Night Falls Fast Read online

  In the future, there will almost certainly be biological tests to assess suicidal risk. These tests—whether for specific genetic markers, measures of serotonergic functioning, or neuroimaging studies designed to detect neurochemical and anatomical changes associated with an increased risk of suicide—will at best predict only partially. All are likely to be fraught with clinical and ethical problems. There will inevitably be ambiguities and inaccuracies in interpreting test results and uncertainty about their specificity and predictiveness. There also will be psychological consequences for the individuals who are tested, as well as for their families (and perhaps employment and insurance repercussions, as well), and there are bound to be issues surrounding the cost of and fair access to the tests. If and when these biological tests become available, however, and if they add to our ability to predict suicide or ascertain those at high risk, they will be a tremendous advance on what we now can do.

  For the moment, we know that some groups of individuals are much more likely to kill themselves than others: those who have previously made serious attempts; those who suffer from depression, manic-depression, alcoholism, schizophrenia, or personality disorders; patients who have recently been released from psychiatric hospitals; young men in jails or prisons, especially those who are mentally ill, isolated, or living in overcrowded spaces; police officers; gamblers; the unemployed; homosexual and bisexual men (who have a higher risk for suicide attempts but not as clearly as for suicide); Native Americans; Alaskan adolescents; and, increasingly, young African-American males. Worldwide, young women in China and adolescent boys in Micronesia are among those at particularly high risk for suicide.

  Schools, communities, and national governments have tried, in very different ways, to deal with the problem of suicide prevention in these high-risk groups, as well as in more general populations. Results have been mixed. Most schoolbased suicide awareness programs, though clearly well intentioned, have not been effective and, in some instances, have been inaccurate, misleading, and even damaging. Some investigators report an improvement in children’s knowledge and beliefs about suicide and others cite a decrease in suicidal behavior. Studies commissioned by the governments of Australia, Canada, and the United States have, however, questioned the utility of currently used programs designed to increase awareness about suicide and its prevention. The Australian review, for example, concluded that the data “do not support the promotion of curriculum based suicide prevention programs, and certainly do not support the mandating of such programs in our secondary schools.” Canadians, likewise, found “insufficient evidence to support curriculum-based suicide prevention programs for adolescents,” and a comprehensive American survey of youth suicide prevention programs found “no justification” to mandate such programs.

  Why these discouraging findings? Is the problem with existing programs, or is it inherent in most educational efforts for this age group? Identifiable problems with existing programs and examples of success suggest an unrealized potential for school-based intervention.

  An extensive and withering analysis of school-based programs, published a few years ago in The American Psychologist, focused on several specific criticisms:

  Many curriculum-based programs are not clearly founded on current empirical knowledge of the risk factors of adolescent suicide. By deemphasizing or denying the fact that most adolescents who commit suicide are mentally ill, these programs misrepresent the facts. In their attempt to destigmatize suicide in this way they may be, in fact, normalizing the behavior and reducing potentially protective taboos.… The incidence of adolescent suicide is sometimes exaggerated in suicide prevention programs because one of the programs’ goals is to increase awareness and concern about the problem.… The danger of exaggeration is that students may perceive suicide as a more common, and therefore more acceptable act.… Magnifying the incidence of the problem is one indication that the developers of curriculum-based programs have not heeded the substantial literature on the imitation or contagion effect in adolescent suicide. Another is the common use of print or visual media to present case histories of adolescents who have attempted or committed suicide. The purpose is to teach students how to identify friends who may be at risk for suicidal behavior. However, the method may have a paradoxical effect in that students may closely identify with the problems portrayed by the case examples and may come to see suicide as the logical solution to their own problems.… Finally, at the most practical level, suicide prevention programs may never reach their target population, adolescents most at risk for suicide. Incarcerated and runaway youths, as well as dropouts, have extremely high rates of suicide.

  Other researchers and clinicians have criticized schoolbased programs for the diffuseness of the audience they aim to reach (all students, rather than those at highest risk), as well as the inaccuracy of the information given about suicide. An in-depth study of 115 school-based suicide prevention programs for adolescents discovered that most of them were only two hours or less in duration and that the majority of the programs focused almost exclusively on a “stress model” of suicide; that is, a model that assumes suicide is a response to extreme stress and that in essence, given sufficient stress, suicide could happen to anyone. Only 4 percent of the programs they reviewed presented the perspective that suicide is usually a consequence of mental illness. Disturbingly, the reviewers also discovered that “students who indicated having made a prior suicide attempt (approximately 11% of the sample) reacted in a generally more negative fashion to suicide prevention curricula. A greater proportion found the program less interesting or helpful, and were troubled by the program.… [A] greater proportion of prior attempters who attended a program than attempters who didn’t attend said they would not want to reveal suicidal preoccupations to others, stated they did not believe that they could be helped by a mental health professional, and that suicide was a reasonable solution to problems.”

  The results of such programs, although discouraging, point out some of the difficulties that need to be resolved. It is clear that the medical dictum of “First, do no harm” needs to be at the heart of any thinking about school programs designed to prevent suicide. It is important, as well, that school administrations avoid romanticizing suicide and that they place the primary emphasis of their educational and screening efforts on recognition and treatment of mental illness and substance abuse.

  David Shaffer and his colleagues at Columbia University in New York have developed a promising program that systematically screens high school students for known predictors of suicide. (There are no lectures given about suicide, and no responsibility is placed on teachers or students to “act like mental health professionals.”) If, when a student fills out a brief self-report questionnaire, the responses indicate that he or she may be at risk, he or she then completes a computerized diagnostic interview. The computer generates a diagnostic impression that is given to the clinician, who, in the third and final stage of the process, personally interviews the student. On the basis of this interview, the clinician determines whether the student should be referred for treatment. A case manager gets in touch with the parents if treatment is necessary and helps to facilitate follow-up care.

  The Columbia program has been very effective in locating students at risk for suicide and getting them into treatment. (Of the students who were identified through the screening process as suffering from major depression, only a third were in treatment. Of those who had actually attempted suicide, only half were receiving treatment.) The screening system is now being used by more than seventy groups worldwide, including schools in South Africa and Australia, as well as in the United States.

  Community-based suicide prevention programs, such as the Samaritans in Britain and the Suicide Prevention Centers in America, have not had a demonstrable effect on suicide rates. An early study suggested a possible lowering of the suicide rate in communities that maintained Suicide Prevention Centers, but virtually every study since has found little or no impact. This
lack of effect is counterintuitive in many ways, but not entirely surprising: Suicide Prevention Centers and crisis hotlines, although very helpful to many people, tend not to be used by the most severely depressed or suicidal individuals. Additionally, many suicides are impulsive, which generally precludes contacting anyone. An analysis of the types of patients and callers to Suicide Prevention Centers suggests that the majority are in need of help but are not suicidal.

  Suicide prevention is not just a clinical problem. Society must deal with the potentially infectious repercussions of suicide, especially among the young, and must somehow try to keep a single tragedy from progressing to deaths of others. The contagious quality of suicide, or the tendency for suicides to occur in clusters, has been observed for centuries and is at least partially responsible for some of the ancient sanctions against the act of suicide. Epidemics of suicide occurred among soldiers and citizens during Greek and Roman times, for instance, as well as among worshipers of Odin in Viking society. Occasionally, decisive action on the part of a leader prevented further catastrophe.

  Six hundred years before Christ, for example, the king of Rome ended a suicide epidemic among soldiers by declaring that the bodies of all suicides were to be nailed to a cross and put on public display. In the fourth century B.C., to stop a widespread epidemic of suicide among young Greek women, a local magistrate decreed that “the body of every young woman who hanged herself should be dragged naked through the streets by the same rope with which she committed the deed.” The epidemic soon stopped. Centuries later, a similar law was passed to halt a suicide epidemic among young women in Marseilles. Again, the threat of public exposure and nakedness appeared to stop the wave of self-inflicted deaths.

  One grenadier in the army of Napoleon Bonaparte killed himself, and then another did. Napoleon moved swiftly to stop the spread of suicide in his troops by issuing an order:

  The grenadier Groblin has committed suicide, from a disappointment in love. He was, in other respects, a worthy man. This is the second event of the kind that has happened in this corps within a month. The First Consul directs that it shall be notified in the order of the day of the guard, that a soldier ought to know how to overcome the grief and melancholy of his passions; that there is as much true courage in bearing mental affliction manfully as in remaining unmoved under the fire of a battery. To abandon oneself to grief without resisting, and to kill oneself in order to escape from it, is like abandoning the field of battle before being conquered.

  The order worked; no suicides were reported for a long time afterward.

  The tendency for suicide to incite imitation, especially if the death is highly publicized or romanticized, is persistent. In September 1774, Goethe published The Sorrows of Young Werther, a book that portrayed a young man who shot himself over the love of a woman. It became a best-seller, as well as the impetus for a spate of suicides: young men were found dead by gunshot, dressed in blue frock coats and yellow waistcoats, with a copy of Goethe’s novel nearby. In an attempt to stop the epidemic of suicides, the book was banned in Italy, Germany, and Denmark. In 1974, the sociologist David Phillips coined the phrase “Werther effect” to describe the phenomenon of suicide contagion.

  Suicide is contagious among family members, as well as among strangers or acquaintances. Olive Anderson describes this in her book Suicide in Victorian and Edwardian England:

  There are many examples of a particular method of suicide running in a family. Experienced coroners knew that one suicide was apt to breed another of the same type, and some made it a rule never to return the razor, cup or gun used for suicide to the relatives, even when they asked for them as a memento, since a suicide instrument had a dangerous fascination. They tried, too, to stop local publicity being given to a suicide in the neighbourhood by an exotic method or in an unusual place. Opinions differed over whether or not the act of suicide itself was likely to be the result of “emotional contagion,” but all agreed that the precise method or place chosen was often the result of imitation. Nor was the field of contagion necessarily limited to the local neighbourhood. The nation-wide publicity given by the press to outstanding sensational or “human interest” stories wherever they took place was repeatedly shown to be baneful and regretted.

  There has been no shortage of suicide clusters in recent years: they have occurred in psychiatric hospitals and clinics; in suburban America—Plano, Texas; Leominster, Massachusetts; Clear Lake, Texas; Mankato, Minnesota; Bucks County, Pennsylvania; Fairfax County, Virginia; South Boston; New Jersey; South Dakota—and on college campuses (there were, for example, six suicides within three months at Michigan State University). There have been suicide outbreaks in Alaskan Eskimo villages, on Canadian Indian reservations, in Japan, in England, and in virtually every country that keeps records of such death patterns. Suicide clustering is primarily, but by no means entirely, a phenomenon of the young. Its mechanisms are diverse and contested. Imitation plays an important role, of course, but presumably a suicide disinhibits or triggers suicidal behavior only in an already vulnerable individual (in a study of two clusters of suicides in Texas, for example, one in which eight adolescents enrolled in the same school district committed suicide within a fifteen-month period and another in which six adolescents killed themselves within a two-to-three-month period, those who committed suicide were more likely than control subjects to have had a history of suicide attempts, threats, and self-destructive behavior). Implausibility also weighs in. Adolescents often imagine that the attention or retaliation denied to them in life may come their way through death or that suicide is made more acceptable by its having been carried out by others more famous or accomplished.

  Many researchers believe that highly publicized media accounts of suicide lead to an increase in suicidal behavior, while others are less certain. Most agree that the strongest impact is on teenagers and concur that the content of the story and the style in which it is reported—be it through newspapers, radio, television, or film—have an influence for better or worse. In Austria, after members of the media consulted with suicide experts, the sensationalized coverage of suicide epidemics sharply declined. In Hungary, beginning in the early 1980s, the media have given less coverage to prominent or sensational suicides and more to the link between mental illness and suicide; the German media have also focused more on the relationship between suicide and psychiatric disorders.

  In 1994, in an attempt to minimize the possibility of suicide contagion, the Centers for Disease Control and Prevention published recommendations for the media. The guidelines, while acknowledging that “suicide is often newsworthy, and it will probably be reported,” also emphasized that “all parties should understand that a scientific basis exists for concern that news coverage of suicide may contribute to the causation of suicide” and that “public officials and the news media should carefully consider what is to be said and reported regarding suicide.” Specifically, the public health facility’s staff outlined certain aspects of news coverage that can promote suicide contagion:

  Presenting simplistic explanations for suicide. Suicide is never the result of a single factor or event, but rather results from a complex interaction of many factors and usually involves a history of psychosocial problems. Public officials and the media should carefully explain that the final precipitating event was not the only cause of a given suicide. Most persons who have committed suicide have had a history of problems that may not have been acknowledged during the acute aftermath of the suicide. Cataloguing the problems that could have played a causative rode in a suicide is not necessary, but acknowledgment of these problems is recommended.

  Engaging in repetitive, ongoing, or excessive reporting of suicide in the news. Repetitive and ongoing coverage, or prominent coverage, of a suicide tends to promote and maintain a preoccupation with suicide among at-risk persons, especially among persons fifteen to twenty-four years of age. This preoccupation appears to be associated with suicide contagion. Information presented to the media
should include the association between such coverage and the potential for suicide contagion. Public officials and media representatives should discuss alternative approaches for coverage of newsworthy suicide stories.

  Providing sensational coverage of suicide. By its nature, news coverage of a suicidal event tends to heighten the general public’s preoccupation with suicide. This reaction is also believed to be associated with contagion and the development of suicide clusters. Public officials can help minimize sensationalism by limiting, as much as possible, morbid details in their public discussions of suicide. News media professionals should attempt to decrease the prominence of the news report and avoid the use of dramatic photographs related to the suicide (e.g., photographs of the funeral, the deceased person’s bedroom, and the site of the suicide).

  Reporting “how-to” descriptions of suicide. Describing technical details about the method of suicide is undesirable. For example, reporting that a person died from carbon monoxide poisoning may not be harmful; however, providing details of the mechanism and procedures used to complete the suicide may facilitate initiation of the suicidal behavior by other at-risk persons.

  Presenting suicide as a tool for accomplishing certain ends. Suicide is usually a rare act of a troubled or depressed person. Presentation of suicide as a means of coping with personal problems (e.g., the breakup of a relationship or retaliation against parental discipline) may suggest suicide as a potential coping mechanism to at-risk persons. Although such factors often seem to trigger a suicidal act, other psychopathological problems are almost always involved. If suicide is presented as an effective means of accomplishing a specific end, it may be perceived by a potentially suicidal person as an attractive solution.