There is evidence that the rate of suicide can be contained by external factors: where guns and barbiturates are hard to get, suicide rates are distinctly lower than elsewhere. Modern technology has made suicide easier and less painful than it has ever been before, and this is extremely dangerous. When England switched its gas services from lethal coke gas to less toxic natural gas, the suicide rate dropped by one-third, with annual gas-related suicides dropping from 2,368 to 11. If suicidality may be expressed impulsively, reducing immediate availability of means to kill oneself would allow the impulse to pass without being realized. The United States is the only country in the world where the primary means of suicide is guns. More Americans kill themselves with guns than are murdered with them every year in the United States. The ten states with the weakest gun-control laws have a suicide rate twice that of the ten states with the strongest laws. In 1910, at a meeting of the Vienna Psychoanalytic Society, David Oppenheim said, “A loaded pistol positively urges the idea of suicide on its owner.” In 1997, about eighteen thousand Americans killed themselves with guns, responding to that urge. Technique may vary by location, age, and situation. In China, huge numbers of women commit suicide by eating toxic pesticides and fertilizers because those substances are so readily available. In Punjab in India, more than half of suicides are committed by leaping in front of trains.
Suicide is often the manifestation of the depressive end of a manic-depressive mood spectrum, and this is the reason usually given for the high rate of suicide among people who are highly successful. It is also the case that people who are successful tend to set high standards for themselves and are often disappointed even in their greatest achievements. Self-examination and rumination may lead to suicide, which occurs frequently among artists and other creative people. But the rate is also high among successful businessmen: it would appear that some of the qualities that make for success also make for suicidality. Scientists, composers, and high-level businessmen are five times more likely to kill themselves than the general population; writers, especially poets, have an even higher rate of suicide.
Approximately one-third of all completed suicides and one-quarter of all attempts are committed by alcoholics. Those suicide attempters who are drunk or on drugs at the time of their attempts are much more likely to succeed in killing themselves than are those who are sober. Fifteen percent of serious alcoholics take their own lives. Karl Menninger has called alcoholism “a form of self-destruction used to avert a greater self-destruction.” For some, it is the self-destructiveness that enables self-destruction.
Advance detection is tricky. When I was deeply depressed, I visited a psychiatrist with whom I hoped to do therapy, who told me that he would take me on as a patient so long as I promised not to commit suicide while under his care. This was, I thought, a bit like having a specialist in infectious diseases agree to treat your tuberculosis so long as you never coughed again. I don’t think that this was simply naïveté. On an airplane on my way home from a conference on brain imaging, I was drawn into conversation by someone who had observed that I was thumbing through a book about depression. “I’m kind of interested in what you’re reading,” he said. “I’ve had depression myself.” I closed my book and listened as he described his psychiatric history. He had been hospitalized twice for severe depression. He had been on medication for a while but had been feeling good for more than a year and had therefore stopped taking his medication. He’d also given up his therapy because he’d worked through the problems that had afflicted him in the past. He had been arrested twice for possession of cocaine and had served a brief prison sentence. He was not in touch with his parents much, and his girlfriend didn’t know he’d ever been depressed. It was about ten-thirty in the morning and he ordered a whiskey on ice from the stewardess.
“Do you often tell strangers a lot about yourself?” I asked as gently as I could.
“Well, sometimes I do,” he conceded. “Sometimes I find it easier to talk to strangers than to people I really know. Y’know? Less judgment and all that. But not just any stranger—you know, it’s like I get a real feeling for people and I just know they’re good people to talk to. Like I had that feeling sitting here next to you.”
Impulsivity. Recklessness. “Do you ever get speeding tickets?” I asked him.
“Wow,” he said. “Are you a psychic or something? I get a lot of speeding tickets all the time; actually I had my license suspended for a year.”
If I had been fresh from a conference on cardiology and were sitting next to a three-hundred-pound man who was smoking like a chimney and eating sticks of butter, and who complained of chest pain that radiated down his left arm, I might have felt that it was appropriate to warn him that he was in real and current danger. To tell someone that he is at risk for suicide is much more difficult. I hinted around the subject, advised my new friend to go back on medications, told him it was good to be in touch with a psychiatrist just in case he ever had a recurrence. Some sense of social convention made it impossible for me to say, “You may feel fine right now, but you’re heading toward suicide and must immediately take preventative measures.”
Animal models for suicide are imperfect since animals presumably do not understand their mortality per se and are unable to seek out their own death. You cannot long for what you do not understand: suicide is a price humans pay for self-consciousness, and it does not exist in comparable form among other species. Members of such species can, however, hurt themselves deliberately, and they frequently do so if subjected to excessive vicissitudes. Rats kept crowded together will chew off their own tails. Rhesus monkeys reared without mothers begin self-injuring actions at about five months; this behavior continues throughout life even when the monkeys are placed in a social group. These monkeys appear to have lower than normal levels of serotonin in crucial areas of the brain; the biological is once more correlated with the sociological. I was fascinated to hear of the suicide of an octopus, trained for a circus, that had been accustomed to do tricks for rewards of food. When the circus was disbanded, the octopus was kept in a tank and no one paid any attention to his tricks. He gradually lost color (octopuses’ states of mind are expressed in their shifting hues) and finally went through his tricks a last time, failed to be rewarded, and used his beak to stab himself so badly that he died.
Recent research with human models has uncovered a close connection between suicide and parental death. One study suggests that three-quarters of completed suicides are committed by people who have been traumatized in childhood by the death of someone to whom they were close, most often a parent. Inability to process this loss early in life leads to an inability to process loss generally. Young people who lose a parent often internalize blame, foreclosing their sense of self-worth. They may also surrender their sense of object constancy: If the parent on whom one so depends can simply disappear from one day to the next, then how can one trust anything? The statistics may be exaggerated, but clearly, the more a person loses, the more likely he is to destroy himself, other matters being equal.
Suicide early in life is widespread. About five thousand people between eighteen and twenty-four kill themselves in the United States each year; at least eighty thousand make suicide attempts. One in every six thousand Americans between the ages of twenty and twenty-four kills himself. Suicide is showing up more and more often in younger people. Suicide is number three among causes of death for Americans fifteen to twenty-four years old. There is no consensus on why suicide is on the upswing in this group. George Howe Colt has remarked, “To account for this ‘epidemic’ of youth suicide, a host of explanations has been proposed: the unraveling of America’s moral fiber, the breakdown of the nuclear family, school pressure, peer pressure, parental pressure, parental lassitude, child abuse, drugs, alcohol, low blood sugar, TV, MTV, popular music (rock, punk, or Heavy Metal, depending on the decade), promiscuity, lagging church attendance, increased violence, racism, the Vietnam War, the threat of nuclear war, the media, rootlessne
ss, increased affluence, unemployment, capitalism, excessive freedom, boredom, narcissism, Watergate, disillusionment with government, lack of heroes, movies about suicide, too much discussion of suicide, too little discussion of suicide.” Adolescents with high academic expectations of themselves may kill themselves if their performance does not live up to their own or their parents’ expectations: suicide is more common among high-achieving adolescents than among their less ambitious peers. The hormonal disruptions of puberty and the years immediately following are also strong predeterminants of adolescent suicide.
Adolescents who commit suicide have often been protected from a bleak view of death. Many seem to believe that death is not a total cessation of consciousness. In a school with a suicide epidemic, one student who killed himself had said that he found it strange that he should be alive and his friend dead. A small Greenlandic city that I visited in 1999 had seen a bizarre sequence of deaths: one student had killed himself, and soon a dozen others followed. One of those follower suicides had said the day before he took his life that he missed his absent friend, and it seemed almost as though he were killing himself as a means to pass into the place where his friend had gone. Younger people are also more likely to believe that a suicide attempt will not lead to death. These people may use a suicide attempt to punish others; as my mother used to say to me, caricaturing my attitudes, when I was a child, “I’ll eat worms and then I’ll die and you’ll be sorry you were mean to I.” Such acts, no matter how manipulative, are at the very least a loud cry for help. Young people who survive a suicide attempt deserve our gentle attention; their problems are indeed grave, and even if we do not understand why, we must accept the seriousness of the matter.
Though there is a dramatic suicide peak among adolescents, the highest rate of suicide is among men over the age of sixty-five; the subgroup of white men over the age of eighty-five has a suicide rate of one in two thousand. There is a sorry tendency to think the suicides of the elderly less pitiful than the suicides of the young. Despair to the point of death is devastating no matter whom it affects. That every day of life brings us closer to death is evident; but that every day of life makes one’s self-destruction more acceptable is a bizarre variation on this theme. We tend to suppose that elderly suicide is rational, but in fact it is frequently the consequence of untreated mental disturbances. Furthermore, the elderly have in general a rich understanding of death. While adolescents turn to suicide to escape life for a different experience, the elderly tend to see death as a final state. And they know what they are doing: unsuccessful suicide attempts are much less frequent in this population than they are among younger people. The elderly employ particularly lethal methods for their suicides and are less likely than any others to have communicated their intent in advance. Divorced or widowed men have the highest suicide rate of all. They seldom seek professional help for depression and often accept that their negative feelings are simply the true reflection of their diminished lives.
In addition to explicit suicide, many of the elderly engage in chronic suicidal behaviors: they choose not to feed themselves, not to take care of themselves, to let go before their bodies fully fail them. After retirement, they allow their rate of activity to lag and in many instances give up on their recreational activities because of poverty and low social status. They isolate themselves. As they develop particularly exacerbated forms of depression—motor problems, hypochondria, and paranoia—people suffer considerable physical decay. At least half of depressed elderly people have partially delusional physical complaints, which, in the period prior to suicide, they often believe to be more disabling and more intractable than they actually are.
Suicide is chronically underreported, in part because some suicides disguise their actions and in part because those left behind do not wish to recognize the reality of a suicide. Greece has one of the lowest reported suicide rates in the world; this reflects not only the sunny climate and relaxed culture of the country, but also that, per the Greek church, suicides cannot be buried in holy ground. This is a specific reason for not reporting a suicide in Greece. Societies where the level of shame is higher have fewer reported suicides. Then there are plenty of what one might call unconscious suicides, in which someone lives carelessly and dies of the incaution—perhaps through mild suicidality and perhaps through simple boldness. The line between self-destructiveness and suicide can be blurry. People who push their own decay without obvious recompense are proto-suicidal. Some religions differentiate active and passive self-destruction; ceasing to nourish yourself in the late stages of a terminal illness may be blameless, while taking an overdose of pills is a sin. One way and another, there is much more suicide in the world than you think, whatever you think.
The means of suicide are fascinatingly various. Kay Jamison catalogs some exotic techniques in Night Falls Fast, such as drinking boiling water; pushing broom handles down the throat; thrusting darning needles into the abdomen; gulping down leather and iron; jumping into volcanoes; thrusting turkey rumps down the throat; swallowing dynamite, hot coals, underwear, or bedclothes; strangling oneself with one’s own hair; using electric drills to bore holes in the brain; walking into the snow with no protective clothing; placing the neck in a vise; arranging for self-decapitation; injecting peanut butter or mayonnaise into the bloodstream; flying bomber planes into mountains; applying black widow spiders to the skin; drowning in vats of vinegar; suffocating in refrigerators; drinking acid; swallowing firecrackers; applying leeches to the body; and strangling on a rosary. In the United States, the most common methods are the obvious ones: guns, drugs, hanging, and jumping.
I am not given to overpowering suicidal fantasy. I think about suicide often, and at my most depressed the idea is never far from my mind; but it tends to stay in my mind, glossed with the irreality with which children imagine old age. I know when things are getting worse because the kinds of suicide I imagine become more various and to some extent more violent. My fantasies leave behind the pills in my medicine chest and even the gun in my safe and extend to figuring out whether the blades of a Gillette sensor razor could be used to slit my wrists, or whether I would be better off using an X-Acto knife. I have gone so far as to try a beam just to see if it would be strong enough to support a noose. I have worked on figuring out timing: when I would be alone in the house, at what hour I could carry things through. Driving when I am in such a mood, I think a lot about cliffs, but then I think about air bags and the possibility of hurting other people, and that way usually feels too messy for me. These are all very real imaginings and can be very painful, but they have so far remained in my imagination. I have engaged in some reckless behavior that could be called para-suicidal, and I have often wanted to die; at low points, I have toyed with the idea, much as I have at high points in my life toyed with the idea of learning to play the piano; but it never flew out of control in me or turned into much of an accessible reality. I wanted out of life, but I had no impulse to drain my being out of existence.
If my depressions had been either worse or longer, I can imagine that I would have become more actively suicidal, but I don’t think I could have killed myself without hard evidence that my situation was irreversible. Though suicide assuages present suffering, in most instances it is undertaken to avoid future suffering. I was born with a strong optimism from my father’s side of the family, and for reasons that may well be purely biochemical, my negative feelings, though sometimes intolerable, have never felt conclusively immutable to me. What I can remember is the curious sense of futurelessness that came to me at low points in my depression—feeling inappropriately relaxed during the takeoff of a small plane because I genuinely didn’t care whether it crashed and killed me or flew and delivered me to my destination. I took foolish risks when they presented themselves to me. I was game to eat poison; I was just not particularly inclined to find or brew it. One of my interviewees, who has survived multiple suicide attempts, told me that if I’d never even slit my wrists, I’d never re
ally been depressed. I chose not to enter that particular competition, but I have certainly met people who have suffered enormously but have never made attempts on themselves.
In the spring of 1997, I went skydiving for the first time, in Arizona. Skydiving is often discussed as a para-suicidal activity, and if I had in fact died while I was doing it, I imagine that it would have been tied in the imagination of my family and friends to my mood states. And yet—and I believe this is often the case for para-suicidal action—it felt not like a suicidal impulse but like a vital one. I did it because I felt so good that I was capable of it. At the same time, having entertained the idea of suicide, I had broken down certain barriers that had stood between me and self-obliteration. I did not want to die when I jumped out of an airplane, but I didn’t fear dying in the way I had feared it before my depression, and so I didn’t need so rigorously to avoid it. I’ve gone skydiving several times since then, and the pleasure I’ve had from my boldness, after so much time lived in reasonless fear, is incalculable. Every time at the door of the plane, I feel the adrenal rush of real fear, which, like real grief, is precious to me for its simple authenticity. It reminds me what those emotions are actually about. Then comes the free fall, and the view over virgin country, and the overwhelming powerlessness and beauty and speed. And then the glorious discovery that the parachute is there after all. When the canopy opens, the updrafts in the wind suddenly reverse the fall, and I rise up and up away from the earth, as though an angel has suddenly come to my rescue to carry me to the sun. And then when I start to sink again, I do it so slowly and live in a world of silence in multiple dimensions. It is wonderful to discover that the fate you have trusted has warranted that trust. What joy it has been to find that the world can support my most rash experiments, to feel, even while falling, that I am held tightly by the world itself.
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