Suicide has been practised in every culture and religion, all around the world, throughout history. The first account may be that of Pyramus and Thisbe, Babylonian lovers who independently killed themselves because each thought the other dead. Suicides are reported in the Iliad (Ajax), the Bible (Judas), Aesop’s fables (snake and wasp), Metamorphoses (Hercules), the Kalevala (Aino) and the Edda (Brunhildr). Novelists who have included suicidal behaviour as a plot component include Boccaccio, Cervantes, Thackeray, Dostoevsky and Tolstoy; poets who have dealt with the issue include Burns, Paterson, Yeats, Plath and many others.
Suicide is a response to (or escape from) intolerable circumstances, such as an unhappy or broken marriage or partnership, public disgrace, incarceration, infirmity, painful illness and social problems. Poverty is often a factor—whenever there is a drought in India, we read of waves of Indian farmer suicides.
Over the last century medical authorities have claimed suicide is always or almost always caused by mental disorder. This belief is incorrect, and has stifled community understanding and delayed trials of potentially helpful solutions.
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It is known that people with mental disorder are more likely to commit suicide than those without mental disorder. However, the group without mental disorder is larger than the group with mental disorder, and contributes more to the total suicide deaths. With respect to suicide, mental disorder is best construed as another painful predicament which may be avoided via suicide.
How mental disorder was established and has been maintained as central to suicide is an uncertain, complicated story. One factor is that psychiatry has “medicalised” the human condition—reclassified non-psychiatric human states as psychiatric disorders. All manner of disappointment and unhappiness can be mis-diagnosed as a form of “depressive disorder”. The “proof” of the centrality of mental disorder in suicide comes from a retrospective research method called “psychological autopsy” (PA). In PA, people look at details of the lives of people who have suicided and make a decision as to whether or not the decedent was suffering a mental disorder at the time of their death. The PA method has been heavily criticised.
The medicalisation of distress and suicide delivers some individuals authority and celebrity. Other well-meaning individuals make the leap from “this is a terrible situation and I wish something could be done to fix it” to “something can be done”. Further, a large amount of research money is available for suicide prevention, and it makes sense to fence off your own piece of turf.
There is an apparently reasonable belief that if we could identify all the “risk factors” for suicide, we could prevent all such events. Research into “risk factors” for suicide has been conducted for well over half a century. No useful progress has been made (which is not surprising, given that each individual has different genes and a unique background, and life has infinite types of unpleasant predicament) and risk ranking has been recently debunked. However, when suicide occurs in custodial settings (as is inevitable) coroners and “critical events teams” are quick to criticise security officers harshly in the case of prisons and doctors in the case of hospitals, on the basis that, in retrospect, “risk factors” identified the individual as needing additional supervision.
The problem with suicide “risk factors” is that while they may indicate a population at greater risk, they do not identify the individuals who are going to suicide. They make a vast number of false positives—that is, they indicate a huge population as being at increased risk, but the overwhelming majority of them do not suicide. For example, the greatest risk factor for suicide is being male—around the world three times more men kill themselves than women. In a men’s section of a prison, all the prisoners are men, so they are all at increased risk, but only a minority will harm themselves. Other factors which indicate increased risk include frequent use of alcohol, marital difficulties, unemployment and impulsivity. Again, these factors are common among prison inmates (and civilians), and services cannot provide special care for all people all the time. Most of the people who walk free from prison every day could have been identified at some time during their incarceration as being at “high risk” of suicide. Australian researchers are world leaders in correcting the unrealistic expectations of “risk factors” as the means of preventing suicide.
If we focus exclusively on the medical explanation of suicide, we overlook what other fields have to contribute. One hundred and twenty years ago, the French sociologist Emile Durkheim made the spectacular claim that suicide was generally a feature of society, rather than the individual. He taught that when the individual is not sufficiently integrated into society, there is an increased chance of suicide, and this integration largely depends on societal features.
Having admitted the influence of society, it is possible to push the door a little further open and admit the influence of culture—that is, the attitudes, beliefs and responses common to people living in a particular region. Perhaps the most amazing, and certainly the most often ignored fact about suicide, is that different countries and regions have different suicide rates. These differences continue from decade to decade, and are stable for most places. The Greek suicide rate was 2 to 4.5 deaths per 100,000 people per year for fifty years from 1960. It has recently increased to 5 or 6 since the beginning of the Greek financial crisis. The Netherlands rate is around 8.5, and has been in the range 7.5 to 12.5 for the last fifty years. Australia’s rate is around 10, and has been in the range 9 to 15 for the last fifty years. Lithuania’s rate is around 32 and has been in the range 25 to 35 for the last fifty years. There have been some dramatic changes, such as South Korea, where the rate increased from 7.9 in 1990 to 32 in 2011, but these are exceptions. The problem for South Korea is rapid Westernisation, with resultant damage to the traditional culture.
If mental disorder was the key determinant of suicide, Australia would have three times more mental disorder than Greece, and Lithuania would have three times more mental disorder than Australia. Studies of the rates of mental disorder around the world prove this is not the case—most countries have similar rates of mental disorder.
The different suicide rates of different countries reflect economic, social and cultural differences. The impact of disadvantage and loss of opportunities, goals and self-esteem is clear when aboriginal cultures are disrupted by dominant cultures. The indigenous peoples of Australia, New Zealand, Greenland, Canada and the USA all have very high suicide rates.
Each culture has customary responses to circumstances. Suicide may be conceptualised as a customary response which may be elicited differently in different cultures. This explains much of the difference in suicide rates around the world. Additionally, as noted above, when a culture is disrupted and the traditional supports and goals no longer serve, the suicide rate increases. Wealth status and changes in that status, the quality of housing, child care, transport, nutrition and justice may all affect the desire of the individual to escape, using suicide.
A current suicide prevention method is to stop people talking about suicide so that this response will not be suggested to others. “Experts” develop protocols which journalists should follow when writing about suicide, because of the supposed danger of “copycat” suicide (especially after the suicide of a celebrity). There is no convincing science to support these rules—but, when a lobby group has sufficient traction and conviction, real evidence is not required.
Rather than keeping quiet about suicide, perhaps we should talk about it more. Suicide is a public health issue. Smoking and road deaths are public health issues which have responded to discussion, education and rule changes. Smoking was reduced remarkably by public education, discussion and some sensible taxes. Road deaths were reduced, again, by public education, discussion and rules about roadworthiness, safety belts, speed, and blood drug and alcohol limits. Suicide should be approached in a similar way. In addition to education and discussion, access to lethal means could be reduced, high fences along bridges being an obvious example.
Our current approach to suicide is to see it as an illness or the result of an illness, and provide “treatment”. We call on health professionals, when what most individuals need are friends, family, elders, warmth, encouragement and common sense. Of course, those who do have mental disorders need specialist care. If we want to prevent suicide we need to acknowledge its ubiquity, improve the circumstances of our people, encourage them, teach them alternative, adaptive responses, and have the topic ventilated rather than suffocated.
Saxby Pridmore is Professor of Psychiatry at the University of Tasmania.