The Institute of Medicine's "Reducing Suicide"

Review of “Reducing Suicide” from the Institute of Medicine (written in 2002)
David Lester

I apologize in advance for these comments. I suspect they are not what you wanted. You did not want a critic; rather you wanted a “pat on the head” and an affirmation of “Good job.”

At first, I was puzzled by this book, and then I was displeased. First the puzzlement.

Why This Book?

In the last few years, at least five edited, comprehensive books have appeared on suicide:
1) Maris et al: Assessment and prediction of suicide
2) Maris et al: Comprehensive textbook of suicidology
3) Hawton et al: International handbook of suicide and attempted suicide
4) Lester: Suicide prevention: resources for the Millennium
5) Wasserman: Suicide

These books have provided comprehensive overviews of the field of suicidology and discussed prevention. Interestingly, the three authors of the Comprehensive Textbook (Maris, Berman and Silverman) are all consultants for the IOM volume.

The question is, therefore, why the IOM thought it necessary to prepare this volume.

Of the 14 people on the committee, only two may be considered suicidologists (Brent and Mann), although five others have published on suicide as a side-issue to their major work (Bunney, Fawcett Jamison, May and Tsuang). Perhaps the IOM has not admitted many suicidologists to its membership, in which case one wonders why the IOM is involved in this issue. If suicide is important, shouldn’t the IOM have more suicidologists as members. If the IOM has so few suicidologists, why get involved?

Of the 38 consultants, only 10 are suicidologists, and six of these are contributors to the two volumes edited by Ronald Maris.

Why is the CDC, NIHM, etc. proposing this volume? Supposedly these agencies have staff with doctorates who write on suicide (e.g., Moscicki and Pearson). Indeed, Jane Pearson is co-editor of a volume on geriatric suicide. If these agencies have experts on staff, why can they not prepare such a volume themselves. If they cannot, why do these agencies hire staff with doctoral degrees? The agencies could be run by pure administrators with lesser degrees.

In short, the existence of this volume is a puzzle.

A Deceptive Book

As I read the volume, light dawned. This is not an honest appraisal of the field at all. There is no critical examination of the issues involved and no serious consideration of the debates that exist in the field. No dissident was invited to participate, and no consideration of dissident views was included. The volume is little more than a deceptive advertisement for a product.

(Where are Szasz, Humphry, Kervorkian, the Hemlock Society, Compassion in Dying? Why weren’t they involved?)

What is the product? Eight laboratories/centers are proposed. The volume is in fact a proposal for funding. It is not an accurate evaluation of the research in suicidology.

Preface

This is evident very quickly. In the Preface (see also page 25 in Chapter 2), there is the usual statement of the huge cost to the nation from suicide. Kip Viscusi, an economist, argued convincingly that each pack of cigarettes sold saves the nation about 55 cents through reduced nursing home costs, medical costs, social security costs, etc. from the premature deaths of smokers. Lester and Yang (1997; 2002) have applied Viscusi’s ideas to suicide and noted that the savings to the nation from each suicide would be even higher since, in addition to the savings noted by Viscusi, there would be reduced costs from not having to treat the psychiatric disorders of suicides and because suicides are typically marginal people whose income over their lifetime is much less than the average American.

Why was not Viscusi invited to participate? The staff at the sponsoring agencies must know of his ideas. He was not invited because you did not want dissident ideas.

Again in the Preface (and later) the usual platitudes about what a serious problem suicide is in the USA. The USA has one of the lowest suicide rates among developed nations. If Germany, Austria and Sweden had the American rate of suicide, they would consider the problem solved, just as if we had their crime rates, we would consider the crime problem solved. These are the kinds of platitudes we read in the Introduction to almost every scholarly article on suicide. Spare us!

And, as usual, even Ed Shneidman’s name is spelt wrong in the text.

Summary

Suicidality is treated with lithium and antidepressants. Really? You mean it isn’t the underlying psychiatric disorder that is treated by these medications?

The Gotland project was a success. Really? There was a huge debate over the success of that project – letters and comments every time Wolfgang Rutz published a paper on the project.

Again there seems to be a deliberate goal of avoiding dissent and debate. This makes the volume dishonest.

The Chapters

The Chapters were mostly fine. They are the typical, unfocused chapters in the edited books mentioned above, but not as good. For example, Lester had his contributors discuss the past, present and the future of their topic/field. Maris et al. discussed the right to die movement.

In Chapter 1, there is the usual mention of the “problem” of terminology. I have always thought that this issue is a non-issue. I do not think the field has been hampered by lack of consistent definitions. For the psychiatric disorders, such as schizophrenia, there is terrible inter-judge reliability, and the APA Diagnostic Manual is a travesty of science in its disregard for causality. Compared to this, the definitions in suicidology are far superior.

In Chapter 4, page 18, the section on twin studies is nonsense. There has been no study of MZ twins separated at birth or early in life with regard to suicide. MZ twins raised together do not provide sound evidence for genetic effects. Why didn’t you get Bouchard’s team at the University of Minnesota involved in this section? They have an on-going study of MZ twins separated early in life?

The same is true for Chapter 5. James Rogers has written a critical review of the childhood sexual abuse-suicidality connection which makes clear that the connection has not been established in a methodologically sound manner. Rogers’ paper is in press, and so your writers may not know of it, but they could have done as good a review had that been their intention.

I didn’t bother to check every section and every reference, but I suspect that the cursory reviews in these chapters are, indeed, cursory. They are not of the quality that one would see in a review published, for example, in Psychological Bulletin. Your authors did not attempt any new meta-analysis. The question is, therefore, why bother with these cursory reviews?

In Chapter 8, there is no mention of the dissenting view of Gary Kleck and Lott regarding gun control. There is also in this chapter and in other places a surprising absence of references to the meta-analyses that have been conducted on some of the issues.

But, as I said, that was not your goal. Your goal is to justify the 8-centers project.

The Proposal

This is a difficult issue to respond to. On paper, the proposal for 8 centers looks good. But this is government. Senator Harry Reid got an appropriation a couple of years back for a suicide center, and of course, the money was wasted. It had to go to his home state, to a unit that had no track record in suicidology, rather than a young, enthusiastic team with ideas and skills in the field of suicidology. I was angered by this!

Government programs do not have to succeed. They simply have to appear to be useful. Money goes to the Harvards and MITs because that looks good to the public. For example, I’ve been on a site visit where a research-incompetent team got funded while the good researchers did not primarily because it was Massachusetts General Hospital (“well-known” and “well-liked” principal investigators) versus Boston City Hospital (“Who are these guys?”).

The War on Poverty was lost. The War on Drugs was lost and is still being lost. The War on Suicide will probably fare no better.

The idea of funding 8 research centers is, superficially, fantastic news for suicidology. The choice of the centers, and the people who are involved, will probably be most disappointing. Rather than seeking out new, controversial and innovative ideas, the money will go to the “old farts” with good track records and no new ideas.

I haven’t seen a new idea in suicidology over the last 10 years. Since the data-bases on-line do not go back more than ten or twenty years, many researchers are not aware of the older research on suicide. Consequently, they do tend to “reinvent the wheel.”

I support your idea of 8 centers. Funding for suicidology should be supported. However, I expect to be disappointed by the choices made, and I do not expect any innovative ideas to come from them. This volume is a good beginning for my disappointment.

Reflections on suicidology (written in 1999)

REFLECTIONS ON SUICIDOLOGY (written in 1999) David Lester 

 It is not surprising that people's desires for power and self-aggrandizement intrude into the scholarly world for, after all, those desires pervade human behavior in general. Nevertheless, the appearance of these desires in scholars is disappointing because scholars, of all groups, might be expected to be above such concerns. How do these desires manifest themselves in suicidology? The People And The Organizations The first way is in the fragmentation of groups concerned with suicide prevention. One organization is formed and then, apparently, some who feel that their importance is not recognized by the organization form their own organization. Everyone wants their own little kingdom, and the idea of working together in harmony is never contemplated. There are three international organizations which organize telephone crisis intervention centers -- Befrienders International, IFOTES and Life Line International. The International Association for Suicide Prevention was followed by the European Symposium and then the International Academy for Suicide Research. In the United States, the first national organization developed to advance the cause of suicide prevention, the American Association of Suicidology (AAS), was followed by the American Suicide Foundation (now renamed) and then SPAN. Each of these groups has its own leaders, and it does seem that each new leader primarily craved the spotlight. To be sure the cause is of some importance to these leaders, but the attention and trappings of power appear to be equally seductive. After all, if the cause was really important, more could be achieved by one large organization than by many smaller ones fighting for attention. AAS has been a fine organization. It has been active, fair, and inclusive -- embracing scholars, crisis centers and survivors. Founded by Edwin Shneidman and now admirably run by Alan Berman, it has proven itself to be an effective organization. I see no need for rival organizations, and I distrust the true motives of the founders and directors of AFSP and SPAN. They could easily have worked with AAS if they truly valued the cause and if they had been able to subjugate their desires for recognition. And note, I am one who frequently attacked AAS for its policies in the journal I edited in the 1970s (Crisis Intervention). The Money There have been two recent disappointments regarding the funding of suicidology. First, the widow of Arthur Sommer Rotenberg helped to raise enough money to endow a chair in suicidology at the University of Toronto. Here was a chance to appoint a leading suicidologist to organize a center for the study of suicide, and Canada has half a dozen fine scholars who merit the position. Instead, the university chose to appoint a psychiatrist who, in my opinion, was a mediocre research in borderline personality. Perhaps funding for his position had run out? I wrote to the university president to protest this waste of an opportunity. Senators and congressmen in the United States often appropriate tax-payers money simply to provide funds for their constituents. It is called "pork" and it is, again in my opinion, unethical behavior on the part of these individuals since it is not part of a rational and planned expenditure for government functions. As an example, recently a congressman in Pennsylvania removed the tolls for trucks from one exit of the Pennsylvania Turnpike so that truckers would exit there and use the restaurants and gas stations in his district. Recently Senator Harry Reid obtained $1.5 million for a suicide center and, since he was the Senator from Nevada, the center was of course established at a university in Nevada, unfortunately one with no history of suicide research. There are many fine young suicidologists across the United States who could have formed the nucleus for a center -- David Brent, Yeates Conwell, Thomas Joiner, John Mann, David Shaffer etc. Some institutions already have a couple of suicidologists on the staff, and AAS would have been able to make fine use of the funds. But the Senator was from Nevada, and so the money had to go to Nevada. When these events happen, we are supposed to cheer and be enthusiastic. Isn't this great for suicidology? To their credit, some qualified individuals have tried to work with Paul Links in Toronto, and others are working with the University of Nevada School of Medicine. But hold the cheering. Both of these events are tragic because they are both missed opportunities. We could have had a vibrant center for the study of suicide in Canada, led by Leenaars, Mishara, or Tanney. We could have had an exciting program in the United States led by Alan Berman, David Brent, Yeates Conwell or Thomas Joiner. But we don't. We have money wasted that suicidology could have usefully put to work.

Introduction

This blog is not for the suicidal. If you are suicidal, please go to www.suicidology.org or www.befrienders.org

This blog is for those interested in the field of suicidology: the research, the theory, and especially the politics.

February 16, 2006

David Lester