Lecture 9
      
                               Mood Disorders: Suicide
      
      
      Lecture Outline
      
      I.  Introduction
      II. Who Commits Suicide?
           A. Age
           B. Race
           C. Sex
           D. Marital Status
           E. Occupational and Educational Status
           F. Psychiatric History
           G. Culture
      III.Why Do People Commit Suicide?
           A. Cognitions 
           B. Loss
           C. Communication
           D. Current State
           E. Social Factors
      IV. Prevention
      [Film/Guest Speaker]
      
                     -------------------------------------------
      
      I. Introduction
      
           The effects of Mood Disorder on an individual's life can be
      profound and devastating.  The DSM-III-R list of symptoms make this
      clear:  behavioral, cognitive, physiological, and emotional consequences
      are all an aspect of the Mood Disorders.  In addition, there are often
      relationship difficulties, occupational problems, and substance abuse. 
      The potential and most tragic consequence is self-destruction. 
      (Depression is certainly not the only cause of suicide - Suicide is also
      clearly associated with Schizophrenia, substance abuse, and some of the
      personality disorders, for example).
      
      Some estimates (Carson, et al., 1988; Klerman, 1982; Wekstein, 1979):
      
      Suicide is one of the leading causes of death in Western countries,
      and rates are on the rise in the U.S.
      
      In the U.S.:
      
      200,000 persons attempt suicide each year
      
      27,000 successful each year (about one every 20 minutes)
      
      A major cause of death for adolescents and young adults (10,000 or  
       more college students every year attempt suicide)
      
      [These numbers are undoubtedly underestimates - suicide is often
      kept secret by family and even by professionals]
      
      II.  Who commits suicide?
      
           Depression is clearly associated with suicide: perhaps more than
      half are depressed (Barraclough, Bunch, Nelson, et al., 1974; Murphy,
      1983).  The lifetime risk of suicide for people with Mood Disorders has
      been estimated to be anywhere from 15% to 50%  to even 90% (Murphy,
      1983). 
           Note:  Much of what we know about the characteristics of suicide is
      based on "psychological autopsies":  interviews with close friends,
      relatives, doctors, etc. conducted shortly after the death.  Problems
      with this approach include things like memory biases, intentional
      distortions. 
      
           Other characteristics of people who commit suicide:
      
      A. Age:  Suicides are attempted by preteens to the elderly, but
      rates are highest for people between the ages of 45 - 60 (Davison &
      Neale, 1986).
      
      B. Race:  Suicide rates are greater for whites than nonwhites
      (Firestone, 1986; Seiden, 1984).
      
      C. Sex:  Three times as many men as women succeed at killing
      themselves (Davison & Neale, 1986; Firestone, 1986).  But three
      times as many women as men attempt suicide (Davison & Neale, 1986). 
      This is because women tend to act impulsively, are relatively
      public about their attempts, and tend to use relatively less
      serious means.  Men, in contrast, tend to give prior warning signs
      of their intentions (indicating that the act was not purely
      impulsive, but thought out in advance), and they use highly
      effective methods (eg: a gun, jumping from a high place) (Clayton,
      1983).
      
      D. Marital Status: People who are single, divorced or widowed are
      2-3 times as likely to commit suicide as married people, especially
      among men (Clayton, 1983; Murphy, 1983).  For married women (esp.
      ages 20 to 30), there is some evidence that they are more likely to
      attempt suicide than single women (Shneidman & Farberow, 1970).  
      
      E. Occupational and Educational Status:  White collar workers are
      more likely to commit suicide than blue collar workers (Firestone,
      1986).  At particular risk are white males with affluent
      backgrounds (Seiden, 1984), for example: psychiatrists,
      psychologists, physicians and lawyers (Davison & Neale, 1986).  In
      addition, college students who excel in academics are more likely
      to commit suicide, perhaps because they tend to be the most self-
      critical (Seiden, 1966; Firestone, 1986).  
      
      F. Psychiatric History:  Individuals who have mental health
      problems and individuals who have been hospitalized because of such
      problems are at greater risk for suicide (Clayton, 1983; Murphy,
      1983; Motto, 1979).  Especially at risk are those with MAjor
      Depression, Bipolar Disorder, or chronic alcoholism.
      
      G. Culture:  Suicide rates vary from one culture to another.  For
      example, here are some suicide rates (per 100,000) for a number of
      different cultures (DeCatanzaro, 1981; Kidson & Jones, 1968;
      Wekstein, 1979):
      
      Aborigines
      of Australia............0.0
      
      Greece..................less than 9.0
      
      United States...........12.2
      
      Sweden..................20.8
      
      Czechoslovakia..........22.4
      
      Hungary.................40.7
      
      H. Handout 9-1 includes some of these factors, as well as other
      factors, which distinguish between high-risk and low-risk groups.
      
      III. Why do people commit suicide?
      
           There are numerous attempts to explain why someone would want to
      kill themselves.  Yet, even with these theories, it is notoriously
      difficult to predict who will actually attempt suicide (Murphy, 1983). 
      We will review some of the theories that have been suggested by
      investigators.  Each of these theories undoubtedly captures only certain
      aspects of this very complex phenomena.  Perhaps the most fruitful
      approach will thus be a theory that combines variables from these
      various approaches.  
      
      A. Cognitions:  Various theories have been developed that place
      cognitions (beliefs, imagery, thought processes, etc.) in a central
      causal role for psychological disorders (eg: Beck & Emery, 1985;
      Ellis & Harper, 1976).  A person contemplating suicide may do so
      because he or she wishes to make amends for some act committed, or
      rid him/herself of unacceptable thoughts, or because of other
      thoughts or cognitions he/she has (Mintz, 1968).  Freud believed
      suicide was a result of aggression turned inward - we're angry at
      mom, but that's unacceptable, so we turn it in on ourself. 
      Excessive self-criticism and self-aggression are also often posited
      as the reason for suicide.
      
      Example: The "Inner Voice" (Firestone, 1986) - Some people
      have a system of hostile thoughts and attitudes that
      constantly nag, judge, attack and punish oneself.  This inner
      voice is part of one's "internal dialogue" (the thoughts that
      run through our heads all the time).  For example:
      
      "You clumsy fool!  Look at what you did!"
      "Can't you do anything right?"
      "Oh no.  I know I'll make a fool of myself."
      "I can't do that, I'm too stupid."
      
      The "voice" operates on a continuum:  We have all experienced
      it to some extent.  When it becomes vicious and predominant,
      self-destruction may result (eg: substance abuse, psycho-
      somatic illness, suicide).
      
      The voice is learned:  Typically arising because of overly
      punitive and critical parents (or other important persons)
      during one's childhood.  This attitude then became internaliz-
      ed.  Although it is likely that innate factors such as
      temperament may set the stage for one's inner voice.
      
      B. Loss:  The loss of a loved person may result in great despair
      and hopelessness.  Even Freud experienced the effects of lost love: 
      At 29, he wrote a note to his fiancee:  "I have long since resolved
      on a decision (suicide), the thought of which is in no ways
      painful, in the event of losing you" (Jones, 1963, p.85)/ 
      
      C. Communication:  Two-thirds of all suicide attempts are estimated
      to be actually attempts to communicate something to others (Carson,
      et al., 1988).  For example: the need for love, the desire for
      others to feel guilty, unmet needs in general.  Thus, the method
      used in the attempt is typically nonlethal, and it is done when and
      where others are likely to discover the person and intervene.
      
      D. Current State:  The intention to kill oneself is not a constant
      condition for the individual.  It comes and goes.  This suggests
      that the intention to commit suicide is "state-dependent": the
      intent only arises when the person is in an appropriate state
      (cognitive state, mood state...).  For example, there is some
      evidence that indicates suicide rarely occurs in a person who is
      not currently going through a depressive episode (Murphy, 1983). 
      It should be noted, however, that other evidence suggests that it
      is when the depressed person is beginning to feel better that
      suicide risk is highest (Beck, 1967).
      
      E. Social Factors:  Emile Durkheim, a famous Sociologist of the
      1800's, identified three types of suicide.  According to Durkheim
      (1951), the motivation to commit suicide is largely a social
      phenomenon.
      
      Durkheim's three types of suicide:
      
      1. Altruistic Suicide - A person who highly identifies with a
      social groups' morals, interests, and norms will be willing to
      sacrifice his/her life for the goals of the group.  Or, the
      sacrifice may arise because the group requires a his/her
      death, or in other cases because he/she violated certain group
      norms.  What ever the case, the person willingly commits
      suicide because of his/her high integration with the group.
      
      Examples:
      
      a) Jonestown mass suicide: more than 900 followers
      of the religious leader Jim Jones committed suicide
      in 1978 in an isolated commune in Guyana
      b) Martyrs
      c) Kamakazie pilots of the Japanese WWII airforce
      
      2. Egoistic Suicide - In this case, the individual is weakly
      integrated into the group.  Durkheim described these people as
      self-centered, with no emotional attachments to others or to
      the group.  Thus, he/she loses social restraints, he/she has
      no sense of commitment, and so judges that suicide will not
      effect anyone but him/herself.
      
      3. Anomic Suicide - Durkheim described a state of being called
      "anomie": a sense of normlessness that one experiences when
      one has no clear idea of what the expectations of the group
      are in terms of moral and appropriate behavior.  He or she is
      left in a state of limbo and disorientation.  Anomie occurs
      during times of rapid social changes, when one's relation to
      the group changes in sudden and unanticipated ways.  The rapid
      social changes Durkheim discussed were 1) industrialization,
      2) urbanization (the growth of and move to cities), 3)
      modernization.  These changes are still occurring.  The world
      of your parents childhood was very different from yours.  How
      do you learn the rules?  What are the rules?  Such uncertainty
      may increase the risk for suicide.
      
      IV. Prevention
      
           [Film or Guest Speaker]
      
      Suggestions for films:
      
      1. Depression and suicide:  You can turn bad feelings into
      good ones.  26 minutes, Pennsylvania State Univ: Psychological
      Cinema Register.  Explores some of the causes of depression in
      teenagers and ways to prevent such feelings of loneliness or
      sadness from becoming overwhelming.
      
      2. The suicide clinic.  28 minutes, University Extension,
      Indiana Univ: Audio Visual Center.  Illustrates work of
      suicide clinic, and discusses psychological characteristics of
      suicides.  Links most suicides with long-term depression.
      
      Suggestions for Guest Speakers:
      
      1. Paul Joffe, and/or 
         Judy Ellickson
         (University of Illinois Counseling Center's "suicide team")
      
      2. Grant Willis or Dave Crowley
         (CCMHC crisis services, including crisis line)