November of the Soul

by George Howe Colt

  It is there to keep you warm.

  And in those times of trouble

  When you are most alone,

  The memory of love will bring you home.

  On a gray, drizzly day Justin was buried a quarter mile from the church at Rose Hills Memorial Park. Giles and Anne had placed several things in the casket with their son: the sheet music to “Perhaps Love,” some Beethoven tapes including a recording of the Ninth Symphony, and the jelly beans and valentine that Justin had never received.

  II

  THE SLOT MACHINE

  ON THURSDAY EVENING, two days after Justin Spoonhour’s death, a public meeting was held at Putnam Valley Junior High. The topic of the meeting, which had been called by school superintendent Richard Brodow, was “Adolescents in Crisis,” but everyone knew it was really about suicide. Although 250 chairs had been set up in the auditorium, by the time the meeting started, people were standing in back. The audience consisted mostly of parents and teachers but included some teenagers. Diana Wolf and Mike LoPuzzo were there.

  Kenneth Schonberg, a pediatrician from nearby Chappaqua whom Brodow had asked to speak, could feel the tension in the room. He had conducted meetings like this before. Nine months earlier in the town of North Salem, fifteen miles east of Putnam Valley, a high school girl had hanged herself in the restroom of a drive-in movie after a quarrel with her boyfriend. A month later the boy hanged himself in his family’s home. Schonberg had spoken to the town’s anxious parents. He sensed that tonight’s crowd was even more tense because the suicide had occurred so recently. Although he knew he could give them no real answers, he wanted to ease their fears, to put Justin’s death in some perspective. He gave a brief overview of adolescent suicide and talked about the complexities of parent-child relationships. He said that feelings of anger, guilt, fear, and sadness were natural responses to the tragedy. “What you must understand and let your children know is that they are not to blame for what happened.”

  Although Justin was on everyone’s mind, his name was rarely mentioned. Parents worried that what had happened to Justin could happen to their own children. A couple whose son had known Justin was concerned because he didn’t want to talk about Justin’s death. A mother who had been taking notes asked, “What if a youngster denies feeling suicidal but he walks the floor all night?” Another mother wondered, “How do you make your child talk about it if he doesn’t want to?” Schonberg suggested that parents not force the issue but ask gently whether something was on their child’s mind and be ready to listen. “Ninety-nine percent of this is not to prevent another suicide,” he said, “but to make your kids feel comfortable talking about it.” One woman voiced the fear shared by most parents at the meeting: “What happens if we go through all this, we talk about it, and we have another one?” Said Schonberg, “It’s the same chance as lightning hitting twice in the same place. There’s no reason for anyone to think that this is a contagion. Just because it happened to one child doesn’t mean it will happen again.”

  Near the end of the meeting a gray-haired man stood and said, “I’ve been a resident of this community for a long time, and I can remember previous incidents of this kind. What disturbs me is that it takes an event like this to bring us together. Kids want to talk, but parents don’t. We as parents should discuss these things.” He sat down to applause.

  By the end of the meeting there was a feeling of catharsis and a sense that the community was pulling together. As they drifted out, people greeted their friends and neighbors. Many of them stopped to thank Schonberg and to pick up a directory of crisis services available in the area and a list of “the warning signs of suicide.” As couples drove home on the winding roads of Putnam Valley that night, they talked about their families. Some looked in on their sleeping children when they got home. One woman phoned each of her children around the country. “I want you to know I love you,” she told them. “I want you to know you can talk to me.”

  That night, not long after the meeting ended, twenty-five miles south of Putnam Valley in a town called North Tarrytown, an eighteen-year-old boy named Jimmy Pellechi shot himself in the head.

  Much of what Kenneth Schonberg told Putnam Valley parents about suicide that evening was new to them. Because they tend to avoid the subject until it hits close to home, most people are shocked when they find out how many people choose to end their own lives. In 2002, the most recent year for which statistics are available, 31,655 Americans completed suicide. On an average day eighty-seven Americans kill themselves, twelve of them under twenty-five years of age, five, like Justin, under twenty. In a country with one of the highest murder rates in the world, more than half again as many people kill themselves as are killed by others.

  Still, the government-certified statistics are believed to be lower than the actual numbers, because families may cover up evidence, rearrange a death scene, or hide a suicide note in order to qualify for insurance benefits or to avoid stigma. Some coroners and medical examiners have been known to classify a death as suicide only when the circumstances are unequivocal—when a note has been left (about 15 to 20 percent of all cases) or the victim is found hanging. They may overlook shooting, jumping, overdosing, drowning, and other methods that can be interpreted as accidents. Studies in the 1980s concluded that suicide rates were underreported by as much as 50 percent; more recent research places the figure at closer to 10.

  For many years suicide was associated with older white males. Four times as many males as females complete suicide, and the rate rises with age. Over the last five decades, however, a dramatic change has taken place. While the overall suicide rate has remained fairly stable, the rate for adolescents (aged fifteen to twenty-four, as defined by federal statisticians) tripled, from 4.5 suicides per 100,000 in 1950 to 13.8 per 100,000 in 1994. (Underreporting may be particularly prevalent for adolescents, for whom accidents are the leading cause of death, accounting for 40 percent of all fatalities.) During those years advances in medicine lowered the mortality rate for every age group in America except fifteen-to-twenty-four-year-olds, whose rate rose, largely because of the increase in suicides. Most of those suicides were male; five times as many males as females in this age group kill themselves, compared with the four-to-one ratio in the population at large. “The real importance of this is that it shows a real, fundamental change in the phenomenon of suicide in this country,” Mark Rosenberg, an epidemiologist at the Centers for Disease Control and Prevention (CDC), told reporters. “Whereas a few years ago it might have been your grandfather . . . now it’s your son.”

  Hearteningly, over the last decade, the adolescent suicide rate has stabilized and slightly decreased, to 9.9 in 2002. Yet suicide remains the third leading cause of death among fifteen-to-nineteen-year-olds, behind accidents and homicides, and the second leading cause of death for twenty-to-twenty-four-year-olds, behind accidents. (While most of the attention has focused on teenagers, a more media-genic demographic, the rate of suicide in the college-age group is 50 percent higher than among high school students.) To illustrate the magnitude of the loss, psychiatrist Kay Jamison compared the number of suicide deaths among males under age thirty-five with those from two more highly publicized causes of death among men in the last four decades. She found that during the Vietnam War, there were almost twice as many suicides (101,732) as war deaths (54,708), and during the height of the HIV/AIDS epidemic, nearly 15,000 more young men died from suicide than from AIDS.

  Suicide deaths, however, represent only one extreme of adolescent suicidal behavior. Official statistics on attempted suicide are not kept, but for every adult suicide there may be as many as twenty-five attempts; for every adolescent suicide, there may be one hundred or more. Psychologist Kim Smith of the Menninger Foundation, assembling data from several studies, has suggested that 2 percent of all high schoolers have made at least one suicide attempt, which would mean that 2 million high schoolers, at some point in their lives, have attempted suicide. Most of them are female. While five tim
es as many adolescent males kill themselves, three times as many females make attempts. And a great many more adolescents think about killing themselves: In 2002, a CDC survey reported that during the previous year, 19 percent of high school students had “seriously considered” suicide, 15 percent had formulated a plan, 9 percent had made an attempt, and nearly 3 percent had made an attempt that required medical attention. In another survey, high school and college students were asked, “Do you think suicide among young people is ever justified?” Forty-nine percent said yes.

  Although clinicians had long been aware of the rising rate of adolescent suicide, national attention turned to the problem only in the mideighties, spurred by the growing recognition that adolescent suicides tend to come in bunches. In 1983, when eight teenagers in fourteen months killed themselves in the wealthy Dallas suburb of Plano, youthful suicide became a big story. Suddenly, suicide seemed to be snatching, according to the media, “the best and the brightest,” who had “everything to live for”—the football captain and the cheerleader as well as the loner and the delinquent. Across the country the questions poured out: Why was the adolescent rate increasing so rapidly? Why these bunches of young suicides? Why are young people so unhappy? Why are they killing themselves?

  No one knows exactly why people kill themselves. Trying to find the answer is like trying to pinpoint what causes us to fall in love or what causes war. There is no single answer. Suicide is not a disease, like cancer or polio. It is a symptom. “People commit suicide for many reasons,” says psychologist Pamela Cantor. “Some people who are depressed will commit suicide, and some people who are schizophrenic will commit suicide, and some people who are fine but impulsive will commit suicide. We can’t lump them all together.” And just as there is no one explanation for the four thousand adolescent suicides each year, there is no one explanation for any particular suicide. While it is often said that suicide may be committed by twelve different people for twelve different reasons, it may be just as true to say that one person may choose death for twelve different reasons or one hundred different reasons—psychological, sociological, and biological factors that finally tighten around one place and time like a knot.

  Although some adolescent suicides are said to come “out of the blue,” the vast majority of young people who kill themselves can be found, on closer inspection, to have had clearly discernible and often long-standing difficulties. Certainly, although Justin Spoonhour’s suicide was unexpected, there were many possible contributing factors that might be emphasized by different experts according to their professional orientations. After his death some Putnam Valley townspeople said, “He killed himself because he wasn’t given a flower on Valentine’s Day.” Although this was a risibly simplistic response, a psychiatrist might point out that Justin’s rejection on Valentine’s Day mirrored rejections he had experienced throughout his life by his classmates. Others observed, “He killed himself because he was different—he liked Beethoven and everyone else listened to Michael Jackson.” Although listening to Beethoven is not commonly known to cause suicide, it was one example of Justin’s isolation and how that isolation led to ostracism. Even his few attempts to belong to the “mainstream”—joining the Cub Scouts, becoming the track manager—were met with scorn. Another psychiatrist might point to the high standards Justin set for himself, standards that were difficult for the rest of the world to live up to. His being “different” was encouraged by parents who were themselves somewhat different. A third psychiatrist might point to the lack of a stable family life. Although the child of an intact marriage, Justin was often alone at home, both because of his lack of friends and because his parents’ activities kept them away. Justin seemed, in fact, to be most at home in the fantasy world he created. A fourth psychiatrist might point to Justin’s eccentricities, conclude that he had suffered from an undiagnosed “adjustment disorder,” and suggest that he should have tried a course of antidepressants.

  Other experts would highlight other influences. A sociologist might point out the effect of changing social mores and the difficulties faced by a child of sixties parents growing up in the conservative eighties. Although much of Justin’s isolation seemed to be self-imposed, another sociologist might stress that in rural towns like Putnam Valley, making and keeping friends is especially difficult when they are all a car ride away. A philosopher might point to Justin’s extreme sensitivity to the problems of the world, especially his apparent anxiety over the nuclear threat. A physician or a developmental psychologist would certainly observe that all of these influences were heightened by the traditional chaos of puberty, a time when biological changes were shaking up Justin’s universe and he was beginning to grapple with questions of sexuality. A neurobiologist might wish to have analyzed Justin’s cerebrospinal fluid in an attempt to learn whether his decision might have been linked to abnormally low levels of a brain chemical called serotonin.

  All of these responses might be correct, but separately, no one of them would be the truth. Like the blind men who grab different parts of the elephant and misidentify the beast, suicide experts, exploring suicide from their own perspectives, end up supplying only part of the whole. “Suicide is a biological, sociocultural, interpersonal, dyadic, existential malaise,” says Edwin Shneidman, a psychologist who has devoted his life to the study of suicide. Shneidman’s definition is cumbersome, but it may be the most accurate we have.

  What are some of these “biological, sociocultural, interpersonal, dyadic, existential” variables? Over the last twenty-five years, there has been increasing evidence that some of the most important variables may be biological. Studies of completed suicides have suggested that more than 90 percent occur in individuals with a diagnosable psychiatric disorder—a catchall that covers everything from schizophrenia to alcohol abuse to less easily defined categories such as “conduct disorder.” Over those same years, researchers have found genetic underpinnings for many of those afflictions, including depression, schizophrenia, alcoholism, and substance abuse. Although there is evidence that younger adolescent suicide victims may have lower rates of psychopathology than do adults, it is clear that in a great many adolescents, suicide and suicidal behavior are associated with a diagnosable, and treatable, psychiatric disorder. Yet mental illness doesn’t by itself lead to suicide; while an estimated 90 percent of completed suicides of all ages have a psychiatric disorder, more than 95 percent of people with psychiatric disorders do not kill themselves.

  Of the some three hundred mental illnesses listed in the Diagnostic and Statistical Manual of Mental Disorders, a few are particularly associated with suicide. Although schizophrenia, alcohol and drug abuse, and borderline personality disorder, among others, all carry increased risk, the disorder with which suicide has most closely been identified is depression. Indeed, for many years suicide was linked almost exclusively to depression, as if there were a threshold—different for every person—that one could not bear to sink below. Suicide was seen as depression’s last stop. Although clinicians have since recognized that many people who are not depressed kill themselves, experts nevertheless estimate that six of every ten people who die by suicide suffer from major depression, in either its bipolar form (also known as manic depression) or its unipolar form (often called major depression). If alcoholics who are depressed are included, the figure jumps to nearly eight in ten. According to the National Institute of Mental Health (NIMH), people who suffer from clinical depression have a rate of suicide twenty-five times that of the general population. About 15 percent of Americans will suffer from clinical depression at some point in their lifetime. Thirty percent of all severely depressed patients will attempt suicide; 15 percent will ultimately complete. If mild depression is included, the rate of completed suicide drops to about 3 percent. Of the two main forms of depression, bipolar disorder is the more strongly linked to self-destruction; while an estimated one in five people with major depression will attempt suicide, nearly one-half with bipolar disorder will try to kill
themselves.

  Until three decades ago, however, psychiatric wisdom held that children and adolescents did not experience depression. This belief was based primarily on Freud, who said that depression was anger turned inward by the superego. Children and adolescents, it was believed, did not have fully developed superegos and thus could not get depressed. They could be moody and sad, but such feelings were attributed to the vicissitudes of growing up. The reluctance to recognize depression in younger people no doubt contributed to the belief that adolescent suicide was rare and was another reason why so many young suicides were cataloged as accidents.

  These days, it is accepted that children and adolescents can suffer from depression, although they may manifest different symptoms from those of adults. Children and younger adolescents tend to camouflage depression with overt behavior, acting out their feelings through restlessness and temper tantrums—what psychiatrists used to call masked depression. Older adolescents may show signs of masked depression, such as promiscuity and excessive risk-taking, but they also display classic adult symptoms—insomnia, loss of appetite, inability to concentrate. They may also show irritability, restlessness, aggression, and, particularly in those suffering from bipolar disorder, outbursts of rage. Symptoms are often difficult to recognize because the angst of normal adolescence so often resembles depression. One in twenty teenagers suffers from clinical depression; if mild depression is included, the number jumps to one in five. In a study of the health problems of fifty-six hundred adolescents, depression was second only to colds in frequency. “I think that depression, in a funny way, is an inevitable part of adolescence,” Paul Walters, former director of health services at Stanford University, told me. “In fact, if you don’t get depressed, I think there’s something wrong.”

  Although major depression has consistently been found to be the most prevalent disorder among adolescent suicide victims, situational depression, caused by a reaction to an event—a poor grade, the loss of a relationship—can also be lethal. Such depressive episodes, however intense, may be brief and, coming as they do at a stage of life in which an individual is groping for autonomy and identity, are developmentally normal. Feeling blue after not getting into one’s first-choice college is as appropriate as feeling happy after scoring a winning touchdown. But many adolescents who experience situational depression don’t realize that it won’t last forever. They tend to keep their sadness to themselves. They may believe that depression is a sign of weakness. They may worry that they are going crazy.