Geo Stone
The sociological perspective looks at society's influence on its members; how do various social conditions (and their changes) affect suicide rates. Examples of such social variables are income, unemployment rate, birth order, gun ownership, divorce, and immigration. As its most eminent early proponent, Emile Durkheim, said, "social facts must be studied as things, as realities external to the individual."
The sociological/statistical study of suicide actually began in the 1820's with research by Jean-Pierre Falret in France, and Johann Casper in Germany. Durkheim organized the earlier work and integrated it into a theoretical framework in the late 1800s. His ground-breaking book Suicide: A Study in Sociology was published in 1897.
Durkheim felt that the Industrial Revolution had massively disrupted Western communities. As a result, people who didn't have the structure of ties to family or religion became particularly susceptible to suicidal urges. He called suicide due to such social disintegration "anomic".
In other societies the individual is so highly integrated into the community that his life and behavior are tightly governed by the community's customs. In these circumstances, most suicide occurs because it is expected, almost required, rather than from personal sorrow or guilt.
Examples of such "altruistic" suicide include the Indian custom of suttee where widows (but not widowers) burn themselves to death; Japanese seppuku or hara-kiri where ritual disembowelment (sometimes followed by coup-de-grace decapitation) prevents, or atones for, dishonor. Among military officers in nineteenth-century Europe, suicide-by-pistol was the expected response to inability to pay gambling debts.
Suicide by groups seeing themselves as persecuted also falls into this category; the Branch Davidians (Waco, Texas, 1993) for example, or the members of the People's Temple at Jonestown (Guyana, 1978), who held suicide "rehearsals".
Durkheim's third category, "egoistic" suicide, describes individuals who lack involvement with their reasonably stable societies. Such people are often "misfits" or "criminals". A prototypic example might be an unemployed, isolated, man or woman living alone in a rooming house.
Sociology's forte is the statistics of suicide. Its self-acknowledged limitation is that it doesn't tell us anything about why one person kills himself while another person, in similar circumstances, doesn't.
One other weakness of this method was that it offers no good explanation of cultural and national differences. For example, if, as frequently claimed, Catholic countries have lower suicide rates than Protestant ones because Catholicism is the more cohesive religion, why does Catholic Hungary usually have the highest suicide rate in Europe, and, often, in the world?
The suicide rate in Hungary, for various age groups, is anywhere between 5 and 25 times the corresponding rate in nearby Greece (in the late 1990s). And, the suicide rate of countries bordering Hungary is highest in the regions near Hungary, and those with large Hungarian populations.
Sometimes there are extraordinary or temporary circumstances that lead to a high suicide rate. In the 1990s Sri Lanka, in the midst of a protracted civil war, has had unusually high rates. However, Greenland (127 per 100,000 population in 1987) has the highest rate in the world.(70) This has been attributed to the cultural and social disintegration of the native Inuit population in the face of well-meaning Danish paternalism.
The psychological/psychiatric approach rose to prominence a bit later than the sociological one, at the end of the nineteenth and beginning of the twentieth centuries. It emphasizes and examines the individual, and the conflicts within a particular mind leading to self-destructive behavior.
"When we learn that the most densely populated parts of the world have the highest incidence of suicide, and that suicides cluster in certain months of the year, do we thereby learn a single adequate, explanatory motive?" asked psychoanalyst Alfred Adler in 1910. "No, we learn only that the phenomenon of suicide is also subject to the laws of great numbers, and that it is related to other social phenomena. Suicide can be understood only individually, even if it has social preconditions and social consequences."
While people with diagnoses of "depression" or "schizophrenia" or "psychosis" have suicide rates five to fifteen times that of the general population, the vast majority of those so-diagnosed do not attempt suicide. One limitation of the psychological strategy is the inability of experts to reliably predict who will carry out suicides and suicide attempts, even among the highest-risk groups.
"Robert Litman...believes that suicide-vulnerable individuals move in and out of periods of suicidal risk, sometimes for brief periods, sometimes for moderate or long periods, as their life circumstances fluctuate.
But of all those people who enter that zone, very few actually kill themselves. "For every hundred people at high risk," he says, "only three or four will actually commit suicide over the next couple of years....It's like a slot machine....You can win a million dollars on a slot machine in Las Vegas, but to do that, six sevens have to line up on your machine. That happens only once in a million times.
In a sense it's the same with suicide." Those spinning sevens represent all the biological, sociological, psychological, and existential variables that are associated with suicide, broken family, locus of control, decreased serotonin [a chemical found in the brain], triggering event, and so on.
"In order to commit suicide, a lot of things have to fall together at once, and a lot of other things have to not happen at once," says Litman. "There's a certain random element determining the specific time of any suicide and, often, whether it happens or not....It's as if you need to have six strikes against you...and we're all walking around with one or two or three strikes. Then you have a big crisis and you have four strikes. But to get all six really takes some bad luck." "
Hopelessness about the future seems to be a better predictor for suicide than is depression. For example, in one group of 207 suicidal patients, 89 were ranked high on a widely used "hopelessness" scale. Thirteen of fourteen suicides within the next five years came from this subgroup, even though only half of them had a diagnosis of depression. Nevertheless 76 of these 89 did not kill themselves, underscoring the difficulty in predicting suicidal behavior, even the highest-risk groups.
Indeed, in one study a computer program was better at identifying people who would attempt suicide than was a group of experienced clinicians. To add insult to injury, half of the patients preferred "talking" with the computer to talking with the human interviewers.
Another issue is that there is dispute as to what extent, if any, various schools of psychological therapy are effective. For example, in one study psychotherapy was found to be counterproductive with those who had attempted suicide. Other studies have been equivocal. Current expert opinion seems to be that psychotherapy is about as effective as drug therapy for mild to moderate depression, but significantly less so for more severe cases.
The biological view sees physical disorders, often a biochemical imbalance, as the "cause" of suicide and other psycho-pathological problems, like schizophrenia. This concept was articulated by Emil Kraepelin, a German contemporary of Freud's. It didn't gain wide acceptance for a half century, largely because the biochemical tools for testing it were lacking.
In suicide, the biochemical problem often seems to be associated with a low level of the chemical nerve-impulse transmitter, serotonin, in the brain. Treatment consists of repairing or overcoming the original neurochemical imbalance. Some drugs increase serotonin levels and are used as anti-depressants with moderate, but increasing, effectiveness.
Some evidence for, and limitations of, the biological model are:
(a) Studies on twins provide the most persuasive evidence of a biological basis for suicide. In two investigations of suicide among twins, the identical twin of a suicide also killed himself in 19 percent of the cases (22 out of 118), while there were no instances (0 out of 254) where the fraternal [non-identical] twin of a suicide had done so.
(b) Suicide tends to run in biological families. Adoption data show a significantly greater frequency of suicide among the biological relatives of suicides than among adoptive relatives. In a study of Danish adoptees diagnosed with depression, there were 15 suicides among 387 biologic relatives while only one suicide occurred in 180 adoptive relatives. Similarly, there were 12 suicides among 269 blood relatives of 57 adoptees who had killed themselves; there were no suicides among their 150 adoptive relatives.
This is not to say that there is a "suicide gene". But there are statistical associations between depression, aggression, and suicide, and depression clearly has a genetic component: for example, in 57% of identical twins studied, if one twin had major depression, so did the other.
This evidence for a biological tendency to suicide is convincing. Yet even among identical twins, in more than four out of five instances the suicide of one twin was not followed by the suicide of the other. Tendency is not fate.
(c) Studies on brain tissue and cerebro-spinal fluid (CSF) show that many people who kill themselves, especially those who use violent methods, have low levels of a brain tissue chemical neurotransmitter, serotonin, and its metabolic breakdown product, 5-hydroxyindoleacetic acid (5HIAA).
"Lower levels of 5-HIAA in CSF have been found to predict a 10-20 times higher mortality from suicide within 1 year after discharge from the hospital."
Especially interesting is the fact that whether the psychiatric diagnosis was depression, alcoholism, schizophrenia, or personality disorder, low 5HIAA was associated with significantly more of the suicides and suicide attempts, as well as other violent or impulsive behavior.
In this model, lower CNS serotonin levels makes people more aggressive and impulsive, and thus increases the effects of stress, depression, and psychosis.
Moreover, the types of anti-depressant drugs that increase serotonin levels are generally more effective in decreasing both suicidal thoughts and suicide attempts, than are other anti-depressants that work by different mechanisms.
There are also animal data that link aggression with low serotonin levels. For instance, blocking the formation of serotonin causes tame house-cats to become ferocious, and nursing rats to bite their pups to death.
The 5HIAA hypothesis is not universally accepted. There are methodological criticisms. Some studies have failed to find any connection between suicide and 5HIAA; and most have found little or no correlation of 5HIAA levels with non-violent suicide.
This murky picture should not be entirely surprising, since "suicide" lumps together groups as diverse as depressed teenagers, prisoners, alcoholic adults, political protesters, and the terminally ill.
Most suicide is probably due to the interaction of multiple factors. Even if 5-HIAA is one of them, it may be overcome or augmented by others. Finally, it's not clear that even if there is a relationship between low 5HIAA and suicide, violence, or impulsiveness, whether the low 5HIAA level is a cause of the behaviors, an effect of the behaviors, or is the result of some other yet undiscovered factor.
One supposed problem with the serotonin model is that there are a number of places, like Denmark, Switzerland, and Japan, that have low rates of outwardly-directed violence (e.g. homicide) along with high rates of suicide. A possible explanation for this is that there are cultural factors that influence whether violent impulses manifest themselves as suicide or as homicide. An alternative view, that suicide is associated with prosperity, is discussed later.
A more significant weakness of the biological model as the prime mover in suicide is its difficulty in explaining the sometimes-large changes in suicide rates seen over short periods of time. For example from 1958 to 1978 the suicide rate for Americans 15-24 years old went from about 4 per 100,00 to about 14 per 100,000, an increase of roughly 250 per cent.
The suicide rate in Norway was an almost constant 7 per 100,000 from 1876, when central records were first collected, until about 1966. It then increased 112 percent (from 7.3 to 15.5 per 100,00 between 1960-4 and 1990), while that of England decreased by 36 percent (11.7 to 7.5 per 100,000 between 1960-4 and 1991) and Ireland increased 170 percent (from 2.7 to 7.4 per 100,000 between 1971 and 1988). A convincing biological explanation is not obvious.
An interestingly different perspective is provided by some evolutionary biologists, who note the persistence of suicide (about 1 percent of all deaths) across culture and time. While such behavior may seem counter-productive in a simple Darwinian sense, if you're dead, you probably won't be passing on too many more genes, they argue that this may represent (like altruism), a trait that has evolutionary benefits.
They suggest that suicide may be the sometimes-inappropriate expression of an instinct for self-sacrifice for the good of surviving relatives, who do pass on the deceased's genes. We see other forms of this in, say, parents perishing to save their children from danger, or old people killing themselves to leave more resources for their families.
Consistent with this, psychiatrists have noted that many people who are considering suicide think of it in altruistic terms, as the best thing for their family and friends.
"If you talk to people immediately after they made a serious suicide attempt, they'll have a very altruistic explanation for what they did," says Dr. David C. Clark. "They believed it was the wise, clever and thoughtful thing to do."
An alternate view is that the tendency for depression, rather than "suicide", is the behavior selected for. In this picture, depression is useful because it forces people to contemplate and, presumably, learn from their mistakes. Suicide is, in this model, due to an excess of that process.
Unfortunately (for the model), most patients with "major depression" never attempt suicide, and suicide rates for people with other diagnoses (e.g. schizophrenia, or substance abuse) are comparable to those with major depression.
Other researchers claim that traumatic or premature births are highly correlated with later suicide and even with the suicide method employed. There is both human and other animal evidence for each of these views, but they are not more convincing than other explanations.
While it simplifies the picture, it may be counter-productive to limit one's understanding of suicide to "biology" or to "sociology" or to "psychiatry". There have been attempts to integrate some of these ideas under the label "suicidology."
For example, Jack Douglas, in The Social Meanings of Suicide, argues that how the individual sees and interprets sociological situations determines their effects on her; a biologist might tack on a biochemically-caused tendency toward impulsivity or violence. But, for the most part, we're still in the same position as the apocryphal blind men each describing a different part of an elephant: each discipline tends to see suicide through its own filters and biases, and there is, as yet, no adequate synthesis.
Yes, no, not necessarily, and so what. Certainly, people with a diagnosis of "schizophrenia" have a high lifetime risk of suicide (10%) as do people with severe depression (15%) and/or alcoholism (2-11%).
But so do people with medical illness (18% to 85%, studies are all over the map, of suicides had a physical illness; for 11% to 69% this was an "important contributing cause"; however, only around 5% were terminally ill.
In addition, the association of suicide with mental illness or alcoholism does not mean that suicide cannot be rational: chronically depressed, alcoholic, or schizophrenic persons may decide that it is better to be dead than to continue living as they are.
And to insist that suicide is irrational and attribute it to depression or mental illness "...is absurd and infuriating to those who have spent time at the bedside of dying patients who are suffering severely with no good choices." Besides, "Who wouldn't be depressed with such severe limitations to a meaningful life as incontinence, inability to speak, heavy curtailment of the ability to move and loss of dignity?"
Moreover, one doesn't need to be terminally ill to decide that one's physical, mental, or emotional limitations have become unacceptable, and that it's pointless to go on living. As an 84 year old woman said to her, son, a professor of health policy:
"Let me put this in terms you should understand, David. My "quality of life" -- isn't that what you call it? -- has dropped below zero. I know there is nothing fatally wrong with me and that I could live on for many years. With a colostomy and some luck, I might even be able to recover a bit of my former lifestyle, for a while.
But do we have to do that just because it is possible? Is the meaning of life defined by its duration? Or does life have a purpose so large that it doesn't have to be prolonged at any cost to preserve its meaning?
"I've lived a wonderful life, but it has to end sometime and this is the right time for me. My decision is not about whether I'm going to die -- we will all die sooner or later. My decision is about when and how. I don't want to spoil the wonder of my life by dragging it out in years of decay. I want to go now, while the good memories are still fresh. Help me find a way."
Studies have claimed to find among suicides about three times the rate of mental disorders as people with non-suicidal natural deaths (77% versus 25%).
Other studies have found similar, higher, and lower rates. However, some of these investigations have had the benefit of hindsight:
"...the highest estimate of mental illness when a sample had been diagnosed before suicide was 22 percent. Afterward the highest estimate was 90 percent."
After-the-fact diagnosis is rightly criticized for lack of objectivity: when a psychiatrist knows that someone died a suicide, his conclusion will be influenced by that knowledge, particularly if the psychiatrist believes that people who kill themselves must be crazy.
The diagnosis of mental illness is especially suspect when it comes to self-destruction. "The argument connecting suicide and mental illness is tautologically based upon our cultural bias against suicide....We say, in essence, `All people who attempt suicide are mentally ill.' If someone asks, `How do you know they are mentally ill?', the implied answer is, `Because only mentally ill persons would try to commit suicide.' ", Z. Stelmachers
But there is a wide range of opinions, even within the psychiatric community:
"Is every suicide mentally ill and in need of hospitalization as [interventionist] Eli Robins believes?....Or is he simply called mentally ill for the purpose of controlling his behavior, as [radical Thomas] Szasz believes? Or does he have the right to kill himself whether or not he is mentally ill as [libertarian Eliot] Slater advocates? These views reflect the diversity of psychiatric thought with regard to suicide.
My own view is that each of these positions contains some truth and that no one of them is an adequate guide for social policy. Most suicide can be diagnosed under present clinical standards as mentally ill; many diagnoses are influenced by the concern with suicide and the desire to prevent it through hospitalization; and the diagnosis of mental illness is not only insufficient to explain suicide but does not by itself justify taking away an individual's rights....[But] Surely confinement for a limited period for the purpose of evaluation with a view to providing help is indicated."
I would agree that it is better to err on the side of temporary intervention. People sometimes regret things they do; suicide is hard to regret. You can usually kill yourself later, but you can't bring yourself back to life.
On the other hand, it remains all too possible to turn "temporary" into permanent; to subject people to conditions that worsen their state; to drug them into submission, or to lock them up indefinitely. There need to be clear limits to both the duration and nature of any intervention; and if someone is persistent in wanting to end their life, that, however distressing, must, and ultimately will, be their decision to make.
The notion that suicidal people are crazy also tends to isolate those who are feeling suicidal. Because of the stigma associated with mental illness, they may not be willing to seek help, even in a crisis.
Thus, one of the ironies of suicide is that a suicide attempt, if survived, is probably the most dramatic and convincing way to draw attention to a problem and get help. Often family, psychiatric, and social service resources become suddenly available. A survey of Swiss survivors found that a majority felt that their actions had positive consequences for them. In Erwin Stengel's words, "The suicidal attempt is a highly effective though hazardous way of influencing others and its effects are as a rule...lasting."
Optimists may derive comfort from the fact that only about 1% of suicide survivors kill themselves within one year; of 886 suicide survivors in another study, only 3.84% killed themselves within five years; or that a Swedish study with 35 year follow-up found 10.9% died by suicide.
A pessimist might note that about half of the people who make a suicide attempt will make a subsequent one; the one-year suicide rate of 1% is 50 times the rate of non-attempters; and 10-15 percent will eventually kill themselves, a rate 10-15 times that of the general population.
Fuente: Suicide and Attempted Suicide http://www.w3.org/TR/REC-html40/loose.dtd
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