Night Falls Fast

by Kay Redfield Jamison

  Risk-taking behaviors, while important, almost always involve considerable speculation about underlying intent. They may involve either immediate risk, such as skydiving, or more remote risk, such as smoking or reckless driving. These indirect, or “subintentional,” deaths—defined by Shneidman as those “in which the decedent has played a covert, partial, latent, unconscious role in hastening his own death”—have come to include, depending on the clinician or researcher, everything from chronic alcohol or drug abuse or involvement in high-risk sports, to a variety of other activities, such as having unprotected sex with partners at high risk for AIDS, handling poisonous snakes, and provoking rage in those known to be physically violent (so-called victim-precipitated homicide).

  Suicidal ideation, which is to say thinking about suicide, is also a problematic concept but one that is more amenable to inquiry and measurement. Thoughts about suicide are relatively common in every age group that has been studied, but the number of people acknowledging such thoughts varies, of course, depending on the nature of the questions asked. The time frame strongly affects the total number of individuals who acknowledge suicidal thoughts or plans: some studies, for example, inquire only about suicidal thoughts during the past week; others ask whether such thoughts occurred during the preceding year; and yet others whether or not the individual has ever, during the course of a lifetime, had suicidal thoughts. Interviewers also ask about the frequency of suicidal thoughts—were the thoughts rare, occasional, frequent, daily, several times a day?—as well as about the severity of intent.

  Twenty-five years ago, in an early community-based study of suicidal thinking and behaviors, University of Cambridge psychiatrist Gene Paykel and his colleagues interviewed more than 700 people in New Haven, Connecticut. The results gave a public face to what had been very private thoughts. More than 10 percent of those interviewed said that, at some point in their lives, they had felt that “life was not worth living,” and a comparable number said that they had, at one time or another, “wished they were dead.” One person in twenty had thought about actually taking his or her own life, and most of those who had thought about suicide had thought about it seriously. One person in a hundred said he or she had attempted suicide.

  Approximately twenty years ago, the National Institute of Mental Health began the largest study ever undertaken of the nature and extent of psychiatric disorders in the U.S. population. It involved extensive interviews of a total of 20,000 people living in the five American catchment areas of Baltimore, Maryland; Piedmont County, North Carolina; Los Angeles, California; New Haven, Connecticut; and St. Louis, Missouri. The study included four questions about suicide, similar to those asked by Paykel and his colleagues, but was more specific in that it required a minimal duration for suicidal thoughts of two weeks. Of the 18,500 individuals who responded to the questions about suicide, 11 percent said they had at some point during their lives felt so low they had thought of committing suicide; 3 percent of the total said they had made one or more suicide attempts. Other investigations conducted in general communities have found that, consistent with these two studies, between 5 and 15 percent of the general adult population acknowledge having had suicidal thoughts at some point in their lives.

  College students, asked the same or similar questions, generally report as high or higher rates. The most comprehensive study of university and college students, the 1995 National College Health Risk Behavior Survey (the Centers for Disease Control and Prevention study discussed earlier), questioned 4,600 undergraduate college students across the United States. Ten percent of the students said they had seriously considered attempting suicide during the twelve months preceding the survey, and 7 percent had actually drawn up a suicide plan. Other research, conducted in Europe and Africa as well as in the United States, has shown that mild to severe thoughts of suicide are common, occurring in 20 to 65 percent of college students.

  High school students also report disconcertingly high rates of suicidal thinking. The 1997 Youth Risk Behavior Surveillance Survey, cited in the last chapter, canvassed more than 16,000 ninth- through twelfth-grade students (fifteen- to eighteen-year-olds) across the United States. Fully 20 percent, or one in five, said that they had “seriously considered” attempting suicide in the preceding twelve months; 16 percent said they had drawn up a plan. Girls were much more likely to have considered or planned a suicide attempt, and Hispanic students were more likely than either whites or African Americans to acknowledge having thought about suicide. Two other studies of American high school students confirmed that thinking about suicide is far from a rare concern: more than 50 percent of New York high school students reported that they had “thought about killing themselves,” and 20 percent of Oregon high school students described a history of suicidal thinking of varying degrees of severity.

  Studies in Europe and other parts of North America report similar findings. One in twenty French boys fifteen to eighteen years old, and one in ten French girls of similar age, stated that they had thought about suicide “fairly often, or very often” during the preceding year. In Canada, one in ten high school students reported having thought about suicide at least once during the preceding week. Another Canadian study, carried out in a slightly younger age group (twelve- to sixteen-year-olds), found that thoughts of suicide almost doubled in girls from the time they were twelve or thirteen to the time they were between the ages of fourteen and sixteen (the rates went from 7.5 to 14.5 percent). The boys showed exactly the opposite pattern, dropping from 6.7 to 3.3 percent in the same age groups. These differences between the sexes almost certainly reflect, at least to some extent, the higher rate of depression in girls and women, which is discussed later in greater detail.

  These statistics are disturbing, but it is of further concern that there is a wide discrepancy between what children report and what their parents actually notice. In one investigation of suicidal behavior in girls, for example, more than 15 percent of the children reported having had suicidal thoughts or behavior. Very few of their parents were aware that of their children’s experiences. This same unawareness of their children’s suicidal thoughts and actions has been found for the parents of boys as well. Parents also seriously underestimate the extent of depression in their adolescent children.

  It is understandably difficult for parents to believe that young children are in such pain as to wish to die, yet many children are. Cynthia Pfeffer, a child psychiatrist at Cornell University, finds that more than 10 percent of a sample of “normal” schoolchildren, that is, children with no history of psychiatric symptoms or illness, report suicidal impulses. One of the children in her study, a ten-year-old girl, described her thinking explicitly and painfully: “I often think of killing myself. It started when I was almost hit by a car. Now, I want to kill myself. I think of stabbing myself with a knife. When Mom yells at me, I think she does not love me. I worry a lot about my family. Mom is always depressed and sometimes she says she will die soon. My brother becomes very angry, often for no reason. He tried to kill himself last year and had to go to the hospital. Mom was in the hospital once also. I worry a lot about my family. I worry that if something happens to them, no one will take care of me. I feel sad about this.”

  Another child, a ten-year-old boy, also described his thoughts both specifically and graphically: “I want to hurt myself when I get upset and angry. I bang my head against the wall or punch the wall with my fist. I wish I were dead. I often think about how to kill myself. I think I will go to France to have myself guillotined. It would be quick and painless. Guns are too painful, so is stabbing myself. Once, I put my head into a sink of water and I got scared. My grandmother found me. I told her I was washing my face. Mom was shocked when she heard about this. She began to cry. She worries a lot and always seems sad.”

  Most instances of suicidal thought, although often frightening and of concern, lead to neither a suicide attempt nor suicide, but some do.

  The line between suicidal thoughts and action is
not as clear as it might seem. A potentially deadly impulse may be interrupted before it is ever acted upon, or an attempt with mild intent and danger of death may be carried out in full expectation of discovery and survival. Often, people want both to live and to die; ambivalence saturates the suicidal act. Some wish to escape, but only for a while. A few use suicide threats or attempts to make others “pay” for a slight or rejection, yet others to provoke change in the decisions and behaviors of people they know.

  Many who attempt suicide later deny or minimize it once the acute crisis or pain is in the past. Novelist Evelyn Waugh, for instance, suffered two professional setbacks, scarcely insurmountable critical reviews of his work, when he was in his early twenties. Desperately unhappy, he decided to end it all. Years later, in recounting his suicide attempt, Waugh questioned how much of what he had done was “real” and how much just “play-acting”:

  One night … I went down alone to the beach with my thoughts full of death. I took off my clothes and began swimming out to sea. Did I really intend to drown myself? That certainly was in my mind and I left a note with my clothes, the quotation from Euripides about the sea which washes away all human ills. I went to the trouble of verifying it, accents and all, from the school text.… At my present age I cannot tell you how much real despair and act of will, how much play-acting, prompted the excursion.

  It was a beautiful night of a gibbous moon. I swam slowly out but, long before I reached the point of no return, the Shropshire Lad was disturbed by a smart on the shoulder. I had run into a jelly-fish. A few more strokes, a second more painful sting. The placid waters were full of the creatures.

  An omen? A sharp recall to good sense … ?

  I turned about, swam back through the track of the moon to the sands.… As earnest of my intent I had brought no towel. With some difficulty I dressed and tore into small pieces my pretentious classical tag, leaving them to the sea, moved on that bleak shore by tides stronger than any known to Euripides, to perform its lustral office. Then I climbed the sharp hill that led to all the years ahead.

  Waugh was not alone in having had his uncertainties about intent and action. There is, in fact, no consistent definition of what is meant by a “suicide attempt”; nor are there universally agreed-upon criteria for distinguishing levels of determination or for classifying the degrees of medical dangerousness from an attempt. Many things need to be taken into account by clinicians and researchers who try to ascertain the seriousness of a person’s will to die or who have to assess the extent of the medical complications from a suicidal act.

  A Suicide Intent Scale was developed by Aaron T. Beck and his colleagues at the University of Pennsylvania for use with patients who attempt suicide but survive. The kinds of clinical observations and questions asked—whether or not the act took place in isolation, the degree of premeditation, the reasons for the attempt—provide an idea of what clinicians and scientists are interested in when they look at issues of intent and suicide planning.

  Suicide Intent Scale

  (for Attempters)

  I. Objective Circumstances Related to Suicide Attempt

  1. Isolation

  0. Somebody present

  1. Somebody nearby, or in visual or vocal contact

  2. No one nearby or in visual or vocal contact

  2. Timing

  0. Intervention is probable

  1. Intervention is not likely

  2. Intervention is highly unlikely

  3. Precautions against Discovery/Intervention

  0. No precautions

  1. Passive precautions (as avoiding others but doing nothing to prevent their intervention; alone in room with unlocked door)

  2. Active precautions (as locked door)

  4. Acting to Get Help During/After Attempt

  0. Notified potential helper regarding attempt

  1. Contacted but did not specifically notify potential helper regarding attempt

  2. Did not contact or notify potential helper

  5. Final Acts in Anticipation of Death (e.g., will, gifts, insurance)

  0. None

  1. Thought about or made some arrangements

  2. Made definite plans or completed arrangements

  6. Active Preparation for Attempt

  0. None

  1. Minimal to moderate

  2. Extensive

  7. Suicide Note

  0. Absence of note

  1. Note written, but torn up; note thought about

  2. Presence of note

  8. Overt Communication of Intent Before the Attempt

  0. None

  1. Equivocal communication

  2. Unequivocal communication

  II. Self-Report

  9. Alleged Purpose of Attempt

  0. To manipulate environment, get attention, revenge

  1. Components of “0” and “2”

  2. To escape, surcease, solve problems

  10. Expectations of Fatality

  0. Thought that death was unlikely

  1. Thought that death was possible but not probable

  2. Thought that death was probable or certain

  11. Conception of Method’s Lethality

  0. Did less to self than he thought would be lethal

  1. Wasn’t sure if what he did would be lethal

  2. Equaled or exceeded what he thought would be lethal

  12. Seriousness of Attempt

  0. Did not seriously attempt to end life

  1. Uncertain about seriousness to end life

  2. Seriously attempted to end life

  13. Attitude Toward Living/Dying

  0. Did not want to die

  1. Components of “0” and “2”

  2. Wanted to die

  14. Conception of Medical Rescuability

  0. Thought that death would be unlikely if he received medical attention

  1. Was uncertain whether death could be averted by medical attention

  2. Was certain of death even if he received medical attention

  15. Degree of Premeditation

  0. None; impulsive

  1. Suicide contemplated for three hours or less prior to attempt

  2. Suicide contemplated for more than three hours prior to attempt

  III. Other Aspects (Not Included in Total Score)

  16. Reaction to Attempt

  0. Sorry that he made attempt; feels foolish, ashamed (circle which one)

  1. Accepts both attempt and its failure

  2. Regrets failure of attempt

  17. Visualization of Death

  0. Life-after-death, reunion with decedents

  1. Never-ending sleep, darkness, end of things

  2. No conceptions of or thoughts about death

  18. Number of Previous Attempts

  0. None

  1. One or two

  2. Three or more

  19. Relationship Between Alcohol Intake and Attempt

  0. Some alcohol intake prior to but not related to attempt, reportedly not enough to impair judgment, reality testing

  1. Enough alcohol intake to impair judgment, reality testing and diminish responsibility

  2. Intentional intake of alcohol in order to facilitate implementation of attempt

  20. Relationship Between Drug Intake and Attempt (narcotics, hallucinogens, etc., when drug is not the method used to suicide)

  0. Some drug intake prior to but not related to attempt, reportedly not enough to impair judgment, reality testing

  1. Enough drug intake to impair judgment, reality testing and diminish responsibility

  2. Intentional drug intake in order to facilitate implementation of attempt

  Note: The responses most indicative of severe suicide intent are highlighted here in bold print.

  Reproduced with permission of Aaron T. Beck, M.D., University Professor of Psychiatry, University of Pennsylvania.

  * * *

  In addition to scales designed to assess the intent to die, there are a number of cli
nical and research measures that assess the medical seriousness of a suicide attempt. Firearms and hanging are likely to kill and hard to reverse, in contrast to self-poisonings, which are less likely to kill and easier to treat. (Availability and quality of medical care also affect the potential deadliness of a method. In developed countries, where access to emergency treatment is more common than not, death from self-poisoning is less of a risk than in less affluent regions of the world, where deadly agricultural pesticides are more readily available but medical care is not.) The actual medical damage sustained from the attempt can be measured by rating, among other things, the level of consciousness, the extent of permanent injury caused by the suicide attempt, and the extent and nature of the medical procedures required (for example, outpatient care only versus admission to a medical or surgical ward or to an intensive care unit).

  Given the disparate views of what constitutes a suicide attempt, it is scarcely surprising that the reported rates for such attempts vary quite widely. In general, however—whether the research is carried out in Europe, North America, Australia, the Mideast, or the Far East—between 1 and 4 percent of all adults state that they have, at some point in their lives, attempted suicide. Adolescents, on the other hand, have higher and more variable rates: between 2 and 10 percent of young people across the world state that they have tried to kill themselves, and a significant number of them report having made more than one attempt. It is unclear why this discrepancy in suicide attempt rates should exist between the older and younger age groups, although several explanations have been suggested.

  Myrna Weissman, a psychiatric epidemiologist at Columbia University in New York, has found compelling evidence of a dramatic doubling or even tripling of rates of suicide attempts over recent decades. Some of this may be due to a “cohort effect,” that is, a genuine increase in rates of suicidal behavior and depression in individuals born in more recent years; this will be discussed later in more detail. There may also be a tendency to forget or minimize suicide attempts over time. In one study carried out in Australia, for instance, 40 percent of those who acknowledged thinking about suicide at one point in their lives, when asked the same questions four years later denied ever having had such thoughts. Less severe suicide attempts may be particularly susceptible to forgetting, and, of course, some of those who attempt suicide when young will kill themselves before ever reaching adulthood. Too, younger people may simply be more willing to acknowledge suicidal behavior.