35 People, when manic or depressed: C. Hammen, “Generation of Stress in the Course of Unipolar Depression,” Journal of Abnormal Psychology, 100 (1991): 555–561; X.-J. Cui and G. E. Vaillant, “Does Depression Generate Negative Life Events?” Journal of Nervous and Mental Disease, 185 (1997): 145–150.
36 no consistent strong relationship: R. D. Goldney and P. W. Burvill, “Trends in Suicidal Behaviour and Its Management,” Australian and New Zealand Journal of Psychiatry, 14 (1980): 1–15; D. M. Shepherd and B. M. Barraclough, “Work and Suicide: An Empirical Investigation,” British Journal of Psychiatry, 136 (1980): 469–478; S. Platt, “Unemployment and Suicidal Behaviour: A Review of the Literature,” Social Science and Medicine, 19 (1984): 93–115; H. J. Cormier and G. L. Klerman, “Unemployment and Male-Female Labor Force Participation as Determinants of Changing Suicide Rates of Males and Females in Quebec,” Social Psychiatry, 20 (1985): 109–114; A. Beautrais, P. R. Joyce, and R. T. Mulder, “Unemployment and Serious Suicide Attempts,” Psychological Medicine, 28 (1998): 209–218.
37 Most research finds: G. W. Brown and J. L. T. Birley, “Crises and Life Changes and the Onset of Schizophrenia,” Journal of Health and Social Behavior, 9 (1968): 203–214; A. Ambelas, “Psychologically Stressful Life Events in the Precipitation of Manic Episodes,” British Journal of Psychiatry, 135 (1979): 15–21; D. L. Dunner, V. Patrick, and R. R. Fieve, “Life Events and Onset of Bipolar Disorder,” American Journal of Psychiatry, 136 (1979): 508–511; A. Ambelas, “Life Events and Mania: A Special Relationship?” British Journal of Psychiatry, 150 (1987): 235–240; R. Day, J. A. Neilsen, A. Korten, et al., “Stressful Life Events Preceding the Acute Onset of Schizophrenia: A Cross-National Study from the World Health Organization,” Culture, Medicine and Psychiatry, 11 (1987): 123–206; A. Ellicott, C. Hammen, M. Gitlin, G. Brown, and K. Jamison, “Life Events and Course of Bipolar Disorder,” American Journal of Psychiatry, 147 (1990): 1194–1198; F. K. Goodwin and K. R. Jamison, Manic-Depressive Illness (New York: Oxford University Press, 1990); P. Bebbington, S. Wilkins, P. Jones, A. Foerster, R. Murray, B. Toone, and S. Lewis, “Life Events and Psychosis: Initial Results from the Camberwell Collaborative Psychosis Study,” British Journal of Psychiatry, 162 (1993): 72–79.
38 although the influence: R. M. Post, D. Rubinow, and J. C. Ballenger, “Conditioning and Sensitisation in the Longitudinal Course of Affective Illness,” British Journal of Psychiatry, 149 (1986): 191–201; R. M. Post, “Transduction of Psychosocial Stress into the Neurobiology of Recurrent Affective Disorder,” American Journal of Psychiatry, 149 (1992): 999–1010.
39 Patients with mood disorders: A. Breier, “Stress, Dopamine, and Schizophrenia: Evidence for a Stress-Diathesis Model,” in C. M. Mazure, ed., Does Stress Cause Psychiatric Illness? (Washington, D.C.: American Psychiatric Press, 1995), pp. 67–86; B. P. Dohrenwend, P. E. Shrout, B. G. Link, A. E. Skodol, and A. Stueve, “Life Events and Other Possible Psychosocial Risk Factors for Episodes of Schizophrenia and Major Depression: A Case-Control Study,” in Mazure, ed., Does Stress Cause Psychiatric Illness?, pp. 43–65.
40 Psychologist Sherry Johnson: S. L. Johnson and I. Miller, “Negative Life Events and Time to Recovery from Episodes of Bipolar Disorder,” Journal of Abnormal Psychology, 106 (1997): 449–457.
41 Sudden heartbreak: E. S. Paykel and D. Dowlatshahi, “Life Events and Mental Disorder,” in S. Fisher and J. Reason, eds., Handbook of Life Stress, Cognition, and Health (New York: J. Wiley and Sons, 1988), pp. 241–263; M. Heikkinen, H. Aro, and J. Lönnqvist, “Life Events and Social Support in Suicide,” Suicide and Life-Threatening Behavior, 23 (1993): 343–358; E. Isometsä, M. Heikkinen, M. Henriksson, H. Aro, and J. Lönnqvist, “Recent Life Events and Completed Suicide in Bipolar Affective Disorder: A Comparison with Major Depressive Suicides,” Journal of Affective Disorders, 33 (1995): 99–106.
42 Difficulties and conflicts: G. E. Murphy and E. Robins, “Social Factors in Suicide,” Journal of the American Medical Association, 199 (1967): 303–308; G. E. Murphy, J. W. Armstrong, S. L. Hermele, J. R. Fischer, and W. W. Clendenin, “Suicide and Alcoholism: Interpersonal Loss Confirmed as a Predictor,” Archives of General Psychiatry, 36 (1979): 65–69; G. E. Murphy, “Suicide in Alcoholism,” in A. Roy, ed., Suicide (Baltimore: Williams & Wilkins, 1986), pp. 89–96; C. L. Rich, R. C. Fowler, L. A. Fogarty, and D. Young, “San Diego Suicide Study: III. Relationship Between Diagnoses and Stressors,” Archives of General Psychiatry, 45 (1988): 589–592.
43 Sometimes the reasons: T. F. Dugan and M. L. Belfer, “Suicide in Children,” in D. Jacobs and H. N. Brown, eds., Suicide: Understanding and Responding: Harvard Medical School Perspectives (Madison, Conn.: International Universities Press, 1990), pp. 201–220, p. 201.
44 In a large Finnish study: M. Heikkinen, H. Aro, and J. Lönnqvist, “The Partners’ Views on Precipitant Stressors in Suicide,” Acta Psychiatrica Scandinavica, 85 (1992): 380–384.
45 Young or adolescent boys: D. Shaffer, “Suicide in Childhood and Adolescence,” Journal of Child Psychology and Psychiatry, 15 (1974): 275–291; C. L. Rich, D. Young, and R. C. Fowler, “San Diego Suicide Study: I. Young vs. Old Subjects,” Archives of General Psychiatry, 43 (1986): 577–582; D. J. Poteet, “Adolescent Suicide: A Review of 87 Cases of Completed Suicide in Shelby County, Tennessee,” American Journal of Forensic Medicine and Pathology, 8 (1987): 12–17; D. A. Brent, J. A. Perper, C. E. Goldstein, D. J. Kolke, M. J. Allan, C. J. Allmen, and J. P. Zelenak, “Risk Factors for Adolescent Suicide: A Comparison of Adolescent Suicide Victims with Suicidal Inpatients,” Archives of General Psychiatry, 45 (1988): 581–588; H. H. Hoberman and B. D. Garfinkel, “Completed Suicide in Youth,” Canadian Journal of Psychiatry, 33 (1988): 494–504; D. A. Brent, J. A. Perper, G. Moritz, M. Baugher, C. Roth, L. Balach, and J. Schweers, “Stressful Life Events, Psychopathology, and Adolescent Suicide: A Case Control Study,” Suicide and Life-Threatening Behavior, 23 (1993): 179–187; L. Davidson, M. L. Rosenberg, J. A. Mercy, J. Franklin, and J. T. Simmons, “An Epidemiologic Study of Risk Factors in Two Teenage Suicide Clusters,” Journal of the American Medical Association, 262 (1989): 2687–2692; M. Marttunen, H. M. Aro, and J. K. Lönnqvist, “Precipitant Stressors in Adolescent Suicide,” Journal of the Academy of Child and Adolescent Psychiatry, 32 (1993): 1178–1183; M. S. Gould, P. Fisher, M. Paridas, M. Flory, and D. Shaffer, “Psychosocial Risk Factors of Child and Adolescent Completed Suicide,” Archives of General Psychiatry, 53 (1996): 1155–1162.
46 David Shaffer: D. Shaffer, “Suicide in Childhood and Adolescence,” Journal of Child Psychology and Psychiatry, 15 (1974): 275–291; M. Shafii, S. Carrigan, J. R. Whittinghill, and A. Derrick, “Psychological Autopsy of Completed Suicide in Children and Adolescents,” American Journal of Psychiatry, 142 (1985): 1061–1064; R. C. Fowler, C. L. Rich, and D. Young, “San Diego Suicide Study: II. Substance Abuse in Young Cases,” Archives of General Psychiatry, 43 (1986): 962–965; D. Shaffer, A. Garland, M. Gould, P. Fisher, and P. Trautman, “Preventing Teenage Suicide: A Critical Review,” Journal of the American Academy of Child and Adolescent Psychiatry, 27 (1988): 675–687; D. A. Brent, J. A. Perper, C. E. Goldstein, D. J. Kolke, M. J. Allan, C. J. Allman, and J. P. Zelenak, “Risk Factors for Adolescent Suicide: A Comparison of Adolescent Suicide Victims with Suicidal Inpatients,” Archives of General Psychiatry, 45 (1988): 581–588; D. Shaffer, “The Epidemiology of Teen Suicide: An Examination of Risk Factors,” Journal of Clinical Psychiatry, 49 (1988): 36–41; M. Shaffi, J. Steltz-Lenarsky, A. M. Derrick, C. Beckner, and R. Whittinghill, “Comorbidity of Mental Disorders in the Post-Mortem Diagnosis of Completed Suicide in Children and Adolescents,” Journal of Affective Disorders, 15 (1988): 227–233; B. Runeson, “Mental Disorders in Youth Suicide: DSM-III-R Axes I and I,” Acta Psychiatrica Scandinavica, 79 (1989): 490–497; F. E. Crumley, “Substance Abuse and Adolescent Suicidal Behavior,” Journal of the American Medical Association, 263 (1990): 3051–3056; M. Kovacs, D. Goldston, and C. Gatsonis, “Suicidal Behaviors and Childhood-Onset Depressiv
e Disorders: A Longitudinal Investigation,” Journal of the American Academy of Child and Adolescent Psychiatry, 32 (1993): 8–20; M. J. Marttunen, H. M. Aro, M. M. Henriksson, and J. K. Lönnqvist, “Antisocial Behaviour in Adolescent Suicide,” Acta Psychiatrica Scandinavica, 89 (1994): 167–173; D. Shaffer, M. S. Gould, P. Fisher, P. Trautman, D. Moreau, M. Kleinman, and M. Flory, “Psychiatric Diagnosis in Child and Adolescent Suicide,” Archives of General Psychiatry, 53 (1996): 339–348; B. M. Wagner, R. E. Cole, and P. Schwartzman, “Comorbidity of Symptoms Among Junior and Senior High School Suicide Attempters,” Suicide and Life-Threatening Behavior, 26 (1996) 300–307; B. Grøholt, Ø. Ekeberg, L. Wichstrøm, and T. Haldorsen, “Youth Suicide in Norway, 1990–1992,” Suicide and Life-Threatening Behavior, 27 (1997): 250–263.
47 The fact that most parents: D. M. Velting, D. Shaffer, M. S. Gould, R. Garfinkel, P. Fisher, and M. Davies, “Parent-Victim Agreement in Adolescent Suicide Research,” Journal of the Academy of Child and Adolescent Psychiatry, 37 (1998): 1161–1166.
48 Recent research shows: M. M. Weissman, S. Wolk, R. B. Goldstein, D. Moreau, P. Adams, S. Greenwald, C. M. Klier, N. D. Ryan, R. E. Dahl, and P. Wickramaratne, “Depressed Adolescents Grow Up,” Journal of the American Medical Association, 281 (1999): 1707–1713.
49 “Once … he wrote a poem”: Quoted in J. J. Norwich, Christmas Crackers (London: Penguin, 1982), p. 105.
50 Neuropsychologists and clinicians: These studies are reviewed in “Thought Disorder, Perception, and Cognition,” in F. K. Goodwin and K. R. Jamison, Manic-Depressive Illness (New York: Oxford University Press, 1990), pp. 247–280.
51 are less able: C. Neuringer, “Rigid Thinking in Suicidal Individuals,” Journal of Consulting and Clinical Psychology, 76 (1964): 91–100; M. Levenson and C. Neuringer, “Problem Solving Behavior in Suicidal Adolescents,” Journal of Consulting and Clinical Psychology, 37 (1971): 433–436; A. Patsiokas, G. Clum, and R. Luscomb, “Cognitive Characteristics of Suicide Attempters,” Journal of Consulting and Clinical Psychology, 3 (1979): 478–484; R. L. Bonner and A. R. Rich, “Toward a Predictive Model of Suicidal Ideation and Behavior,” Suicide and Life-Threatening Behavior, 17 (1987): 50–63; B. C. McLeavey, R. J. Daly, C. M. Murray, J. O’Riordan, and M. Taylor, “Interpersonal Problem-Solving Deficits in Self-Poisoning Patients,” Suicide and Life-Threatening Behavior, 17 (1987): 33–49; I. Orbach, E. Rosenheim, and E. Hary, “Some Aspects of Cognitive Functioning in Suicidal Children,” Journal of the American Academy of Child and Adolescent Psychiatry, 26 (1987): 181–185; D. E. Schotte and G. A. Clum, “Problem-Solving Skills in Suicidal Psychiatric Patients,” Journal of Consulting and Clinical Psychology, 55 (1987): 49–54; A. Bartfai, I.-M. Winborg, P. Nordström, and M. Åsberg, “Suicidal Behavior and Cognitive Flexibility: Design and Verbal Fluency After Attempted Suicide,” Suicide and Life-Threatening Behavior, 20 (1990): 254–266; J. Evans, J. M. G. Williams, S. O’Loughlin, and K. Howells, “Autobiographical Memory and Problem-Solving Strategies of Parasuicide Patients,” Psychological Medicine, 22 (1992): 399–405; W. Mraz and M. A. Runco, “Suicide Ideation and Creative Problem Solving,” Suicide and Life-Threatening Behavior, 24 (1994): 38–47.
52 Their thinking is more: V. J. Henken, “Banality Reinvestigated: A Computer-Based Content Analysis of Suicidal and Forced Death Documents,” Suicide and Life-Threatening Behavior, 6 (1976): 36–43; Antoon A. Leenaars, Suicide Notes: Predictive Clues and Patterns (New York: Human Sciences Press, 1988); I. O’Donnell, R. Farmer, and J. Catalan, “Suicide Notes,” British Journal of Psychiatry, 163 (1993): 45–48.
53 When suicidal patients: J. M. G. Williams and K. Broadbent, “Autobiographical Memory in Attempted Suicide,” Journal of Abnormal Psychology, 95 (1986): 144–149; J. M. G. Williams and B. Dritschel, “Emotional Disturbance and the Specificity of Autobiographical Memory,” Cognition and Emotion, 2 (1988): 221–234; J. Evans, J. M. G. Williams, S. O’Loughlin, and K. Howells, “Autobiographical Memory and Problem-Solving Strategies of Parasuicide Patients,” Psychological Medicine, 22 (1992): 399–405.
54 When asked to think: A. K. MacLeod, G. S. Rose, and J. M. G. Williams, “Components of Hopelessness About the Future in Parasuicide,” Cognitive Therapy and Research, 17 (1993): 441–455; A. K. MacLeod, B. Pankhania, M. Lee, and D. Mitchell, “Parasuicide, Depression and the Anticipation of Positive and Negative Future Experiences,” Psychological Medicine, 27 (1997): 973–977.
55 a sense of responsibility: M. Linehan, J. Goodstein, S. Nielsen, and J. Chiles, “Reasons for Staying Alive When You Are Thinking of Killing Yourself: The Reasons for Living Inventory,” Journal of Consulting and Clinical Psychology, 51 (1983): 276–286.
56 “This is my last experiment”: Quoted in Ellis and Allen, Traitor Within, pp. 175–176.
57 The drawing is taken from A. L. Berman and D. A. Jobes, Adolescent Suicide: Assessment and Intervention (Washington, D.C.: American Psychological Association, 1991), pp. 133–134.
58 Aaron Beck and his colleagues: A. T. Beck, M. Kovacs, and A. Weissman, “Hopelessness and Suicidal Behavior,” Journal of the American Medical Association, 234 (1975): 1146–1149; A. E. Kazdin, N. H. French, A. S. Unis, K. Esveldt-Dawson, and R. B. Sherick, “Hopelessness, Depression, and Suicidal Intent Among Psychiatrically Disturbed Inpatient Children,” Journal of Consulting and Clinical Psychology, 51 (1983): 504–510; A. T. Beck, R. A. Steer, M. Kovacs, and B. Garrison, “Hopelessness and Eventual Suicide: A 10-Year Prospective Study of Patients Hospitalized with Suicidal Ideation,” American Journal of Psychiatry, 142 (1985): 559–563; A. T. Beck, G. Brown, and R. A. Steer, “Prediction of Eventual Suicide in Psychiatric Inpatients by Clinical Ratings of Hopelessness,” Journal of Consulting and Clinical Psychology, 57 (1989): 309–310; A. T. Beck, G. Brown, B. J. Berchick, B. L. Stewart, and R. A. Steer, “Relationship Between Hopelessness and Ultimate Suicide: A Replication with Psychiatric Outpatients,” American Journal of Psychiatry, 147 (1990): 190–195.
59 Jan Fawcett: J. Fawcett, W. A. Sheftner, L. Fogg, D. C. Clark, M. A. Young, D. Hedeker, and R. Gibbons, “Time-Related Predictors of Suicide in Major Affective Disorder,” American Journal of Psychiatry, 147 (1990): 1189–1194.
60 “October 9th”: Excerpts from the journals of Dawn Renee Befano, October 1995.
4 • THE BURDEN OF DESPAIR
1 “One forgets emotions”: Graham Greene, A Sort of Life, p. 127. Graham Greene (1904–1991), like his grandfather, suffered from manic-depression. As a schoolboy, he carved open his leg and attempted to poison himself with deadly nightshade and aspirin; while an undergraduate, he played Russian roulette six times within a period of six months. “I have never understood,” he wrote in The End of the Affair, “why people who can swallow the enormous improbability of a personal God boggle at a personal Devil.” These events are described in Greene’s memoir, A Sort of Life (London: Penguin Books, 1962; first published 1951), pp. 64–68 and 92–96, and in Norman Sherry’s biography, The Life of Graham Greene, Volume I: 1904–1939 (London: Jonathan Cape, 1989), pp. 85–91 and 154–160. The direct quote is from The End of the Affair, p. 59.
2 “Miserableness is like”: Graham Greene, letter to Vivien Dayrell-Browning, 1926 (quoted in Norman Sherry, The Life of Graham Greene, Volume 1, 1904–1939 [New York: Viking Penguin, 1989], p. 276).
3 “I tried out other forms”: Graham Greene, A Sort of Life (London: Penguin, 1972; first published 1971), p. 64.
4 “I felt nothing”: Ibid., p. 91.
5 “I slipped a bullet”: Ibid., pp. 93–94.
6 Study after study: E. Robins, G. E. Murphy, R. H. Wilkinson, S. Gassner, and J. Kayes, “Some Clinical Considerations in the Prevention of Suicide Based on a Study of 134 Successful Suicides,” American Journal of Public Health, 49 (1959): 888–899; T. L. Dorpat and H. S. Ripley, “A Study of Suicide in the Seattle Area,” Comprehensive Psychiatry, 1 (1960): 349–350; B. M. Barraclough, J. Bunch, B. Nelson, and P. Sainsbury, “A Hundred Cases of Suicide: Clinical Aspects,” British Journal of Psychiatry, 125 (1974): 355–373
; O. Hagnell and B. Rorsman, “Suicide and Endogenous Depression with Somatic Symptoms in the Lundby Study,” Neuropsychobiology, 4 (1978): 180–187; J. Beskow, “Suicide and Mental Disorder in Swedish Men,” Acta Psychiatrica Scandinavica, 277 (Suppl.) (1979): 1–138; O. Hagnell and B. Rorsman, “Suicide in the Lundby Study: A Comparative Investigation of Clinical Aspects,” Neuropsychobiology, 5 (1979): 61–73; R. Chynoweth, J. I. Tonge, and J. Armstrong, “Suicide in Brisbane—A Retrospective Psychosocial Study,” Australian and New Zealand Journal of Psychiatry, 14 (1980): 37–45; R. C. Fowler, C. L. Rich, and D. Young, “San Diego Suicide Study: II. Substance Abuse in Young Cases,” Archives of General Psychiatry, 43 (1986): 962–965; D. W. Black, “The Iowa Record-Linkage Experience,” Suicide and Life-Threatening Behavior, 19 (1989): 78–89; B. L. Tanney, “Mental Disorders, Psychiatric Patients, and Suicide,” in R. W. Maris, A. L. Berman, J. T. Maltsberger, and R. I. Yufit, eds., Assessment and Prediction of Suicide (New York: Guilford, 1992), pp. 277–320; A. T. A. Cheng, “Mental Illness and Suicide: A Case-Control Study in East Taiwan,” Archives of General Psychiatry, 52 (1995): 594–603; T. Foster, K. Gillespie, and R. McClelland, “Mental Disorders and Suicide in Northern Ireland,” British Journal of Psychiatry, 170 (1997): 447–452; J. Angst, F. Angst, and H. H. Stassen, “Suicide Risk in Patients with Major Depressive Disorder,” Journal of Clinical Psychiatry, (Suppl. 2) (1999): 57–62.
7 High rates of psychopathology: M. M. Weissman, “The Epidemiology of Suicide Attempts, 1960–1971,” Archives of General Psychiatry, 30 (1974): 737–746; D. J. Pallis and P. Sainsbury, “The Value of Assessing Intent in Attempted Suicide,” Psychological Medicine, 6 (1976): 487–492; J. G. B. Newson-Smith and S. R. Hirsch, “Psychiatric Symptoms in Self-Poisoning Patients,” Psychological Medicine, 9 (1979): 493–500; P. Urwin and J. L. Gibbons, “Psychiatric Diagnosis in Self-Poisoning Cases,” Psychological Medicine, 9 (1979): 501–507; R. D. Goldney, K. S. Adam, J. C. O’Brien, and P. Termansen, “Depression in Young Women Who Have Attempted Suicide: An International Replication Study,” Journal of Affective Disorders, 3 (1981): 327–337; K. Hawton and J. Catalán, Attempted Suicide: A Practical Guide to its Nature and Management (Oxford: Oxford University Press, 1982); K. Michel, “Suicide Risk Factors: A Comparison of Suicide Attempters with Suicide Completers,” British Journal of Psychiatry, 150 (1987): 78–82; A. L. Beautrais, P. R. Joyce, R. T. Mulder, D. M. Fergusson, B. J. Deavoll, and S. K. Nightingale, “Prevalence and Comorbidity of Mental Disorders in Persons Making Serious Suicide Attempts: A Case-Control Study,” American Journal of Psychiatry, 153 (1996): 1009–1014; K. Suominen, M. Henriksson, J. Suokas, E. Isometsä, A. Ostamo, and J. Lönnqvist, “Mental Disorders and Comorbidity in Attempted Suicide,” Acta Psychiatrica Scandinavica, 94 (1996): 234–240.
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