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  A genetic predisposition to suicide by no means implies that suicide is inevitable. It simply makes it more likely that given enough cumulative stress or a devastating, acute one, suicide may be an option more readily summoned. In this respect, it is no different from the “two-hit” model that characterizes many other medical conditions. A genetic vulnerability for heart disease, cancer, or asthma, for example, or for diabetes or sickle-cell disease, does not ensure that the illness will occur. It does mean that it may be more readily triggered by behavior or the environment, for example, through smoking, a sedentary lifestyle, diet, aging, or stress. Depending on the strength of the genetic vulnerability, the predisposing genes may or may not ever be triggered. If an illness is overwhelmingly determined by genetic factors—for example, Huntington’s disease—possession of the responsible gene essentially guarantees that the disease will eventually develop. If, on the other hand, the genetics are more complex or the underlying predisposition is less strong (or protected against by yet other genes), the environment and an individual’s behavior has more sway in whether or not he or she becomes ill.

  For some, suicide is a sudden act. For others, it is a long-considered decision based on cumulative despair or dire circumstance. And for many, it is both: a brash moment of action taken during a span of settled and suicidal hopelessness. Sudden death often waits in the wings for those whose family histories or brain chemistries predispose them to impulsive suicide; they are like dry and brittle pyres, unshielded against the inevitable sparks thrown off by living. If by temperament they are impetuous and volatile, their cast to risk taking will make them generators and throwers of sparks as well: they become instigators of brawls; participants in and perpetuators of tumultuous affairs; gamers and gamblers; high-wire acts; and dealers in discord. They are like the Australian aborigines who, as Stephen Pyne describes them in his book World Fire, “on this, the hottest and driest of the vegetated continents … habitually walked around with flaming firebrands that dribbled embers everywhere.” They are the ones vulnerable to impulsive suicide: those who are volatile and fractious by nature, those who are subject to the Catherine wheel instability of mania or who live the tossed-and-turning lives associated with personality disorders or alcoholism.

  Others kill themselves only after great deliberation and after having lived a long time with pain, mental illness, or chronic stress. Joseph Conrad, who shot himself in the chest when he was a young man but luckily survived, wrote, “Suicide, I suspect, is very often the outcome of mere mental weariness—not an act of savage energy but the final symptom of complete collapse.” For many the cumulative despair simply becomes unendurable; there is a steady erosion in the brake linings of the mental system that apply force against self-murder. Although it is tempting to imagine suicide as obituary writers often do—as an “understandable” response to a problem of life, such as economic reversal, romantic failure, or shame—it is clear that these or similar setbacks hit everyone at some point in their lives. Unless someone lives an unthinkably boring life, has no hopes that can be shattered, no love that can be lost, or transits from birth to death in a bubble above the frays of earth, he or she experiences the same griefs or strains that, for a few, become the “cause” of death. For every grief or strain that appears to trigger a suicide, thousands of other people have experienced situations as bad or worse and do not kill themselves. The normal mind, although strongly affected by a loss or damaging event, is well cloaked against the possibility of suicide.

  John Mann and his colleagues at the New York State Psychiatric Institute have proposed a “Stress-Diathesis” model to explain the relationship between the underlying biological predisposition to suicide and the precipitants that trigger it. Several factors influence the predisposition to commit suicide, and together they act to establish a threshold for suicidal behavior. These include genetic vulnerabilities such as family history and compromised serotonergic functioning in the brain; temperamental variables, such as aggressiveness and impulsivity; chronic alcohol and drug abuse; chronic medical conditions; and certain social factors, such as the early death of a parent, social isolation, or a childhood history of physical or sexual abuse. To some extent, the threshold of suicidal behavior can be raised (that is, suicide can, to a limited extent, be protected against) by religious beliefs, the presence of children in the household, financial security, strong social supports, or a good marriage. In the presence of a strong predisposition to suicide, however, these protective factors may be of limited value.

  The precipitants of suicide, known rather oddly as “triggers,” include stressors such as psychiatric illness, acute intoxication from drugs or alcohol, personal or financial crisis, or contagion from another suicide. The interactions between the threshold factors and the triggers are, of course, complicated. A man who is born with a genetic predisposition to manic-depressive illness, has impaired serotonergic functioning, and comes from a family with a history of suicide is at high risk to kill himself. But his risk may increase even further if he drinks when he is depressed or manic, because this will increase the likelihood that he will have problems with his relationships and his work. It will also make it more likely that his illness will get worse, that his treatment will be less effective, and that his serotonin functioning will be compromised even further.

  Alone, a single risk factor—either predisposing or precipitating—may only slightly increase the odds that an individual will kill himself. But some, such as a genetic or other biological predisposition, especially when coupled with a severe psychiatric disorder, are particularly ominous. When the threshold is set low from birth and the triggers kick in, the likelihood of suicide may become unstoppably high. A slight affront or loss may quickly create a flash point from a lethal mix of elements. It is as with fire: dry grass and high winds may remain, in themselves, only dangerous possibilities, elements of combustion. But if lightning falls across the grass, the chance of fire increases blindingly fast: it leaps from slim to given.

  ACUTE PSYCHIATRIC illness is the single most common and dangerous trigger of suicide. Most people who suffer from depression, manic-depressive illness, alcoholism, or schizophrenia do not kill themselves, but a vastly disproportionate number of them do. For some, the threshold of suicide is lowered because of the characteristics of the illness itself—for example, the extreme irritability and impulsivity associated with mixed states or the mental and physical agitation of severe depression as it begins to clear or as it worsens—but for others, those who even when well have endangeringly low CSF 5-HIAA levels and who are aggressive and reckless by temperament, mental illness may trigger the underlying chronic propensity to commit suicide. Many things in the environment or a person’s behavior may in turn precipitate or worsen psychiatric illness. We saw earlier, for example, how psychological stress can play a pivotal role in vulnerable individuals.

  Sleep loss is probably the strongest element in triggering a manic episode, and mania in turn puts the individual at a very much increased risk for depression, mixed states, and subsequent suicide. A sharp reduction in sleep—from stress, grief, childbirth, jet lag, work that involves sudden alterations in sleep patterns (such as military training, shift work, war, or medical internships), acute seasonal changes in light, alcohol or drug abuse—sets in motion powerful biological changes in the brain. Medications such as antidepressants and steroids can also induce profound mood changes or provoke agitated and restless states in vulnerable individuals; so, too, can many medical conditions, such as thyroid disorders, Cushing’s disease, myocardial infarctions, postoperative states, hemodialysis, AIDS, head trauma, stroke, and infections. A diet that results in low levels of cholesterol or is deficient in omega-3 essential fatty acids may also have an impact on the suicide threshold, although the extent of its importance is unclear. Even though, as Emil Kraepelin described nearly a hundred years ago, “the attacks of manic-depressive insanity may be to an astonishing degree independent of external influences,” there is no que
stion that there is a complex causal relationship among the major mental illnesses, behavior, and the physical environment. These in turn exert a strong influence on the underlying biological and temperamental vulnerabilities to suicide.

  There are other major influences on suicide as well. Age is particularly significant. Suicide, we know, is rare before the age of twelve. One percent of all suicides occur in the first fifteen years of life, but 25 percent occur in the second. What causes this abrupt upturn in rates?

  Several researchers have suggested that very young children do not commit suicide because they have highly unrealistic notions of death—more than half of six- to eleven-year-olds, for example, believe that death is reversible—but it is not obvious why such a belief would protect a child against killing himself (indeed, it could be argued that thinking of death in such terms would make suicide more likely). Of more relevance, perhaps, is the fact that the planning and carrying out of suicide are cognitively quite complex, and young children usually lack the necessary ability. Most important, major psychopathology (mood disorders, alcohol and drug abuse, and the psychotic illnesses) is uncommon in very young children. The severe mental illnesses are far more likely to occur first after puberty than before.

  Puberty, which generally begins between the ages of twelve and fourteen, coincides with the first significant rise in the rate of suicide. It brings with it a whirlpool of hormones and a steady increase in the prevalence of major psychiatric disorders. The average age of onset for manic-depression is eighteen; for drug and alcohol abuse and schizophrenia, twenty-one; and for major depression, twenty-six. The rise in the prevalence of severe mental illnesses parallels the rise in suicide, making increasing age a significant risk factor.

  Gender, as well as age, plays a determining role in suicide. Some of the differences in suicide between men and women were discussed earlier: women, although they are more prone to depressive illness than men and are more likely to attempt suicide, do not actually kill themselves nearly as often. To some extent, this is because men are less likely to recognize depression in themselves and to seek treatment for it, but it is also because they are more inclined to drink heavily when mentally ill and to reach for firearms or other highly lethal means in order to kill themselves. Impulsivity and violence, which predispose to suicide, appear to be more innately characteristic of males, although the differences between the sexes in terms of serotonergic functioning have not been well studied.

  There is some evidence that blood levels of serotonin rise during pregnancy, which may partially account for the lower rate of suicide during this period. (Unlike cerebrospinal fluid measures of serotonin, which measure serotonergic functioning in the brain, blood levels of serotonin are strongly influenced by dietary and other factors). The risk for suicide in women in the year following childbirth is generally very low, except in those who have a history of severe psychiatric illness. (For these women the risk of postpartum suicide is much higher.) The evidence is somewhat conflicting for changes in the rates of suicide during different phases of the menstrual cycle, but most studies find an increase in suicides, suicide attempts, and calls to suicide prevention centers during the week immediately preceding menses or during menstruation itself. A London autopsy study of twenty-three women who had killed themselves found, from endometrial examination, that all but one of the women was in the luteal phase of her cycle (that is, in the fourteen days preceding menstrual bleeding). Autopsies of Hindu women who had committed suicide by burning themselves with kerosene revealed that nineteen of the twenty-two were menstruating at the time of death. There is some evidence that suicide attempts during the first week of the menstrual cycle may be associated with low levels of estrogen.

  Although there is a strong male predominance in completed suicides across the world, there are a few countries where this is not true, for example in Malta, Egypt, Papua New Guinea, western Ethiopia, and China. In 1990, more than 180,000 Chinese women committed suicide (during the same time period, 159,000 Chinese men killed themselves), which was more than one half of the world’s female suicides. Most of the five hundred Chinese women who kill themselves every day are young, in their early twenties, and live in rural parts of the country.

  The explanations for such a high rate of suicide in young Chinese women are many and controversial. Among the most logical, although by no means entirely explanatory, is the easy access that rural Chinese women have to deadly pesticides. An impulsive act that would be far less life-threatening if the substance ingested were instead a medication, or if emergency medical care were more readily available, under these circumstances becomes lethal. An impulsive suicide attempt is quickly transformed into suicide.

  Some have suggested that the rapid shift to a market economy may be partially to blame for the high suicide rate, although this is not a situation unique to China, nor is it clear why such a shift should affect women more adversely than men. Others speculate that China, which does not have strong sanctions against suicide, may make it psychologically easier for young women to make the decision to commit suicide. Social scientists have stressed that Chinese society places a low value on women, but while this perception of women’s low status may be true, China is not very different in these attitudes from many other countries that have far lower suicide rates. Family disputes, arranged marriages, and other domestic problems are also important factors, but these or similar stresses and conflicts exist in all societies. They may play a precipitating role, but it is unlikely that they are the primary cause of suicide.

  There is a spirited debate now under way about the extent to which mental illness is central to suicide in China. Michael Phillips, a Canadian psychiatrist based in Beijing, believes that only 50 percent of suicides in China are linked to psychiatric illness, unlike in other countries, which report at least 90 percent. Most of the others, he believes, are impulsive in nature. Andrew Cheng, a Taiwanese doctor, whose studies conclude that more than 95 percent of suicides in Taiwan are closely tied to mental illness—and whose findings are more consistent with those reported elsewhere throughout the world—strongly disagrees with Phillips. It will be some time before these differences of opinion are sorted out, but in the meantime everyone is in agreement that something needs to be done. Recently, Chinese doctors have begun to focus on identifying and treating depression; access to pesticides is being curtailed; suicide prevention programs have been started; and young girls are being taught better ways to handle the stresses they encounter.

  WE ARE, with the rest of life, periodic creatures, beholden for our rhythms to the rotations of the earth around the sun and the moon around the earth. The chemistry of our brains and bodies oscillates in adaptation to the earth’s fluctuations in heat and light, and probably its electromagnetic fields as well. Like other mammals, our patterns of eating, sleeping, and other physical activities sway with the seasons, varying in accordance with changes in day length and temperature. A master biological clock, genetically determined, controls the cycling of our brain’s constituent chemicals and shapes our responses to our physical environment.

  Suicide is far from immune to the effects of the earth’s daily rhythms and yearly seasons. Most suicides occur between 7 A.M. and 4 P.M., which one nineteenth-century scientist (who had observed a similar pattern in a large number of European countries) explained by saying, “Shocks and reverses are most frequently met with in the busiest hours, and to those already sick of the toils and worries of life, entrance upon a new day, no brighter than its predecessors, is often more than they can bear.” Hospital suicides tend to be committed very early in the day, most often between 5 A.M. and 7 A.M. Some of this may be an artifact of activity on the wards and the availability of nursing staff, but more likely it reflects the well-established diurnal variation that exists in moods, particularly in those who suffer from major depression or manic-depression. Mood, especially in individuals with manic-depression, tends to be much worse in the morning and then improve as the day wears on. Cognitive
impairment, including attention, memory, and concentration, reaction time, and physical strength also show profound diurnal fluxes in those with mood disorders. These mood and cognitive changes, and their relationship to diurnal patterns in suicidal behavior, will be discussed more fully in the context of diurnal rhythms in the brain’s chemistry. There is no evidence for a link between suicide and the lunar cycle although the moon may have had a more powerful influence on moods and behavior in the time before modern lighting came into existence. Nor is there a link between suicide and birthdays or national holidays such as Thanksgiving and Christmas. (One study in Britain did find an increase in suicide attempts on Saint Valentine’s Day.) There is, however, a fairly consistent increase in suicides on Mondays. This has been attributed by some to a “broken-promise” effect, a sense of despair or betrayal when the beginning of the new week, which ought to be a psychological beginning, proves not to be any different from the days preceding it. For others, if severely depressed or disturbed, the tasks of the new week, laid out on a desk or in an appointment book, may prove to be crushing.

  The seasonal variation in suicide is one of the most robust and consistent findings in the research literature. In the late 1800s, Enrico Morselli studied suicide in eighteen European countries and showed that in seventeen of them the maximum suicide rate occurred in the spring or summer months. (Conversely, in virtually every country, the minimum occurred in the winter.) Several years ago, I reviewed more than sixty studies of seasonal patterns in suicide and found a similar pattern. The peak months for suicide were, with rare exceptions, in the late spring and summer. Likewise, the lowest rates were always found in the winter months. This late-spring-to-summer peak has also been found in a series of Belgian, Finnish, American, and Chinese studies completed since the time of the review. Seasonal variation in suicide appears to correlate not with the dark and dismal months but with the brightness and extended duration of spring and summer light instead. Consistent with this, studies carried out in the Southern Hemisphere—in Australia, Chile, Uruguay, and South Africa—show that suicide peaks in the months making up their springs and summers. In the Northern Hemisphere, men have one peak in suicide—in April, May, and the summer months—whereas women appear to share that peak but to have a second smaller one in October and November as well.