for Gayle

  to engage in serious suicidal behavior if she chooses is a quick change

  in her feelings of connection and effectiveness. Accordingly, routine

  assessment of risk status is required with someone like Gayle. By

  contrast, someone like Sharon is unlikely to engage in serious self-

  harm because she has not beaten down the instinct to live. Even if

  What We Know and Don’t Know about Suicide ● 25

  Sharon feels disconnected from others and ineffective, she lacks the

  capacity to translate the desire for death into action. These points

  will be expanded on in a later chapter on clinical implications.

  Notes from Scientific Research

  The science about suicide is not especially well developed and has

  certainly not permeated the public consciousness. I was reminded of

  this the other day at my sons’ soccer game. There were five or so full-

  field games going on—approximately 150 people out on the fields.

  Off in the distance, lightning struck, and the field administrators de-

  cided to cancel the games. There was some grumbling about this de-

  cision of course, but everyone understood the rationale—lightning

  can be lethal.

  But just how lethal is lightning? In other words, how many people

  die from lightning strikes? In fact, from 1980 to 1995, there were ap-

  proximately eighty deaths per year from lightning strikes in the

  United States. During this same time period, there were more than

  eighty deaths per day from suicide.

  Why do people scramble to prevent death by lightning strike but

  don’t scramble in the same way to prevent death by suicide? The

  latter is approximately 365 times more common than the former.

  One could invoke bias or stigma against mental health problems,

  but I think a more mundane answer is available. It is fairly easy

  to understand how and why people die by lightning strike, and pre-

  vention is straightforward too—you just get out from under the

  weather. By contrast, it is not at all easy for people to understand how

  and why people die by suicide, and prevention is not clear-cut at all.

  To make the prevention of suicide more like the prevention of light-

  ning strikes, people need a clearer understanding of how and why

  people die by suicide. This book is intended to provide such an un-

  derstanding.

  The example of lightning strikes does not really illustrate bias

  26 ● WHY PEOPLE DIE BY SUICIDE

  against suicide; rather, it simply indicates that lightning is a well-

  characterized phenomenon and its prevention is straightforward.

  But in other examples, bias and stigma are detectable. In Tad Friend’s

  2003 New Yorker article on suicide at the Golden Gate Bridge, he

  points out that a main reason for community resistance to a suicide

  barrier fence (which would clearly save lives) is aesthetics. For the

  past twenty-five years, however, a large section of the bridge has been

  festooned with an eight-foot-tall cyclone fence directly above a site

  where tourists can walk below. The fence’s purpose is to prevent

  people dropping things—including, to take a real example, bowling

  balls—on other tourists below. Friend cites the bridge’s former chief

  engineer as saying that the fence is needed because “It’s a public-

  safety issue.” True enough, it is a public safety issue, but not one that has ever killed anyone, bowling balls notwithstanding. By contrast,

  around thirty people die by suicide each year by jumping from the

  bridge. The acceptability of a debris fence coupled with the un-

  acceptability of a suicide barrier seems misguided and unfair.

  To digress a bit, the stigma and taboo of suicide are topics that

  warrant their own book. The stigma, pervasive and enduring, can be

  found even in the seventh circle of Dante’s Inferno. As A. Alvarez4

  summarizes, “In the seventh circle, below the burning heretics and

  the murderers stewing in their river of hot blood, is a dark pathless

  wood where the souls of suicides grow for eternity in the shape of

  warped poisonous thorns . . . At the Day of Judgment, when bodies

  and souls are reunited, the bodies of suicides will hang from the

  branches of the [thorns], since divine justice will not bestow again

  on their owners the bodies they have willfully thrown away.” Accord-

  ing to Dante, my dad is, as I write this, below the murderers, and will hang from thorns for eternity—stigma indeed.

  To return to the Golden Gate Bridge, aesthetics does not really

  provide a convincing explanation for the lack of a suicide barrier, but

  what about cost? As Friend points out, cost did not prevent the re-

  What We Know and Don’t Know about Suicide ● 27

  cent construction of a barrier between the bridge’s walkway and

  traffic, designed to separate bicyclists from traffic. This barrier cost

  5 million dollars, and yet no bicyclist has ever been killed on the

  bridge. Five million dollars and zero deaths for bicyclists; zero dollars

  and over a thousand deaths by suicide: it is difficult to avoid the con-

  clusion of stigma and bias.

  Regarding knowledge about suicide and its prevention, much re-

  mains to be learned and to be done. Some facts are established, but

  even for these, fitting the facts into a coherent overarching theory has

  proven elusive. This book provides the outlines of one such theory.

  Any compelling explanation of suicide should shed at least some

  light on various established facts, including prevalence of suicide; the

  associations of suicide with age, gender, race, neurobiological indices,

  mental disorders, and substance abuse; impulsivity; and childhood

  adversity, as well as issues like treatment and prevention efforts and

  the clustering and “contagion” of suicide. Each of these topics is de-

  fined here and accounted for later, at least in part, by the theory pro-

  p
osed in this book.

  Definition

  One might imagine that defining suicide is relatively easy. Indeed, the

  dictionary definition could not be clearer—“the act of killing oneself

  intentionally.” This definition seems to apply to my dad and many

  others who will be mentioned throughout the book, like the poets

  Hart Crane and Weldon Kees and the musician Kurt Cobain. But

  what about people on the upper floors of the World Trade Center

  who jumped to their deaths on September 11, 2001? At least fifty

  people died in this way, and the actual number is probably closer to

  200. Did they die by suicide? According to the dictionary definition,

  they did, but according to the New York medical examiner and intu-

  itively to many of us, they did not. All September 11 deaths at the

  World Trade Center were classified as homicides. What about the

  28 ● WHY PEOPLE DIE BY SUICIDE

  September 11 terrorists, whose actions, in addition to all of their

  horrible consequences, caused the terrorists’ own deaths? Did they

  die by suicide? Again, according to dictionary definitions, they did.

  But the terrorists themselves would more likely have characterized

  their deaths as martyrdom or casualties of holy war than as suicide.

  Difficulties in defining suicide arise in other situations. Did Mari-

  lyn Monroe die by suicide, or was she killed? Virtually all the evi-

  dence points to suicide, but the idea of homicide resurfaces, often for

  spurious reasons.

  How about people who die alone in single-car motor vehicle acci-

  dents who are later found to have been intoxicated at the time of

  death? We cannot know with certainty whether these deaths were in-

  tentional or accidental. One basis on which to make the designation

  might involve the facts of the accident, such as the angle at which the

  car was driven into a tree or the pattern of skid marks. Someone who

  brakes or swerves at the last instant could be viewed as simply having

  fallen asleep at the wheel. This is certainly possible, but it is also pos-

  sible that someone intended suicide and changed his or her mind too

  late. This appears to happen relatively frequently, as seen in cases of

  those who jump from high places, survive, and report that they re-

  gretted their decision in midair.

  There are still other ambiguities regarding the definition of sui-

  cidal behavior. One of my adolescent patients took a regular sewing

  needle, inserted it in the side of her wrist a millimeter or two, and

  immediately told her mother she had attempted suicide. This sce-

  nario is of clinical concern (and of course was of great concern to

  the mother), but does this qualify as a real suicide attempt? Is it

  of the same quality as more serious attempts, such as what my

  patient “Gayle” had in mind (severing her hand and bleeding to

  death)?

  I am aware of no current theory that adequately handles all of

  What We Know and Don’t Know about Suicide ● 29

  these definitional problems, but in this book I will at least address

  each one.

  Prevalence

  Though rates vary somewhat from year to year, approximately

  30,000 people in the United States and more than half a million peo-

  ple worldwide die by suicide each year. A useful common metric for

  death rate is deaths per 100,000 in the population. The rate of death

  by suicide has been between 10 per 100,000 and 15 per 100,000 for

  decades. In 2001, suicide was the eleventh leading cause of death

  overall in the United States.

  On the one hand, 30,000 U.S. deaths per year—one every eighteen

  minutes or so—is a lot. On the other hand, relatively speaking, sui-

  cide is a rare cause of death. For example, given that a person has

  died, the chance that the cause was heart disease or cancer is 52 per-

  cent. The chance that the cause of death was suicide is a little over 1

  percent.

  Suicide is thus a relatively rare form of death, and any compelling

  theory should be able to account for this fact. Many theories of sui-

  cide run aground on the simple shores of prevalence rates—for ex-

  ample, they propose a cause that is very common, yet do not fully ex-

  plain why relatively few die by suicide. The theory to be developed in

  this book has something to say about the relative rarity of death by

  suicide.

  Gender

  Men are approximately four times more likely than women to die by

  suicide; women are approximately three times as likely as men to at-

  tempt suicide. This pattern of male lethality is partly related to a ten-

  dency toward violent behavior more common in men than women.

  Women’s attempts are more frequent but less violent. Two of three

  30 ● WHY PEOPLE DIE BY SUICIDE

  male suicide victims in the United States die by firearm, as compared

  to one of three for women—the most common cause of death by

  suicide in women is overdose or poisoning. With one key exception,

  men are more likely to die by suicide than women in every country

  of the world.

  The exception is China, where roughly as many women as men die

  by suicide. A persuasive account of death by suicide will need to ex-

  plain the overall pattern of male lethality and address the interesting

  exception of China.

  Suicide “Contagion” and Mass Suicide in Cults

  From time to time, completed suicides cluster in space and time. For

  example, in a high school of approximately 1,500 students, two stu-

  dents died by suicide within four days. During an eighteen-day span

  that included the two completed suicides, seven other students at-

  tempted suicide. Occasionally a spate of deaths by suicide will occur

  following a well-publicized suicide, especially if media coverage in

  any way glorifies it. What is the mechanism underlying suicide clus-

  ters?

  In 1999, I proposed an explanation that involves the concept of

  assortative relating, which means that people form relationships

  nonrandomly—they assort based on shared interests, characteristics,

  even shared problems, such as substance abuse. I believe that suicide

  clusters are, in a sense, pre-arranged, in that vulnerable people

  assortatively relate and then are simultaneously impinged upon by

  some serious stressor, which activates the suicide potential of each

  member of the potential cluster.5 I provide some empirical support

  for this view in a study of college roommates, some of whom related

  assortatively in that they chose to room together, others of whom related randomly, in that they were paired with one another by the uni-

  versity housing agency. If my explanation of suicide clusters holds

  water, the suicide potentials of roommates who chose to room to-

  What We Know and Don’t Know about Suicide ● 31

  gether should be more similar than the suicide potentials of those

  who were randomly assigned to one another. This was in fact the

  finding.6

  The Internet provides another, sometimes more pernicious way in

  which people can assortatively relate. Consider, for example, the

  “pro-suicide” website alt.suicide.hol
iday (or ASH), where suicide is

  construed favorably. Visitors to the site are instructed on the best

  methods for suicide. As many as twenty-four completed suicides

  have been connected to the site. Other web forums have been docu-

  mented to encourage self-destructive behavior too. On January 12,

  2003, a twenty-one-year-old man died in his bedroom after ingesting

  huge amounts of prescription drugs, marijuana, and alcohol. It was

  later determined that many people had witnessed the death through

  the man’s webcam, and that several of the onlookers had typed

  things like, “Eat more!” as the man ingested obviously dangerous

  numbers of pills. The man and the onlookers were part of an ongo-

  ing chat room that regularly discussed substance use. Excessive sub-

  stance use brought these people together (assortatively related them),

  and in this case, self-destructive behavior was explicitly encouraged

  from within the group. Indeed, experimental studies have evaluated

  the connection between group norms and self-aggression. These

  studies use a self-aggression paradigm (self-administered shock dur-

  ing a task disguised as a reaction-time game, with self-aggression de-

  fined by the intensity of shock chosen). In this research, high levels of

  self-administered shock occurred when group norms were manipu-

  lated to encourage self-aggression.

  In his 2003 New Yorker article, Tad Friend documents the death of

  a fourteen-year-old girl who left her high school by taxi, rode to the

  Golden Gate Bridge, and jumped to her death. The girl’s mother later

  discovered that she had been visiting a website that offered advice

  about completing suicide and showed graphic autopsy photos. The

  site discourages methods like poison, drug overdose, and wrist cut-

  32 ● WHY PEOPLE DIE BY SUICIDE

  ting, since less than 15 percent of people who attempt by these meth-

  ods die. By contrast, the site recommends jumping from a high place

  because “jumps from higher than . . . 250 feet over water are almost

  always fatal.”

  Suicides occasionally do cluster in space and time; concepts like

  assortative relating and group norms may partially explain them.

  These concepts are starkly illustrated in some of the most horrific

  suicide clusters, those occurring in cults. In Jonestown, where 914

  people died, the majority died from drinking a grape-flavored drink