Impossible suicide rates!

            A recent article (Jacob, et al., 2007) had a table that had suicide rates for 191 nations of the world. What is surprising about this is that rates were provided for countries such as Afghanistan (6.49 per 100,000 per year), Democratic Republic of the Congo (4.79), Somalia (7.57) and Sudan (7.12). The article gave no citation for the source of these suicide rates. I have already been sent an article to review for a scholarly journal which utilized this set of suicide rates! I e-mailed several of the authors of the paper, as well as Lancet, and received no replies. These suicide rates are most unlikely, and they should not be used for research.

Reference

Jacob, K. S., Sharan, P., Mirza, I., Garrido-Cumbrera, M., Seedat-Mari, J. j., Sreenivas, V., & Saxena, S. (2007). Mental health systems in countries. Lancet, 370, 1061-1077.

Reflections on being President of IASP

REFLECTIONS ON MY TERM AS PRESIDENT OF THE INTERNATIONAL ASSOCIATION FOR SUICIDE PREVENTION (1991-1995)

David Lester

            When I joined the board of the International Association for Suicide Prevention (IASP) in 1989 as Vice-President, I saw two problems with the organization. First, previous Presidents had stayed in office for as long as they wished, despite the existence of many fine suicidologists. For example, the founder, Erwin Ringel was President from 1961 to 1971. Walter Poldinger was President from 1979 to 1985. Second, IASP was a flower that bloomed only every two years. In between those appearances (at the conferences), it died.

            The President from 1989-1991 was a fine gentleman , Nils Retterstøl, and he wanted to reign as President for only two years. I was elected President in 1991, and I intended to stay as President for only two years. With a board whose members agreed with me, we met to plan a future for IASP. The board consisted of myself, Hans Wedler (Germany), Gernot Sonneck (Austria), Rene Diekstra (the Netherlands), and Unni Bille-Brahe (Denmark). The board agreed with my suggestion to invite Vanda Scott, the Secretary-General of the Befrienders, to join us. There were frictions from time to time. Criticism of the 1991 IASP conference almost led to an international incident but, on the whole, we were an amicable board. We met often in Europe, including a wonderful weekend retreat at a converted convent in England arranged by Vanda, led by a professional group leader.

            A major problem arose. I wanted to have IASP focus on the leading suicidologists in the world, whereas the majority of the board wanted to encourage more participation by all nations, regardless of whether there were any good suicidologists in that country. In my view that would have led IASP in the wrong direction, watering it down rather than strengthening it.

            At the 1993 IASP conference in Montreal, Rene presented our progress to that point, and we delayed electing a new board until 1995. Since the board wanted to go in a different direction to my preference, I let them take the reins and make those decisions, but they felt that I had abandoned them. My intentions were good (to let them proceed unimpeded by my objections) but were not well received.

            I did step down as President, as planned in 1995, and IASP has proceeded in the direction I had desired. Presidents have stayed in office for no more four years (although I think the term should be limited to two years), and IASP has formed committees and working groups to develop position papers on important issues in suicidology, such as media guidelines. I think that IASP is a much stronger organization these days.

            Interestingly, because IASP did disappear for two years at a time, the European Symposium developed, meeting in those years that IASP did not meet. I attended an early meeting in Edinburgh in 1988, hosted magnificently and generously by Stephen Platt. In those days, attendance was limited to 100, and American participation was purposely limited. It has since opened attendance to all who desire to attend. The European Symposium still meets in those years that IASP doe not.

            During Nils’s term as President, Rene decided that he wanted to start a research academy. We tried at first to keep the International Academy for Suicide Research (IASR) as part of IASP, and the IASP board attended the opening ceremony, hosted (again magnificently and generously) by Diego De Leo in Padua, Italy, in 1990. Rene and I gave the opening addresses, and then we went off to a splendid banquet. It proved impossible to keep the Academy as part of IASP, and it soon became independent, although often holding brief meetings at meetings of IASP and other conferences.

            The journal for IASR was to be published by Kluwer and edited by myself. However, Kluwer is a Dutch publisher, and Rene kept interfering in negotiations and in the editorial process. I offered him the editorship, but he declined. The solution that I proposed was to have a fine Dutch suicidologist living and working Canada, Antoon Leenaars, take over the editorship. I thought that he would work more efficiently and smoothly with Kluwer since he, obviously, spoke fluent Dutch and could by-pass Rene. Antoon edited the Archives of Suicide Research for the first ten years, building it into a strong journal. Barbara Stanley has taken over and continues to produce a fine scholarly journal.

Understanding the suicidal mind: Can attempted suicides inform us?

Understanding the suicidal mind: Can attempted suicides inform us?

David Lester

            Turning Points (De Leo, 2010) presents us with moving accounts from nine people who attempted to kill themselves, but who survived. All of them but one are happy to have survived. The question asked in his essay is whether the essays written by these individuals provide clues to the suicidal mind.

The Attempters

Trevor

            Trevor is a young man who became a drug and alcohol abuser. The woman he loved rejected him for another man, and his substance abuse worsened. He confided to no one. One night, he was drinking heavily and smoking dope, and he went home to change his clothes in order to go to a disco. He sat down and thought that he did not want to go out or do anything anymore. He got his roommate’s shotgun and ammunition and waited for his friends to come by. He sat down and wrote a suicide note: Tell Mum and Dad that I’m sorry and I love them. He squeezed the trigger, but he had left the safety on. He tried again and, as he squeezed the trigger, changed his mind and tried to pull his head out of the way, but he shot much of the front of his head off.

            De Leo noted that Trevor’s account was rather “dry,” and there is a lack of premeditation. There is also ambivalence as he waits for his friends to stop by. But Trevor seems to have little ability to self-monitor – to tell us what his mood and thoughts were, if any.

Anna

            Anna was sexually abused as a child by several men – neighbors, family friends and her grandfather. The abuse by her grandfather left her confused for she loved him and felt close to him but knew what he was doing was wrong. He stopped abusing Anna when she was twelve, and died two years later.

            On the day that he died, Anna was stoic, “numb to the grief around me.” She had been fighting with her parents to be allowed to go away with friends. Her relationship was “tumultuous” with her mother and distant with her step-father. Her brother and sister-in-law were “always there for me, but I felt such a burden on them.” She felt hopeless and despair. She went and got her grandfather’s medications and ingested them all.  “I am hopeless, bad at school, I can’t get on with my parents, I am a burden to my support people, I cannot take another moment of this anguish. I can’t cope anymore, I hate my life, I have nothing to live for” (p. 64).

            Anna, therefore, illustrates common elements of the suicidal mind – psychological pain, hopelessness, and a sense of being a burden.

Alessa

            Alessa was born into a wealthy family, but with a dysfunctional mother who could not cope with life and a father who was gone on business much of the time. Her mother made several suicide attempts with overdoses and, when Alessa was fifteen, she found her mother on the floor having tried to cut her throat. Alessa married, but her husband physically abused her, and Alessa left him. Two months later she gave birth to a child with Down’s syndrome. Alessa has a psychotic breakdown.

            Alessa’s mother changed dramatically at that time and became a good surrogate mother to her grandson, while Alessa continued to have symptoms of schizophrenia and became a drug addict. Eventually, Alessa recovered to some extent and got a job as a secretary when, one Easter, she decided it was time to die. “It happened all of a sudden….Basically, I wasn’t doing badly. Yet that Saturday afternoon I decided that my hour had come, that the time was right, and that there was no point in going on’ (p. 84). “I was suddenly overcome by the conviction that everything had been horrible and that I could no longer do anything with passion or hope. I was overcome by a sense of suffocating anxiety….My head was spinning and I felt I couldn’t breathe anymore” (p. 85). She swallowed two laundry bottles of stain remover.

            What is interesting here is the anxiety attack that immediately preceded her suicide attempt. She swallowed the poison in the midst of this emotion.

Sergio

            Sergio, a father, feels responsible for letting his son drive a tractor when he was only twelve years old, which crashed and crippled the young boy. Sergio never recovered from the guilt, and his life became full of a sense of oppression, pain and guilt. In the months before his suicide attempt, this became unbearable. He could not sleep and began to drink heavily.

            Sergio does not remember much of the day he tried to kill himself, but he remembered climbing the silo, shaking strongly and crying. He thought that his pain would soon be over. But as soon as he jumped, he decided that he did not want to die. He reoriented himself while falling and damaged only his feet and ankles.

Sandro

            Sandro became a concert pianist and married young. But, although Sandro liked playing in bars, performing in concerts caused great tension for him. He began to drink, and eventually his wife left him. He was an alcoholic, with no job and no confidantes. He decided to kill himself.

            He was sleeping only about two hours each night. He was tense and irritable, yelling at his mother. One night at 2 am, he drove to his ex-wife’s apartment and tried to kill himself with car exhaust. He wanted his ex-wife to see his corpse the next day. As he sat in the car, he drank some cognac and began writing a suicide note to his parents and to his ex-wife, mostly to her. He described the letter as full of accusations, anger, and threats.

Fabrizio

            Fabrizio was diagnosed as having bipolar affective disorder at the age of 22. He lived in the countryside with his parents (his father was a policeman) and an uncle who shot himself at the age of 55. After his fourth or fifth admission for depression, Fabrizio began to think about committing suicide. During one hospitalization, Fabrizio met a woman whom he liked very much but who disappeared out of his life. During his last admission, he found out that she had hung herself. After his discharge he went home, got his father’s gun and went into the basement. “I think my heart was beating fast. Rather strangely, while my head was in complete turmoil, my movements were correct and coordinated” (p. 115).

            Again, like Alessa, Fabrizio reports only anxiety. Interestingly, he has two models for his choice – his uncle and the woman he liked – and he attempted suicide immediately after release from the psychiatric hospital, a common time for suicides in psychiatric patients.

Lucia

            Lucia is married with two children. Her father, suffering from a bipolar disorder, committed suicide by hanging when she was 27. His body was discovered by her younger brother. Her marriage was not good. There was no love and little sex. On the day, Lucia jumped from the third floor window of her apartment, she was tired from her work that day as a school teacher, and she reported a sensation of never-ending anxiety which she had been living with for some time.

            Her husband, who was director of a museum, was tense that day and wanted Lucia to accompany him to a museum affair at which the Mayor was attending. There was tension between them in the car when she asked him to wait for her to go upstairs to the toilet. “I climbed the stairs again. It was suffocating inside there. My head was so heavy and my legs grew increasingly weaker…..I opened the door of the balcony….I didn’t look down, I didn’t hesitate – I just closed my eyes and I jumped….I thought that I was going to put an end to everything that was horrible and senseless. I was going to free myself, forever” (p. 124).

Umberto

            Umberto was an old man and has to use a wheelchair. His wife died of cancer fifteen years earlier, and his four children are grown up. His two daughters lived nearby but “Even if I have cancer, I don’t want my daughters to sacrifice their lives to remain close to me” (p. 130). Umberto had a friend, crippled in a car wreck that killed his wife, with whom he spent time. Unmberto visited him regularly, and they sat out on a balcony. Umberto secretly stole barbiturate pills from his friend over a period of months. He thought about using them to “reach” his wife whenever he chose, yet he did not believe in an afterlife. “What was there to live for?” He chose to overdose on the anniversary of his wife’s death. He wrote notes to his children and to his friend. Worried that his friend would imitate him, Umberto wrote that, “my condition would have rapidly worsened anyway. More suffering, more medical visits, more interventions. More money spent, more assistance, more concern from my children. Better to end it as soon as possible” (p. 134). Umberto took the overdose and, in contrast to those above who reported being anxious in the moments leading up to the attempts, Umberto reported being calm.

Maria

            Maria is an elderly lady, in a nursing home, talking to Diego rather than writing. Maria suffered from a bipolar disorder and had attempted suicide in the past. Her life had been traumatic, with emigrations, the death of her husband and the suicides of her two sons. She jumped from the window of her apartment and suffered a spinal injury that left her paraplegic. “I don’t know why I did it….and if someone would try to explain it to me, I would probably not believe it. The only thing that I remember is the tension that was devouring me, the incredible disquiet that I felt. I was confused. I could not clearly think about anything….I didn’t want to suffer any more…..I did want to stop that tension, to put an end to that unbearable suffering. I am not sure if you really know what anxiety is, that particular anxiety. It is like a devil that bites you inside, that squeezes your lungs. You cannot breathe, you really cannot breathe” (pp. 147-148.).

Discussion

            The most noteworthy feature of these accounts is how little insight the people had into their mental state and their psychodynamics. They do illustrate several features well-know to suicidologists, such as escape from mental and physical pain (Sergio and Maria), anger (Sandro), hopelessness and a feeling of being a burden (Anna), and suicide soon after discharge from a psychiatric hospital (Fabrizio).

            What is noteworthy is the anxiety noted by two of the individuals, Alessa, Fabrizio, Lucia and Maria. Alessa, Lucia and Maria all talk of suffocating and not being able to breathe any more, and two of them (Lucia and Maria) indicate that the anxiety was long-standing and not simply a result of the decision to kill themselves. In fact, Maria tried to die to get away from the anxiety.

            This suggests that clinicians should evaluate clients who are potentially suicidal for anxiety as well as depression and hopelessness.

REFERENCE

De Leo, D. (2010). Turning points. Bowen Hills, Australia: Australian Academic Press.

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