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  Jewish custom forbade funeral orations for anyone who committed suicide; mourners’ clothes were not encouraged, and burial was generally limited to an isolated section of the cemetery, so as “not to bury the wicked next to the righteous.” The Semachot, the rabbinic text on death and mourning, states that “He who destroys himself consciously (‘la-daat’), we do not engage ourselves with his funeral in any way. We do not tear the garments and we do not bare the shoulder in mourning and we do not say eulogies for him.” Over time, a greater latitude and compassion was extended to suicides committed while of an unsound mind. “The general rule,” states one scholar of Jewish tradition, “is that on the death of the suicide you do everything in honour of the surviving, such as visit and comfort and console them, but you do nothing in honour of the dead apart from burying them.” In Islamic law, suicide is a crime as grave as, or even graver than, homicide.

  Strong religious and legal sanctions against suicide are scarcely surprising; it would be odd indeed if society had no reaction to such a dramatic, seemingly inexplicable, frightening, frequently violent, and potentially infectious form of death. Dante, writing almost seven hundred years ago in The Inferno, assigned a particularly grim fate to those who committed suicide. Condemned to the seventh circle of Hell and transformed into bleeding trees, the damned and eternally restless souls of the suicides were subject to continuous agony and fed upon mercilessly by the Harpies. They who in “mad violence” killed themselves were, unlike all others who resided in Hell, also denied the use of their earthly human forms.

  The civil desecration of the corpses of suicides was common, as were attempts to prevent untoward influence upon the living by physically isolating and constraining the body and its potentially dangerous spirit. The bodies of those who killed themselves were, in many countries, buried at night and at a crossroads. The greater traffic over such crossroads was thought to “keep the corpses down,” and the intersection of paths, it was believed, would make it more difficult for the spirit to find its way home. In early Massachusetts, cartloads of stones were unloaded at the crossroads where a suicide had been buried. Not uncommonly, a stake was driven through a suicide’s heart, a practice that has suggested to at least one scholar its similarity to the fate of a fourteenth-century murderer whose body was discovered years ago in the peat bogs of Sweden. The murderer’s captors, in order to stop the dead man from “walking,” drove birch stakes through his back, side, and heart; they then sank his body into a fen, at the meeting point of four parishes, in the not altogether unreasonable belief that he would be unlikely to escape.

  The Finns believed that because the act of suicide was a sudden one, it was impossible for the living to make peace with the dead, and the soul of the suicide was therefore “particularly restless and spooky.” The body of a suicide victim was handled with dispatch and wariness:

  The deceased was washed as soon as possible after the death and clad in graveclothes. The male deceased were washed by men while the female ones by women. Epileptics, lunatics and suicides were not washed; on the contrary, they were buried prone on their stomach in the clothes they wore when they died. They were lifted into the coffin with pokers, never with bare hands, since it was feared that diseases and curse would catch hold of the family.

  Up to the early 1900’s the one who had committed suicide was buried without any funeral services. The grave was located beyond the fence of the churchyard, often even far away in the woods. It was a general opinion that the corpse of the suicide was heavy. Among the common people there were plenty of stories afloat that the coffin of the suicide had been too heavy even for a horse to haul.

  In France, the body of a suicide was dragged through the streets, head downward, and then hanged on a gallows. French criminal law in the late seventeenth century also required that the body thereafter be thrown into a sewer or onto the city dump. Clergy did not attend the burial of a suicide, and corpses could not be buried in consecrated ground. In parts of Germany, the corpses of suicides were put in barrels and floated down the rivers so that they would not be able to return to their home territories. Early Norwegian laws dictated that the bodies of suicides were to be buried in the forest with those of other criminals, or “in the tide, where the sea and the green turf meet.” Suicide was, strongly and simply put, “an irreparable deed.”

  Gradually, both religious and legal sanctions against suicide lessened. Although many theologians continued to assert that suicide was among the more unforgivable of sins—Martin Luther, for example, wrote that suicide was the work of the Devil; the Puritan religious leaders deemed it abhorrent, despicable, and an “individual submission to Satan”; John Wesley declared that the bodies of those who killed themselves should be “gibbeted and … left to rot”; and philosophers such as Locke, Rousseau, and, more recently, Kirkegaard railed vociferously against any kind of social or religious acceptance of suicide—judicial systems and the public increasingly considered suicide to be an act of an unbalanced mind, rather than the result of weakness or personal sin. Corpses were no longer buried at crossroads; gradually, instead, they were buried on the north sides of churchyards. Rather than suffering damnation in isolation, the bodies of suicides now kept the geographic company of society’s other disreputables and non-Christians: excommunicants, unbaptized infants, and executed felons.

  Robert Burton’s widely read and influential The Anatomy of Melancholy, which depicted with compassion the bonds between madness, melancholy, and suicide and argued for mercy for those who were in such despair and agitation as to kill themselves, was published in 1621. Twenty-five years later, Biathanatos, a landmark treatise about suicide, was published. Its author, poet John Donne, was also the prominent dean of St. Paul’s Cathedral in London. In Biathanatos, Donne declared that suicide was, on occasion, justified; certainly, he argued, it ought to be humanly understandable. It was, for him, personal. “Whensoever any affliction assails me,” he confessed in the preface to his work, “methinks I have the keys of my prison in mine own hand, and no remedy presents itself so soon to my heart as mine own sword.”

  Two recent authors of excellent accounts of suicide trace similar patterns in the changing attitudes and laws in England and the United States. Mark Williams, in Cry of Pain, reports that in mid-seventeenth-century England fewer than one in ten suicide verdicts was judged to be non compos mentis, or due to insanity. By the 1690s that figure had climbed to 30 percent; in 1710 it was 40. By 1800, essentially all cases of suicide were regarded as being due to insanity.

  The Massachusetts Puritans and other early American colonists generally treated those who killed themselves not only as sinners but also as criminals; over time, however, public attitudes and laws changed. In the seven decades from 1730 to 1800, as Howard Kushner has documented in American Suicide, the Boston Coroners’ Juries made one non compos mentis determination for every two or three felonious ones. By 1801–1828, the ratio had flipped: there were two insanity decisions for every one felony suicide; at century’s end, as in England, non compos mentis was the usual verdict in suicide. (Of historical interest, the earliest suicide of an English settler in Massachusetts was probably that of Mayflower passenger Dorothy Bradford, the wife of William Bradford, who became the governor of Plymouth Colony. Dorothy Bradford, it was said, “accidentally fell overboard” from the ship and drowned in Cape Cod Harbor; historian Samuel Eliot Morison and others, however, believe that her death was a deliberate act rather than a mischance. Bradford himself does not mention his wife’s death in his own account of the early colony.)

  Most European countries formally decriminalized suicide in the eighteenth and nineteenth centuries, although it remained a crime in England and Wales until 1961 and in Ireland until 1993. Certainly, public understanding of suicide has increased over recent years, although not to a degree commensurate with what has been learned from medical and psychological research. The harshness of centuries-old views of suicide still touches the present, both in social policy and in mo
re personal ways. In my copy of the Book of Common Prayer, for instance, in the small print that precedes the burial rites—a service that is at once of such consolation and ancient familiarity: “I am the resurrection and the life.… O death, where is thy sting?”—there is a damning reminder of archaic taboos and exclusions: the Order for the Burial of the Dead, the prayer book clearly states, “is not to be used for any that die unbaptized, or excommunicate, or have laid violent hands upon themselves.”

  HISTORY HAS reflected in its laws and attitudes at least a measure of the complexity of suicide. An act against the self, suicide is also a violent force in the lives of others. It is incomprehensible when it kills the young; it is awful in the old, inexplicable in the physically healthy or the successful, and too glibly explained away in the sick or failed. There are no simple theories for suicide, nor are there invariable algorithms with which to predict it; certainly, no one has ever found a way to heal the hearts or settle the minds of those left behind in its dreadful wake. What we do not know kills.

  Yet we know a mastodonic amount about suicide.

  We know, for example, a great deal about the underlying conditions that predispose an individual to kill himself—heredity, severe mental illness, an impulsive or violent temperament—and we know, too, that there are some events or circumstances in life that interact in a particularly deadly way with these predisposing vulnerabilities: romantic failures or upheavals; economic and job setbacks; confrontations with the law; terminal or debilitating illnesses; situations that cause great shame, or are perceived as such; the injudicious use of alcohol or drugs. We have much knowledge, as well, about who commits suicide: the most vulnerable age groups and the social backgrounds and gender of those most at risk; and we know, too, about the hows and wheres and whens of suicide: the methods used; the places, times, and seasons chosen.

  But we are less certain of why people kill themselves. Psychological states, complex motives, and subtle biological differences are difficult enough to ascertain in the living; determining their existence, or the role they may play in those who die by suicide, is something else again. Inevitably, the research literature on suicide reflects the complexities, inconsistencies, and shortcomings in our understanding. It also reflects centuries of attempts to explain the incomprehensible act of self-murder. No one who has had close experience of this literature—the fifteen thousand scientific and clinical papers in the last thirty years alone, as well as the hundreds of books and monographs—can come away from it unimpressed by its depth and breadth of knowledge. No single book, or five, could capture the best of the historical literature or the most exciting of the new scientific and psychological studies.

  I wrote Night Falls Fast with an awareness of these realities and a tremendous respect for the work done by earlier writers and researchers. My hope was to find a way to maintain an individual perspective—through an emphasis on the psychology of suicide and an extensive use of the words and experiences of those who seriously attempted to, or eventually did, kill themselves—but to keep that individual perspective firmly grounded in the sciences of psychopathology, genetics, psychopharmacology, and neurobiology. It is easy to become so focused on individual lives and deaths that one loses sight of the extraordinary scientific and medical advances of recent years—advances that can alleviate great suffering and save lives. Likewise, it is hard not to get so swept up in the excitement of gene hunting, brain imaging, and serotonin pathways that one forgets, as English poet and critic A. Alvarez has put it, that suicide is not only a “desperately sensitive and confused subject,” it is also a problem “to be felt in the nerves and the senses.”

  It should not be necessary, at the end of a century so rich in literature, medicine, psychology, and science, to draw arbitrary lines in the sand between humanism and individual complexities, on the one hand, and clinical or scientific understandings, on the other. That they are bound and beholden to each other should be obvious. Yet it is undeniable that Maginot Lines exist. For many, the aesthetics of complexity—the singular appeal of psychological case histories, especially ones laced with sociological and cultural explanations—are far more compelling than statistical findings obtained from coroners’ reports or DNA gels.

  But such a focus on psychological complexity, at the expense of understanding psychopathological, genetic, or other biological factors, is as certain to fail as any consideration of biological causations and treatment that does not take into account the range of individual differences in experience, behavior, ability, and temperament. For those whose primary interests are in the arts and humanities, it will almost always be more intriguing to read about psychological conflicts or social determinants of suicide—and certainly, such matters are crucial to the understanding of suicide—but these factors alone may not be terribly helpful in predicting or preventing unnecessary early death in others.

  Suicide as an existential issue is a core problem for philosophers, writers, and theologians; it is an issue of importance for most of us, whatever we do or do not believe. (Albert Camus, for one, believed that “Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy.”) But this book, although centrally concerned with the psychology of suicide, is also about suicide as a medical and social problem. Specifically, it is about why suicide occurs, why it is one of our most significant health problems, and how it can be prevented.

  The book’s focus is on suicide in those younger than forty, but this is in no way meant to downplay the terrible problem of suicide in those who are older. Study after study has shown that the elderly are inadequately treated for depression—the major cause of suicide in all age groups—and that suicide rates in the elderly are alarmingly high. Suicide in the older age groups is a topic for a book in its own right, however, and many of the issues raised in the context of geriatric suicide—“rational” suicide and physician-assisted suicide, especially within the context of disabling or life-threatening illness—are much less relevant to those who are younger.

  Suicide in the young, which has at least tripled over the past forty-five years, is, without argument, one of our most serious public health problems. Suicide is the third leading cause of death in young people in the United States and the second for college students. The 1995 National College Health Risk Behavior Survey, conducted by the Centers for Disease Control and Prevention, found that one in ten college students had seriously considered suicide during the year prior to the survey; most had gone so far as to draw up a plan.

  The figures for high school students surveyed in 1997 are even more worrying. One in five high school students said he or she had seriously considered suicide during the preceding year, and most of them had drawn up a suicide plan. Nearly one student in ten actually attempted suicide during the twelve-month period. One out of three of the suicide attempts was serious enough to require medical attention. These 1997 figures for high school students are substantially the same as those reported for high school students in 1995 and 1993.

  Clearly, there is a difference between reporting the presence of suicidal thoughts or plans and actually attempting suicide; so, too, there is a crucial difference between attempting suicide and dying by it. Still, a suicide attempt remains the single best predictor of suicide, and these figures are reason for grave concern. Suicide, by any reckoning, is a major killer of the young.

  Perhaps the magnitude of suicide in the young can best be illustrated by comparing the number of deaths from suicide with those from two other highly publicized causes of death in young men in the United States during the past forty years: the Vietnam War and the acquired immunodeficiency syndrome (HIV/AIDS) epidemic. I have graphed the number of deaths, in males under the age of thirty-five, for each of these three causes (see opposite page). Each—suicide, war, HIV/AIDS—has disproportionately killed young men. Obviously, any kind of death in this age group is terrible, whether it is from war, disease, or one’s own hand. The Vietnam War took an appalling toll, but
after twelve years it was over. A direct comparison of American male war deaths under the age of thirty-five during the official years of the Vietnam War, 1961–1973, with American deaths from suicide in the same age group, during the same time period, shows that there were almost twice as many suicides (101,732) as war deaths (54,708). Most Vietnam War–related deaths occurred during only a portion of those years (1966–1970), however.

  A similar comparison of deaths from suicide and HIV/AIDS, carried out for the ten-year period 1987–1996, shows that almost 15,000 more young men died from suicide than from AIDS. (Although some patients with AIDS committed suicide during this period, they were relatively few.) The American HIV/AIDS epidemic has fortunately become somewhat less lethal in recent years, due to the availability of combination antiretroviral therapy and public health education campaigns. (Of interest, the 1995 National College Health Risk Behavior Survey cited earlier found that one out of two college students received education about HIV/AIDS prevention but fewer than one in five received information about suicide prevention.)

  Deaths in males (35 years or younger)

  Suicide, however, continues unabated, with little evidence of a decline. Indeed, the sharp increase in suicide in adolescents and young adults since the mid-1950s is obvious in the graph. So, too, is the cumulative death toll. Possible reasons for the increase—more accurate ascertainment of suicide deaths by coroners and medical examiners; an earlier and increased access to particularly lethal means, such as firearms; a younger age of first alcohol and drug use; an earlier age of onset of the severe mental illnesses; and increasing rates of depression—are discussed more extensively later in this book. Thirty thousand Americans kill themselves every year and nearly half a million make a suicide attempt medically serious enough to require emergency room treatment.