BY WILLIAM POLKOWSKI
Kay Redfield Jamison — author of the autobiography “An Unquiet Mind” and “Touched With Fire,” a study of the connection between creativity and bipolar disorder (or manic depression) — wrote “Night Falls Fast” in an attempt to understand suicide more deeply. Dr. Jamison, who lives with bipolar disorder, once attempted suicide. She knew that this would be a difficult book for her to write. She knew that, besides studying relevant literature, she would be interviewing survivors of suicide attempts and family members of those who had completed suicide. She would be reminded of her own dark depression and attempt at suicide and also be exposed to the deep pain of others. She was aware that old emotional scars would be torn away and her wounds exposed to herself and her readers. But, for her, the topic was important enough to examine and write about in the hope of saving lives and helping others cope with their loss.
The book covers a variety of topics. It includes a history of suicide across the centuries and cultural influences in different parts of the world. There are classifications of different types of suicide and attempted suicide, and also issues of determining whether a death is really suicidal, complicated by issues of stigmatization and how people die. Some drug overdoses, drownings and “accidents” may be ambiguous in ways that gunshot wounds to the head or hanging are not. Measures of suicidal intention and self-reports about attempted suicide are used to estimate the “seriousness” of the attempt. Charts and tables are used to compare causes of death in various populations. Throughout, the book emphasizes suicide in the young, particularly those in their teens and twenties, and adults of middle age. One limitation is that the book was published in 1999, and more recent statistics are not included.
Jamison points out that mental illness is particularly associated with suicide — especially depression, bipolar disorder, schizophrenia and substance abuse. According to Jamison, study after study has shown that 90 to 95 percent of people who complete suicide had a diagnosable mental illness. (Yet I wonder about this statistic because so many have died so young and mental illness has not yet been diagnosed. Also mental illnesses are notoriously under-diagnosed.) Mental illness constitutes a vulnerability, and particular events and stressors may “trigger” the attempt. Suicide is often an impulsive act among those who are vulnerable. This is one reason drinking alcohol, which lowers inhibitions and increases impulsivity, may be part of a lethal combination of predisposing mental illness, life stressors and feelings of hopelessness.
Many have considered ending their life for a long time and have even made several attempts. A previous attempt is the best predictor of a subsequent attempt and a completed suicide. Those who have previously attempted to take their own life are 38 times more likely to make a subsequent attempt than those who have not attempted suicide. Those suffering from major depression are 20 times more likely to take their own life, and those with bipolar disorder are 15 times more likely. Most people with these diagnoses do not attempt suicide, but there is a decided vulnerability.
The causes of suicide are complex. One might think that suicide notes might illuminate the perceptions, emotions, and thinking that precede taking one’s own life. But notes are seldom helpful. With most suicides, no note is left behind; but when notes are left, they tend to be stereotypical and unrevealing. Part of this may be the result of the constricted thinking typical of depression. Besides a sense of hopelessness and an inability to imagine things ever getting better, personality factors are relevant. Quite apart from mental illness, some people are more impulsive than others, some are more easily angered and more violent. These all increase the risk of suicide. Women experience greater rates of depression than men and make more suicide attempts, but men are much more likely to actually take their own life. They generally employ more lethal and violent means — in America, firearms. Sometimes people think that if a person fails to have one means available, another will be chosen. In many cases this is true, but certainly not always. Some people would not dream of killing themselves in certain ways, but would do so in others. Firearms in the home greatly increase the likelihood of suicide.
There are two chapters on the biology of suicide. Genes play a prominent role, particularly in the mood disorders — especially bipolar disorder. Suicide runs in families. Much of this has to do with genetic inheritance, but it may also in part be caused by learning that ending one’s own life is a way of solving serious problems with living. In behavioral genetics, through twin studies, attempts have been made to disentangle genetic and environmental contributions to attempted and completed suicide. Jamison discusses the neurobiology of the brain. Low levels of serotonin are implicated in both violence and suicide. And seasonal patterns may in part be explained by varying levels of serotonin at different times of the year. Violent suicides are much more likely to be seasonal than nonviolent ones. Contrary to what one might expect, the dark days of winter are the least common time for violent suicides, while spring is the most common.
The last section deals with the prevention of suicide. One chapter deals with treatments for the individual — medication and psychotherapy. Various drugs are discussed and their effects on the brain. Antidepressants and mood stabilizers are described. Differential diagnosis is important. Antidepressants can trigger mania and one needs to know when mood stabilizers are needed. Another chapter deals with public health issues and what can be done at a societal level to lower the incidence of suicide. Included are discussions of altered medical practice and attempts at education in the schools, which may be ineffective and make things worse by normalizing suicide.
Reports in the media need to be done in ways that don’t make other suicides more likely, and Dr. Jamison shares some ideas about that. A third chapter in this section deals with those left behind — how important it is to have supportive family and friends, the helpfulness of religious faith and the use of psychotherapy and counseling. One of the most effective ways of dealing with the suicide of a loved one is by forming a self-help group for people who have survived another’s suicide. This fits in wonderfully with the mission of NAMI.