Suicide

  Suicide is a tragic, but not infrequent, occurrence in psychiatry. About a quarter of those who commit suicide are in current contact with psychiatrists and in the UK two-thirds have consulted their GP in the last month (40 per cent in the last week). The psychiatric disorders with the highest risk for suicide are alcoholism and depression, although it is increasingly recognized as a long-term risk in psychotic disorders and anorexia nervosa. Although suicide attempts are more common in young people and women, completed suicides are three times as common in men and increase steadily with age. Because of the distress and stigma associated with suicide (attempted suicide has been punished as a crime in many societies and was illegal in the UK up till the 1960s) some have sought to show that almost all who commit suicide have some form of mental illness. This is fairly unconvincing but understandable as the state of mind of the person who committed suicide used to have serious implications (such as loss of the right to burial in consecrated ground).

  The French sociologist Durkheim’s book La Suicide published in 1897 opened a dramatically different perspective. It focused on the different rates of suicide in Catholics and Protestants and emphasized the importance of social isolation. He believed the Catholic faith protected from suicide and Catholic countries indeed do report lower suicide rates. This may be because they are more reluctant to acknowledge a death as suicide; in Dublin in the 1970s psychiatrists asked to assess the cause of sudden deaths concluded suicide four times as frequently as did local coroners. However there are undoubtedly variations in suicide rates between different countries.

  Contrary to enduring myth, it is not Sweden that has the highest suicide rate but the countries of central and eastern Europe – e.g. Hungary, the Czech Republic, former East Germany. Currently there are astronomically high suicide rates in the collapsing former Soviet Union, with rates of 70 male suicides per 100,000 population (compared with the US 17 and the UK 12). Lithuania has the highest recorded rate at 76 per 100,000 and dramatically demonstrates the societal influence on suicide rates. As Russian speakers have gone from being the privileged elite to being the unwelcome minority their suicide rate is now much higher than Lithuanian speakers. It was previously the other way round. Nor are differences just reporting practices. The same national rankings are maintained in immigrants to the US from these different countries.

  With such an environmental effect it could be argued that suicide is not a particularly psychiatric issue. But there is some encouragement that psychiatry is able to influence suicide. There is no specific ‘anti-suicide treatment’ (apart from some rather specialized psychological interventions to reduce suicidal ruminations in chronic depression). However, active identification of mental illnesses and their treatment may have an impact. There is no truth in the old wives’ tale that those who talk about it don’t do it (as 40 per cent consulting their GP in the preceding month testifies). A programme of teaching GPs on a Swedish island to enquire about depression and suicidal thinking and then treat the depression demonstrated a fall in the rate.

  There are also known risk periods (e.g. just after discharge from psychiatric hospital) when extra support can make all the difference. The suicidal impulse is not static – it comes and goes. Consequently simply making it more difficult does reduce the risk – reducing the pack size of dangerous painkillers has significantly reduced deaths in the UK as has introducing non-lethal gas instead of the old coal-gas. Even netting off bridges helps – perhaps introducing delay and time to reflect, allowing the impulse to fade. The worldwide access to help lines such as the Samaritans who offer a sympathetic ear attests to the need to think things through and make human contact.

  While the last century saw an overall decline in the suicide rate (with two marked dips during the wars) there is continuing cause for concern. There has been a steady rise, worldwide, in suicides in young men, and rates in some high-risk groups (small farmers, young South Asian women) are still distressingly high. Some of this is due to easy access to lethal means (pesticides and shotguns for farmers and an increasing use of car exhaust fumes) but some is probably due to weakening family ties, a sense of powerlessness plus the complications of drug and alcohol misuse.

  Perhaps even more challenging is the change in society’s attitudes towards suicide. While still desperately traumatic for the family it now attracts little stigma. Indeed it is increasingly seen as just one more option available to individuals with serious and painful illnesses (always a high-risk group) or those who feel their life has run its course. Switzerland has legalized assisted suicide in such cases, although those with mental illnesses are generally excluded. As living wills become increasingly accepted and if legally assisted suicide spreads from Switzerland (as it undoubtedly will), suicide may over time be seen as again more a moral and ethical issue of personal autonomy rather than a psychiatric one. Even more important, then, that suicide driven by judgements distorted through the lens of a mental illness should be prevented to protect such true autonomy.