SUICIDE

James M. A. Weiss
 e-Book 2016 International Psychotherapy Institute

From American Handbook of Psychiatry: Volume 3 Silvano Arieti

Copyright © 1974 by Silvano Arieti and Eugene B. Brody

All Rights Reserved

Created in the United States of America

 Table of Contents

SUICIDE
Definitions and Types

Basic Etiological Approaches

Basic Epidemiological Patterns

Relationships to Clinical Entities

Indicators of Suicide Potential: Implications for Prevention

Bibliography

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 SUICIDE

James M. A. Weiss

The suicide of a patient, because of its finality, is perhaps the most

devastating experience in the practice of psychiatry. And suicide, considered

as a sign of mental disorder, is a prime cause of death among psychiatric

patients. Inextricably involved with the attitudes, folkways, mores, taboos,

and laws of culture and subculture, with tragedy for the person and the

group, with emotions and values, suicide is a sociopsychiatric phenomenon

about which much confusion exists. The nature of this phenomenon is

complex, and its scientific study is difficult, in part for the obvious reason that
persons who have committed suicide successfully are no longer available for

psychological or psychiatric study. The universal fascination of the study of

suicide, however, is reflected in the great bulk of literature concerning this

subject. There are now more than 7000 books and articles about suicide

(exemplified by Farberow’s extensive bibliography and an American journal

—the Bulletin of Suicidology— devoted solely to this topic). But much prior

research into suicide and attempted suicide has tended to be either actuarial
and at times somewhat superficial, or clinical and often anecdotal, or oriented

to depth psychology and rather speculative.

It does seem evident that there are three chief etiological factors in

American Handbook of Psychiatry 5

suicide: the group attitudes in each particular society, the adverse extraneous
situations that each person must meet, and the interaction of these with his

character and personality. This last single variable appears to be the most

important one. Obviously, different persons meet adversity differently. One

whose personality is poorly integrated may respond to stress by taking or

attempting to take his own life. Yet anthropologists and epidemiologists have

demonstrated that suicide may be completely unknown among certain

primitive tribes, that suicide rates are extremely low in certain countries, and,
alternatively, that suicide is not only acceptable but obligatory as a

consequence of certain specified activities or happenings in certain other

cultures. The ancient warrior people of Germany and Scandinavia, as well as

the Greek Stoics, approved of suicide, Oriental and Hindu cultures sanctioned

it under specified conditions, and in some

South Sea Islands it is looked upon even today as an honorable act.

However, as cultural patterns affect large numbers of people who do not

always act similarly, and as every person must meet difficult and dangerous

situations in an environment that can never be “sterilized” psychologically, it

appears likely that some degree of personality disintegration is the most

important single variable in the etiology of suicide. The psychiatric concept

applies, that external tensions are reacted to in proportion to the amount of

internal tension already existing.

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 Definitions and Types

Even the definition of suicide presents difficulties. The “suicidal patient”

may be one who successfully commits suicide, unsuccessfully attempts

suicide, threatens suicide, demonstrates suicidal ideation, or behaves in

generally self-destructive patterns. “The expression ‘suicidal act’ is used . . .

[by the World Health Organization] to denote the self-infliction of injury with
varying degrees of lethal intent and awareness of motive. . . . ‘Suicide’ means a

suicidal act with fatal outcome, ‘attempted suicide’ one with non-fatal

outcome.” Operationally, some possibility of self-inflicted fatal termination is

most commonly the distinguishing criterion of the term “suicidal.” Thus, most
investigators define successful or committed suicide as a violent self-inflicted

destructive action resulting in death. Attempted suicide is usually defined

similarly, except that there is no fatal termination; but, as Stengel has pointed
out, the action must have a “self-destructive intention, however vague and

ambiguous. Sometimes this intention has to be inferred from the patient’s

behavior.” The suicidal gesture is similar except that persons performing such
an action neither intend to end life nor expect to die as a result of their action,

although the action is performed in a manner that other persons might

interpret as suicidal in purpose. In suicidal threats, the intention is expressed,

but no relevant action is performed; in suicidal ideation, the person thinks or

talks or writes about suicide without expressing any definite intent or

performing any relevant action. (The term “parasuicide,” to designate

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attempted suicide and related actions, has recently come into vogue. That

term is, however, both ambiguous and a solecism, and should be deleted.)

The problem is further complicated by persons in the category termed

by Farberow and Shneidman the “sub-meditated death group,” in whom

unconscious or preconscious motivation to die or be killed is such that a large

number of conditions (purposive accidents, provoked homicides, neglected

personal health care, involvement in dangerous activities, and even severe

psychosomatic disorders) might be considered suicidal equivalents. Whether

such acts, as well as one-car accidents, voluntary overwork, drug addiction,

chain-smoking, and alcoholism, are in fact “partial” or “chronic” suicidal

attempts is debatable. Tabachnick found that “suicidal and self-destructive

factors which we tested for do not play a significant role in the general
[automobile] accident picture.” Choron stated, “One could maintain that it is

the lesser evil to drown one’s sorrows in alcohol than to drown one’s self,”

and suggested that such behavior might actually be a defense against suicide.

Actually, all medical-legal definitions of “suicide” or “attempted suicide”

do include the concept that the person played a major role in bringing about,

or trying to bring about, his own demise, and that his conscious intention in
his behavior was to die. However, increasing evidence indicates that

successful suicide and unsuccessful suicidal attempts represent two different

kinds of acts performed in different ways for different reasons by different

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groups of people, although there is some overlapping. For example, successful
suicides are more common among older people, males, and single, divorced,

or widowed persons; reported unsuccessful suicidal attempts are more likely

to occur among younger people, females, and the married population. In the
United States during the past fifty years, about two-thirds of the persons who

successfully committed suicide used the two methods of shooting or hanging;

most persons reported to have attempted suicide unsuccessfully used

ingestion of poison, cutting or slashing, or inhalation of gas—all less efficient

than shooting and hanging, which only rarely fail to cause death. Several

studies have indicated that the success of the suicidal attempt varies

markedly with the reported conscious “motive.” Thus, for the modal
committer of suicide the motive is most likely to be judged as “concern about

ill health” or “loss of a loved one,” as compared to the modal attempter of

suicide for whom the motive is most likely to be “domestic or family worries”

or “difficulties in love affairs.”

Stengel and Cook have reviewed the confusion that exists in the

psychiatric literature relating to evaluation of the seriousness of suicidal

attempts, and concluded that to understand such phenomena it is necessary

to consider separately the degree of psychological intent and the degree of

medical injury. Stengel, Weiss et al., and other investigators have therefore

rated cases as “serious” in psychological intent when an unambiguous

impulse to suicide is admitted by the patient and also borne out by the

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patient’s behavior before, during, and after the attempt. In such cases, the

patient does not inform anyone else of the attempt in order to effect a rescue,

does not make the attempt when other persons are present or nearby or

likely to arrive in time to prevent death, and expects that he or she will
certainly die as a result of the act. Attempts are rated as “gestures” when the

patient clearly does not expect to die, as evidenced by his overt admission and

behavior. Such gestures seem to be made most often to gain attention or to

influence other persons, and the attempter often takes considerable

precaution to make sure of remaining alive by making the attempt with other

persons present, informing someone of the attempt, or initiating his own

rescue. Suicidal attempts that are neither serious nor gestures have been

defined by Weiss as “gambles,” insofar as the patient is uncertain about the

possible consequences of the act or does not know for sure whether he can
expect certain death as a result of the act but believes there is some chance

(even a good chance) of dying, as evidenced by his overt admission and

behavior.

As to the medical consequences, suicidal attempts are rated as

“absolutely dangerous” when the act results in severe danger to life with a

very high probability that the patient will die, except for timely medical
intervention. Generally, such acts produce such consequences as coma,

bloody diarrhea, penetrating injuries, fracture of a major bone, or laceration

of a major artery. Cases are rated as “absolutely harmless” when there is no

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chance that the act will cause death under any foreseeable circumstances.

“Somewhat dangerous” serves as an in-between category.

Weiss et al. have termed the medically dangerous, psychologically

serious attempts “aborted successful suicidal attempts,” since these attempts

were found to be qualitatively different from all others, and attempters in this
group appeared to be epidemiologically more similar to persons who

successfully committed suicide than to other classes of attempters. Probably,

most persons who make such aborted successful suicidal attempts are

brought to the attention of police, physicians, or hospitals, and are included in

the statistical reporting of suicidal attempts. At the other end of the

continuum are the persons who make medically harmless suicidal gestures,

who are only rarely brought to the attention of reporting agencies. The
remaining suicidal gambles, with varying severity of medical consequences,

might be termed “true suicidal attempts,” in the sense that persons making

this sort of attempt appear to perform a violent, self-inflicted, destructive

action with ambiguous intent, but with some chance of fatal termination. Of

course, in some of these true suicidal attempts the gamble with death is

undoubtedly lost—the attempter dies and the attempt is counted as a

completed successful suicide. Many true suicidal attempts may not be

brought to the attention of the authorities, but the large numbers that are

made known to them appear to comprise the major segment of all reported

cases of suicidal attempts.

American Handbook of Psychiatry 11

 Basic Etiological Approaches

Dublin’s comprehensive review of the history of suicide indicates a

marked interest in the subject since ancient times, but the scientific study of
this phenomenon began only toward the end of the nineteenth century. In

1897, Emile Durkheim published his famous monograph, “Le Suicide,” an

exhaustive statistical and sociological examination of the problem. Durkheim

concluded that the common factor in all suicide patterns was the increasing

alienation between the person and the social group to which he belonged. He

suggested that a basic element, anomie—a sort of psychosocial isolatedness

that occurs whenever the links that unite individual human beings into
consolidated groups are weakened—is primary in the understanding of

suicide in modern society.1 Other ecological studies have provided important

information to this end. Cavan related the suicide rates in urban districts of
Chicago to the degree of social disorganization in those areas. Gruhle

demonstrated how suicide rates were altered with social and cultural
variations in different geographic sections of pre-World War II Germany.

Sainsbury, in a study of suicide in London, found that measures of social

isolation correlated significantly with suicide rates. Yap’s report on suicide in

Hong Kong also indicated the importance of the social matrix, noting

especially high rates among immigrants from rural areas.

Most psychiatrists and psychoanalysts have identified suicide with self-

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directed aggressive tendencies. Freud emphasized that melancholy and
subsequent suicide are often the result of aggression directed at least

partially toward an introjected love object, that is, a love object with whom

the subject had previously identified himself. Later, Freud established suicide
as the extreme manifestation of the active component of the death instinct

directed against the self. Schilder, writing alone, and with Bromberg, believed

that “suicide is obviously merely a symptom and not a clinical entity” and

that, although suicide can serve as a form of self-aggression or as self-

punishment for aggressive behavior previously directed toward another

(loved) person, it may also serve as a form of punishment for a person who

earlier may have denied love to the subject, or as a form of peace (or reunion
with a love object), or certainly as an escape from insupportable difficulties.

Bernfeld’s classic formulation of the basic mental mechanisms

underlying suicide was this: A person committing suicide does so because of

strong, unconscious murderous impulses against another person, but the

committer must also unconsciously identify himself with the hated

(previously loved) object, so that he kills that object in killing himself. Since
the committer usually feels guilty because of his murderous impulses, a

tendency to self-punishment is commonly involved, and the choice of the

method of suicide may have symbolic significance. Menninger- has elaborated

these mechanisms in his well-known statement that the true suicide must

expect to kill, be killed, and die, as well as in his discussions of “partial” or

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“chronic” tendencies to self-destruction. Menninger saw suicide in any form

as the result of the struggle between Thanatos and Eros, with the former

winning. All varieties of physical and psychological self-damage can be

subsumed under his definition, with the suicidal act arising out of the conflict
between an aggressive drive directed toward the self and the countering

tendency toward both the preservation of the self and the restoration of the

self’s relations with other (loved) human beings. Jung stressed unconscious
wishes for a spiritual rebirth in a person who has a strong feeling that life has

lost all its meaning, and Adler emphasized inferiority, narcissism, and low

self-esteem, as the characteristics of the potential suicide victim. Sullivan

regarded suicide as evidence of a failure arising out of unresolved

interpersonal conflicts, and according to Horney it occurs within a context of

extreme alienation of the self resulting from great disparity between the
idealized self and the perceived psychosocial self-entity (a formulation that

becomes more attractive the longer one studies this subject).

In one symposium, Lindemann suggested that the “state of readiness for

violent behavior,” the form of aggression that may or may not end in suicide,

be termed “hypereridism” (from Eris, the Greek goddess of wrath and anger).

Fenichel summed up the psychoanalytic characteristics of this state as “an

ambivalent dependence on a sadistic superego and the necessity to get rid of

an unbearable guilt tension at any cost.” The person submits to punishment

and to the superego’s cruelty, and may express the passive thought of giving

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up any active fighting; more actively, and at the same time, there is a turning

of sadism against the person himself, a rebellion against the punishing

superego. The intensity of this struggle is reflected in the depressed patient’s

strong tendency toward suicide. The ego, trying to appease the superego by
submissiveness, has erred. The hoped-for forgiveness cannot be achieved

because the courted part of the personality, through regression, has become

sadistic, and, from the standpoint of the superego, the suicide of the
depressed patient results from a turning of this sadism against the person

himself. On the other hand, from the standpoint of the ego, suicide is an

expression of the fact that the tension induced by the pressure of the

superego has become unbearable. Frequently, the loss of self-esteem is so

complete that any hope of regaining it is abandoned. As Fenichel wrote, “To

have a desire to live evidently means to feel a certain self-esteem, to feel

supported by the protective forces of a superego. When this feeling vanishes,

the original annihilation of the deserted hungry baby reappears.”

Other suicidal acts may have a far more active character, for they are

simultaneously extreme acts of submission and extreme acts of rebellion

(that is, murder of the original objects whose incorporation created the

superego). Psychoanalyses of persons attempting suicide have frequently

demonstrated that ideas of a relaxing gratification, or hopeful and pleasurable

fantasies, may be connected with the idea of suicide. Such ideation is

unconsciously related to hopes of forgiveness and reconciliation, with a

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simultaneous killing of the punishing superego and reunion with the

protecting superego—thus putting an end to all losses of self-esteem by

bringing back original fantasies of omnipotence.

These and similar psychodynamic theories of suicide may be valid, but

they may also contain inherent methodological errors. They are based on data
derived either from persons who, during or after a period of psychoanalytic

scrutiny, have committed suicide successfully, or from persons who

attempted suicide unsuccessfully. Generalizing from the few cases of the

former type may be incorrect, for it is certainly possible that new dynamic
forces —occurring between the last interview and the time of the actual

suicide, and therefore unavailable for analysis—played a part. The relevance

of premortem idiographic data to an understanding of the actual crisis that

resulted in any particular successful suicide is therefore open to some

question. And, since current data make it clear that successful suicide is not

simply an exaggerated or completed form of attempted suicide, formulation

of dynamic theories about successful suicide by extrapolation from what has

been learned in clinical studies of patients who have attempted suicide is

hardly justified.

However, the basic psychoanalytic concept involving self-directed

aggression appears to hold, since suicide rates and homicide rates are often
inversely related by cities and other regions, probably by countries, among

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certain racial and ethnic groups, and in periods of prosperity and depression.
As Henry and Short noted, “When behavior is required to conform rigidly to

the demands and expectations of other persons, the probability of suicide as a

response to frustration is low and the probability of homicide as a response to

frustration is high. . . and vice versa. The often surprisingly low suicide rates

among persons living under grim conditions—concentration camps, for

instance, or really bad slums, or front-line combat—seem to support this

observation. West studied murderers in England and found that about one-
third of them killed themselves after killing their victims. (About two-fifths of

the suicidal murderers in this group were women.) Such suicidal murders

were more likely to be involved in killing a spouse, lover, or child, and there
was some evidence indicating that motivation may have been more related to

despair than aggression.

The psychoanalytical point of view therefore may be as valid as the

sociological theory stressing anomie and the lack of integration within human
groups as etiological, but some synthesis of the two points of view is possible

and should prove more comprehensive. The most frequently cited common
characteristic of persons who later kill themselves is loneliness, or

psychosocial isolation. Many investigations have pointed to a disruption of

close personal relationships, particularly bereavement or loss, as being a

main precipitating factor in suicidal behavior. Such isolating factors as broken

homes, unemployment, and old age have been noted. Weiss found the major

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factor in the high suicide rates among older people to be such isolation along

with depreciating sociocultural attitudes, low socioeconomic status with loss

of psychologically and socially rewarding occupation, biological decline, and

clinically recognizable psychiatric disorder. Psychological inability, refusal, or

lack of opportunity to relate to others is clearly important, but many people

continue living under such conditions. To precipitate a crisis, something more

is necessary. Alvarez (like West) indicated that this “something more” is

despair. The victim sees no hope; when some possibilities exist, he denies or

overlooks them. He turns to suicide, then, not because of any positive desire

for death, but because he no longer can hope.

Zilboorg, Andics, and others have pointed out that persons who were

denied in childhood a normal loving relationship with their parents or

parental surrogates are likely to feel unloved and unwanted in later life, and

therefore to develop suicidal tendencies. Hendin found differential suicide

rates in three Scandinavian countries to be related to child-rearing patterns.

High rates in Sweden and Denmark were associated with rigid self-demands

for superior performance (with subsequent self-hate for failure) in the

former, and a “dependency loss” dynamic in the latter. The lower rates in

Norway, on the other hand, were associated with persons reared to be

externally aggressive who only become suicidal when that aggression is

inverted toward the self. Hendin’s methodology has been criticized, but other

investigators have found that suicidal acts among children, although rare, are

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related to a need for love and at the same time to a desire to punish both the

self and the human environment. Paffenbarger’s and his colleagues’ studies of

40,000 American male former university students (with examination of

records of fifteen to forty years previous) revealed that early loss or absence
of the father was the dominant distinguishing characteristic of their subjects

who committed suicide. Such developmental patterns may well provide a

common etiological factor, since they are also likely to lead to social isolation,
a hypothesis substantiated in part by the studies of Walton.

Comprehensive psychosocial studies of the etiology of attempted

suicide (rather than successful suicide) have been somewhat more common.

In Stengel and Cook’s extensive investigations, attempted suicide was studied

as a meaningful and momentous event in the person’s life with special

consideration of its effects on the social environment. Their chief conclusions

were: (1) that the suicidal attempt is a phenomenon different from the

successful suicide, one that should be studied as a behavior pattern of its own;
(2) that an appeal to the human environment is a primary function of the

suicidal attempt; and (3) that the suicidal attempt has a variety of social

effects, especially on interpersonal relations, which may determine the

eventual result of the attempt. Stengel and Cook declared that “in our society
every suicidal warning or attempt has an appeal function whatever the

mental state in which it is made.” Their evidence supporting this statement is

strong (although it may not apply to the limited group of aborted successful

American Handbook of Psychiatry 19

suicidal attempts), and their work makes it clear that attempted suicide does

not represent a simple dynamic or even diagnostic pattern but is usually

overdetermined behavior, involving both the person himself and the social

environment in which he functions.

In contrast to this point of view, many persons still regard attempted

suicide simply as a gesture to bring another person to terms. Although this

secondary gain probably motivates the suicidal gesture per se, Weiss

demonstrated that the dynamics of the true suicidal attempt are more

complicated, and involve in all cases a discharge of self-directed aggressive

tendencies through a gamble with death (of varying lethal probability), in

most cases an appeal for help, and in some cases a need for punishment and a

trial by ordeal. First of all, true suicidal attempts are consciously or

unconsciously arranged in such a manner that the lethal probability may vary

from almost certain survival to almost certain death, and “fate”—or at least

some force external to the conscious choice of the person—is compelled in

some perhaps magical way to make the final decision. This appears to hold for

the attempts of hysteric and psychopathic patients, as well as for those of

schizophrenic and depressed psychotics. The psychodynamic factors involved

in such suicidal attempts are probably not unlike those involved in gambling
itself, as described, for example, by Fenichel. There is evidence that the true

suicidal attempt does serve to discharge aggressive tendencies directed

against the self or against introjected parental figures—self-mutilation may

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play a part in this. Both Stengel and Weiss have noted that patients who had

made true suicidal attempts, whether or not they were then treated in any

psychotherapeutic manner, demonstrated considerable subsequent

improvement in affective state and general outlook. In some cases,

improvement following the attempt appeared to be related to a guilt-relieving

mechanism; the patients felt that in the very attempt, and in the associated

gamble with death, they were punished for whatever acts committed or
fantasies entertained that had contributed to their feelings of guilt. Stengel

and Cook noted that the outcome of the attempt “is almost invariably

accepted for the time being and further attempts are rarely made

immediately, even if there is no lack of opportunity. The outcome of the

attempt is accepted like that of a trial by ordeal in mediaeval times.”

In most true suicidal attempts, there is also discernible an effect of

hidden or overt appeal to society, a “cry for help.” The attempts are causally

related to difficulties with interpersonal relationships and the social

environment, but most attempters manage to maintain some contact with

other persons, so that the call for help may be recognized. Stengel and Cook,

and later Farberow and Shneidman, have demonstrated that such an appeal is

inherent in most true suicidal attempts, irrespective of the mental state and
the personality of the attempter. Evoking some change in the social situation,

through the responses of individuals or groups to this conscious or

unconscious appeal for help, is, then, one of the primary functions of such

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attempts. In the unreported cases, the person’s difficulties are probably so

modified as a consequence of the suicidal attempt that no immediate further

action is required. Many people, whether responding as friends, policemen, or

physicians, do not consciously recognize this appeal; nevertheless, they are

shocked and interested by the fact that some human being was so disturbed

as to attempt to take his own life. The suicidal act, although taboo in Judeo-

Christian culture, usually arouses sufficient sympathy to bring about some

change in the circumstances surrounding the person who makes the attempt.

Often, the relationship of the patient to other persons, or to groups,

undergoes marked changes as the consequences of a suicidal attempt. These

changes are not usually consciously planned. Some relationships are

strengthened, some terminated, but almost always the true suicidal attempt
results in some immediate change in the constellation of relationships of the

person to other persons or to the whole social group (although these changes

may not be lasting). The fact that as a consequence of the attempt many
persons are admitted to a hospital, there to remain for varying lengths of

time, in itself often effects proximate changes. The patient is ready to accept

these changes, for he has (it might be said) listened to the demands of a

severe superego, atoned for his sins by attempting suicide in such a manner
that he gambled with death, and accepted the outcome—life— as the answer

(or perhaps reward), in a general sense, of fate or a divine judgment, or, more

specifically, of the superego.

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 Since Weiss et al. found the relatively small but important group of

aborted successful suicidal attempters to be epidemiologically and clinically

more similar to successful than to other non-successful attempters, it seems

likely that those persons whose attempts are both medically dangerous and

psychologically serious may be differentiated psychodynamically as well from

those whose attempts are not, and will in fact demonstrate patterns similar to

those whose attempts are successful. Custer and Weiss found that the
dynamics of the aborted successful suicidal attempters were similar to those

of a matched group of clinically depressed patients who had not evidenced

suicidal behavior, but the attempters in addition had been predisposed both

by a family history of suicide and by loss of one or both parents before age
fifteen. With a past history of prior attempts, these suicidal persons then

made the index serious attempt, precipitated in most cases by loss of a loved

one within three months prior to the act.

It should be noted that the psychodynamics of suicidal attempts among

children and adolescents may be somewhat different from those of adults.

Many studies have indicated that the risk of attempted suicide with non-fatal

outcome may be very high in the younger age groups, particularly among

females and in the lower socioeconomic classes. In contrast with the older age
groups, personal and domestic problems appear to predominate as causes

and several investigators have found a high incidence of broken homes in

early youth.’' Schrut noted that such younger attempters often have been

American Handbook of Psychiatry 23

involved in a series of various self-destructive acts. Such acts appear to arise

from feelings of anxiety and helplessness which may be reduced by arousing

parental concern. Jacobs interviewed fifty adolescent suicide attempters,

examined in detail their life histories, and compared them with those of a
matched control group. The resulting data indicated that adolescent suicide

attempters, as compared to the control non-attempters, demonstrated

longstanding psychological problems, which escalated rapidly and to a

marked degree after the onset of puberty. With subsequent progressive

failure of available coping techniques, these adolescents then became more

and more socially isolated. Finally, in the weeks and days preceding the

suicide attempt, there appeared to be a chain-reaction dissolution of any

meaningful social relationships which might have helped the subject deal
with both old and increasing new problems.2

Basic Epidemiological Patterns

Since the classic research of Durkheim, the frequent occurrence of

certain statistical trends and personality characteristics among persons who

have attempted or committed suicide has been noted in a number of large-

scale studies (reviewed by Dahlgren, Dublin, Farberow and Shneidman, Rost,

Sainsbury, Stengel, and Weiss). Such investigations have indicated that the
more serious or successful suicidal attempts are most likely to occur among
older persons, males, divorced, widowed, single, or married persons without

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children, persons isolated socially, persons with one or more close relatives

dead or who have a history of suicide in the immediate family, persons who

have made prior suicidal attempts, persons who use shooting or hanging as

the attempted or considered method, persons who attribute the act to

“concern about ill health” or “loss of a loved one,” and persons suffering from

affective psychoses, schizophrenic reactions, delirious states, chronic brain

syndromes, or chronic alcoholism, or persons who appear clinically

depressed regardless of diagnosis.3

The validity and importance of epidemiological studies as an adjunct to

clinical analyses have been discussed and justified by numerous authors,

Dublin in particular. At one conference, Faris cited the case of a scientist who

made a newspaper statement to the effect that the marked decrease in United

States suicide rates in the decade from 1937 to 1947 was undoubtedly due to

the great popularity during that period of electric shock treatment of the
mentally ill. The cited scientist was unaware, apparently, that suicide rates

almost invariably decrease in periods (as in the decade noted) of war or

prosperity. Suicide rates do vary from year to year: The rate in the United

States at the beginning of the century was 10.2 suicides per 100,000 persons

per year, and by 1915 it had increased to 16.2. The number of people taking
their own lives decreased sharply in 1916 and continued to decline through

the war years and immediate post-war years until, in 1920, the rate had

returned to 10.2 per 100,000. By 1921, the rate had risen to 12.4, remaining

American Handbook of Psychiatry 25

near this level for the next five years. After 1925, it climbed steadily upward,

reaching its maximum of 17.4 in 1932. In the later depression years, the rate

dropped slowly to about 10 during World War II; thereafter, it has remained

fairly constant between 10 and 12 per 100,000, although the lowest rate since
1900 has been 9.8, reached in 1957.

More than 20,000 suicides now are recorded each year in the United

States, and Dublin has estimated that the true number is no less than 25,000

(more recently, Choron suggested at least 30,000). Death by suicide thus

represents about 1 to 2 percent of all deaths occurring in the United States

during the year. An average of at least 1,000 persons each day commit suicide

throughout the world, 80 of these in the United States. Thus, perhaps half a

million persons in the world die by their own hand each year, and suicide has
ranked among the first twelve causes of death in most European countries

and in North America for many years. If these trends continue, out of every

1,000 white male infants, at least fifteen will eventually take their own lives;
out of every 1,000 white female infants, four will do so, according to Dublin.

Many countries have higher suicide rates than the United States,

especially Hungary, Finland, Austria, Czechoslovakia, Japan, Denmark,

Germany, Switzerland, Sweden, France, and Australia. In striking contrast,

suicide rates for Israel, Norway, the Netherlands, and Italy are low, and those
for Ireland and Spain are extremely low, as are those in several South

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American countries. Sweden’s rate is still roughly what it was before
implementation of extensive welfare programs. Recent investigations have

shown that suicide in developing countries is a more important problem than

was formerly suspected.

It is notable that suicide in white America is concentrated among older

people: The rates for white males increase consistently with each advancing
age group, while for white females they do so until the mid-fifties or early

sixties, after which they tend to level or begin some decline. (Rates for

nonwhite persons show somewhat different and less decided patterns.)

Children rarely kill themselves, although, because of the often spectacular and

tragic nature of the act, successful suicides of children and adolescents are

sometimes thought to be quite frequent. Recent age-specific rates do show

upward trends for the younger and middle ages, with a slightly downward

trend for the older ages. There has been a marked rise in successful suicide

among adolescents aged from fifteen to nineteen, and suicide is now the
third-ranking cause of death in this age group. In college students, suicide is

the second-ranking cause of death (after accidents). However, in the United

States, among adolescents and young adults, the suicide rate still runs only

from about 4 to 6 per 100,000, but the successive increment in each

succeeding age group imposes a maximum rate of 25 to 33 per 100,000 by the

age period of seventy-five years and over. This correlation with age is

especially marked for white males: At the younger ages, the rates for males

American Handbook of Psychiatry 27

are about three times those for females, but among the aged the ratio is ten to

one, or more. In almost all European countries as well, about two to three

males commit suicide for every female who does, although rates for females

are increasing in many countries.

The suicide rate of foreign-born American men is significantly higher

than that of the native-born, and the differences among the foreign-born

population are similar to those found in their respective homelands. The

Negro in this country is far less likely to commit suicide than the white,

although rates among blacks are increasing, especially in the cities, and
Hendin found that young urban Negro males have a suicide rate that is

probably higher than that for white men of the same age. Nonwhites other

than Negroes generally have higher rates than white persons.4 These
differences, however, should not suggest that predisposition to suicide is

inherited. Kallmann and Anastasio, studying suicide in twins, found no

evidence to implicate definite hereditary factors. But the work of Pitts and

Winokur indicates that at least a tendency to affective disorder and

associated suicide may be related to familial patterns, especially in males.

Suicide has been more common in urban than in rural areas, but, as the

United States has become more urbanized, the gap in suicide rates has been

greatly narrowed. Suicide rates also vary among the major centers of
population, and tend to be highest in the Western states and lowest in the

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Southern (except Florida and Virginia). Six metropolitan areas have very high
rates: Tampa-St. Petersburg, San Francisco-Oakland, Los Angeles-Long Beach,

Seattle, Sacramento, and Miami. Other cities (including such very large

centers as New York and Chicago) have moderate or even low rates. West
Berlin is said to have the highest rate of any city in the world. In general, the

incidence of suicide is not significantly related to climate, although in the

great majority of countries suicide rates follow a certain rhythm with the

changing seasons of the year, a maximum incidence occurring in springtime.

In the United States, April nearly always has the highest daily average number

and December the lowest.

Although there is no simple causal relation between economic factors

and suicide, suicide rates do tend to decrease in times of prosperity and

increase during depression. The relation between suicide rates and

socioeconomic status is somewhat contradictory, although there is good

evidence that members of the lower socioeconomic classes have lower

suicide rates than do members of the upper socioeconomic classes, except

after the age of sixty-five, when the rate for lower-class males becomes
considerably higher than that for upper-class males. Suicide rates among

physicians are three times the national average, and among these
psychiatrists may have even higher rates. Age-adjusted suicide rates are

highest for divorced persons, next for widowed, next for single, and lowest for

married persons.

American Handbook of Psychiatry 29

 Suicide rates also decrease during war, apparently a universal

phenomenon that has been reported in all wartime countries and has even

been observed in some neutral nations during wartime. This latter

phenomenon is always more marked among men than among women, and, in

this country, among white than among black persons. It is difficult to measure

statistically the influence of religion on the suicide rate, but suicide mortality

is generally (although certainly not uniformly) lower in countries where a

large proportion of the population is Catholic; however, suicide rates among

Catholics living in non-Catholic countries may not be significantly lower than

among Protestants living in the same countries. The rates among Jews have

been variable, but, particularly in recent years in the United States and Israel,
have tended to be low.

Early in the nineteenth century, one Matthew Lovat, an Italian

shoemaker in Venice, attempted to commit suicide by nailing himself to a

cross. Other fantastic suicide methods in history have included swallowing

red-hot coals, self-suspension from a bell clapper in a village church, and

beheading with a self-made guillotine. Most people, however, choose one of a

very few common suicide methods. Almost nine-tenths of all successful

suicides in the United States involve shooting, hanging, poisoning, or

asphyxiation. Since the beginning of the century, shooting has increased in

frequency and now accounts for almost half of all U.S. suicides, whereas
poisoning and asphyxiation by gas (by far the leading methods in 1900)

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declined in popularity for some years but—in the form of ingestion of

analgesic and/or soporific substances or asphyxiation by motor vehicle

exhaust gas—are again being used more frequently. Cases of self-poisoning

have constituted 4 to 7 percent of admissions to the medical wards of general

hospitals in Great Britain. Dublin suggested that the choice of method is in

part determined by availability and accessibility of the agent, but he pointed

out the multitude of means available to any determined seeker of suicide,

noting that persons intent on self-destruction have used any method

conveniently at hand, even crashing one’s head against a wall or drowning in

a few inches of water.

Another factor involved in the choice of a specific method may be

related to suggestibility. Although suicides actually have occurred in epidemic

form (in the United States in 1930, in Copenhagen during World War II), they

are not generally manifested as such violent reactions under such singular

circumstances. A “law of series” in suicides, claiming a high probability that

after one suicide at a given location more will follow, has been mentioned in

some earlier works. Modern data indicate, however, that such “series” usually

consist of only a few cases, employing similar methods, which, although

widely publicized, occur but rarely. Dublin emphasized that individual

psychological factors are most important: “The mental economy of the suicide

is such that he sometimes will go to great lengths to kill himself in a particular

manner that satisfies some personal or symbolic requirement.” A case in

American Handbook of Psychiatry 31

point is that of the would-be suicide who some years ago jumped from the

Brooklyn Bridge. Conscious after hitting the water, he refused to grab a rope

lowered to him by a nearby policeman—refused, that is, until the policeman

threatened to shoot him.

Epidemiological patterns of attempted suicide are far more difficult to

analyze than those of successful suicide, because reports of the rates of

suicidal attempts represent only a fraction of the real incidence of all suicidal

attempts among the general population. To be included in any statistical

study, a suicidal attempt must result in the person’s being brought to the
attention of a physician, a policeman, or some similar authority; and that

authority must report the attempt. For a variety of reasons, most suicidal

attempts are not so registered; moreover, there is some evidence that those
attempts that are reported involve specially selected groups and that the

selective factor varies in different places at different times. Such samples are,

then, almost always unrepresentative.5

In many statistical reports, the number of suicidal attempts is listed as

less than the number of successful suicides. The Metropolitan Life Insurance
Company has ventured the educated but conservative estimate that the real

rate of suicidal attempts is at least six or seven times as great as that of

successful suicides; Farberow and Shneidman reported a ratio of eight

attempted suicides to one successful suicide in Los Angeles—a figure that

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Stengel has suggested as probably appropriate for at least the urban
populations in the United States and England. Parkin and Stengel found the

actual ratio between attempted suicide and suicide (in England) to be 9.7 to 1,

and thought this was an underestimate. Choron has calculated that between
six and seven million U.S. residents have attempted suicide. Paykel et al.

conducted an extensive and careful survey of 720 subjects in the general

population of New Haven, Connecticut. They found a ratio of thirty-two

suicidal attempts to everyone expected completed suicide for their subjects,

with 0.6 percent of the total group reporting having made a suicidal attempt

during the previous year, 1.5 percent having seriously considered suicide, and

approximately 9 percent having had some sort of suicidal thoughts during the
same period. These suicidal feelings were reported more by females than

males, but otherwise appeared largely independent of sociodemographic

status. They were strongly associated with other indices of psychiatric

problems, social isolation, and life stress.

Certain facts are known about such unsuccessful attempts: They are

more common among females than males, especially in the population group
under thirty years of age. In a very detailed survey conducted in Edinburgh,

Kessel found very high rates of attempted suicide among teenage girls and
women in their early twenties. The author suggested that these young women

who attempt suicide, even though married and possibly looking after

children, tend to be emotionally isolated. The peak for both sexes in Kessel’s

American Handbook of Psychiatry 33

study was in the twenty-four to thirty-four age group, and in that age group

the rates for widowed and divorced persons were especially high. The

percentage of successful attempts becomes greater with increased age;

attempted suicides among the young are the least successful. The
socioeconomic class distribution among persons reported as attempting

suicide tends to correspond to that of the general population, although some

recent studies indicate a disproportionate concentration in the lower classes.

The most efficient suicide methods (shooting, hanging, drowning, jumping

from high places) are generally more common among men, whereas females

are more likely to use poison, the least efficient method.

If those who attempt suicide and those who successfully commit suicide

do represent two different, but overlapping, populations, one would expect

that the number of persons later committing suicide who have made earlier

unsuccessful attempts would be proportionately small. Although difficult to

collect, there are some limited data to this point. The studies of Sainsbury and
Stengel and Cook suggest that about one-tenth of all persons who commit

suicide have made one or more prior suicidal attempts. Other investigators

have found a somewhat higher fraction—up to one-quarter. Dorpat and

Ripley reviewed twenty-four published studies bearing on the relationship

between attempted and committed suicide and reported that the incidence of

prior suicidal attempts among those who completed suicide and the incidence

of completed suicide among attempters were both much higher than that of

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the general population.

Since such reported suicidal attempts probably represent only a small

sample of all suicidal attempts, both reported and unreported, information

gathered to indicate just how many of those who attempt suicide finally do

kill themselves also may be only approximate. But several such studies have
been made and show surprisingly consistent results, despite reference to

different countries and different times. In the comprehensive review by the

World Health Organization, some twenty investigators (including Dahlgren,

Ringel, Schmidt et al., Schneider, and Stengel) conducting various types of

frequently extensive follow-up studies of persons attempting suicide found

that from about 2 percent in less than a year to about 10 percent in ten years

subsequently killed themselves. Schmidt et al., Rosen, Greer and Lee, and
Weiss and associates all found definitely higher rates of subsequent

committed suicide among those who made “serious” attempts, and in the

WHO study it is noted that “if there have been two previous attempts, the
subsequent risk of suicide is considerably increased.” Therefore, although the

total number of persons who finally commit suicide after a previous suicidal

attempt obviously increases as the period following the attempt lengthens—

at least up to ten years—it can be seen that only a limited proportion of those
reported as having attempted suicide finally kill themselves, and that the

proportion of all persons attempting suicide who finally kill themselves is

probably quite small. However, it should be apparent that the risk of eventual

American Handbook of Psychiatry 35

successful suicide is still far higher among those persons who have attempted

suicide than among the general population, and that those persons who have

made one or more medically dangerous, psychologically serious prior

attempts are at far higher risk of committing subsequent successful suicide

than those whose prior attempts were of lesser medical danger and/or

psychological seriousness.

Relationships to Clinical Entities

It is also difficult to determine the quantitative relationship between

categorical psychiatric disorders and suicide rates. Most such information is

based on records of patients in hospitals. Kraepelin indicated that psychiatric

disorder was a factor in at least one-third of all successful suicides, and other
early studies provided similar evidence to this effect. Jamieson, Norris, and
Raines and Thompson have all analyzed numerous case records, pointing out

that suicide is most common among persons diagnosed as suffering from the

affective psychotic disorders but is not uncommon among schizophrenics,

and noting cases in which unplanned suicides have resulted from patients’

confused states in delirium. Malzberg (cited by Dublin) found an annual rate

of 34 suicides per 100,000 resident patients per year, for New York State’s

mental hospitals in the two-year period from 1957 to 1959. Suicide was most

common among patients suffering from manic-depressive and involutional

disorders, and next most common among patients with cerebral

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arteriosclerosis and those suffering from schizophrenia. Shneidman et al.

found that successful suicide among schizophrenic patients in psychiatric

hospitals occurred in almost all cases after there had been a remission of

illness, rather than in the depths of the psychotic process.

Sletten et al. studied patients who had committed suicide in hospital or

on one-year convalescent leave, and found that the rate was much higher for

this group than for the general population. Rates among these subjects were

higher for men than for women, for white than black, for married than single,

and for Catholic than Protestant, but did not regularly go up with age. In
decreasing order, rates were highest for those patients with a diagnosis of

depression, schizophrenia, and personality disorder. Rates were also highest

during the first months after admission to the hospital.

The difficulties in diagnosis, particularly among non-hospitalized

suicide victims, have led to several extreme points of view. Zilboorg believed

that most suicides are committed by persons considered “normal” before the
act. Lewis, on the other hand, considered that all persons who either commit

suicide or make serious attempts are, by virtue of the act, essentially

psychotic. Stengel, after reviewing the literature, concluded that suicidal acts
—successful or not—may be associated with almost any clinical psychiatric

disorder. Seager and Flood’s study of 325 suicides in Bristol, England, over a
five-year period, indicated that a family history of mental illness was present

American Handbook of Psychiatry 37

in 10 percent, a previous suicidal attempt in 16 percent, a disabling physical
illness in 20 percent, and previous psychiatric illness requiring specialized

treatment in 30 percent. There was evidence of mental illness of some kind in

over two-thirds of the cases. Sainsbury’s investigations of persons who had

committed suicide in England also demonstrated a psychiatric diagnosis of

serious depressive illness in a large majority of cases, and reports from

several major studies on the relationship between psychiatric disorders and

ultimate death from suicide reveal that about 15 percent of persons found
suffering from depressive illness will ultimately die by suicide (as compared

to probably 1 percent of the general population). Osmond and Hoffer

followed for twenty-five years 3,521 patients diagnosed as schizophrenic and

found a suicide rate among these patients much higher than the normal rate

of the countries concerned. These authors believe that the rate of suicide

among schizophrenics at least approaches that among manic-depressives.

Numerous investigators have also reported a high frequency of suicide among

alcoholics, and of alcoholics among samples of persons who have committed

or attempted suicide. A large number of alcoholic fathers among young

people attempting suicide has been noted, and Murphy and Robins found that

among alcoholics per se who committed suicide, almost one-third had

experienced disruption of affectional relationships within six weeks prior to

the act.

Probably the most rigorous study relating clinical entities to suicide was

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made by Robins’ group in St. Louis. These investigators studied 134

consecutive successful suicides, including systematic interviews with family,

in-laws, friends, job associates, physicians, ministers, and others, a short time

after the suicide act. Using careful and well-defined criteria for illness, their
results indicated that 94 percent of those committing successful suicide had

been psychiatrically ill, with 68 percent of the total group suffering from one

of two disorders: manic-depressive depression or chronic alcoholism. (If one

summarizes other international cross-study data, it seems probable that of

those persons who commit suicide, about half are suffering from serious

depressive illness, perhaps one-fifth to one-quarter from some degree of

chronic alcoholism, and a significant but smaller number from

schizophrenia.) These results should be compared with those in an earlier

study of 109 patients who attempted suicide, in which Schmidt et al. found
that the psychiatric disorders represented could be classified into nine

different diagnostic categories; no attempter was thought to be “normal”

prior to the attempt. Thus, attempted suicide is most likely a symptom or sign

associated with a large variety of clinical psychiatric disorders, whereas

successful suicide (probably including the aborted successful suicidal

attempt) is most likely to be associated with depressive disorder of psychotic

proportions and chronic alcoholism, and probably, to a lesser degree, with

schizophrenia and organic brain disorder.

Indicators of Suicide Potential: Implications for Prevention

American Handbook of Psychiatry 39

 Recent studies have indicated that successful suicide is far less often an

impulsive act without prior indicators than had previously been supposed.

Robins et al. found that in their series a majority of the persons committing
suicide had been under medical or psychiatric care, or both, within one year

preceding the act. many of them within one month. In another paper, Robins

and his colleagues noted a high frequency among persons who later

committed suicide of the communication of suicidal ideas, by specific

statements of intent to commit suicide, by statements concerning

preoccupation with death and desire to die, and by communications

associated with unsuccessful attempts. These statements were made to

family, friends, job associates, and many others, and were repeatedly

verbalized, by well over half of those who did later kill themselves. Rudestam

also found that 60 percent of his fifty consecutive cases of confirmed suicide
in both Stockholm, Sweden, and Los Angeles had made direct verbal threats

prior to taking their lives, while more than 80 percent had voiced either

direct or indirect threats.

Although many people who communicate suicidal intention may not

commit suicide, it is clear from such studies and those of Shneidman and

Farberow that most people who actually commit suicide communicate their

intention beforehand. Gardner et al. also noted that in the high-frequency,

successful suicide groups of older patients with depression, chronic

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alcoholism, or paranoid schizophrenia, there is a tendency to deny illness and
to communicate any suicidal intention or need for help in an indirect,

distorted manner. Shneidman and Farberow found a critical period of about

three months following a severe emotional crisis during which persons are
most likely to commit suicide. An increase in psychomotor activity, therefore,

does not necessarily indicate “improvement” in the long run.

Litman and Farberow have noted that the potential for successful

suicide increases specifically with age, prior suicidal behavior, loss of a loved

person, clinically recognizable psychiatric disorder, physical health problems,

and lowered interpersonal, social, and financial resources. They emphasize as

warning signs withdrawal from and rejection of loved ones, suicide threats

(particularly those giving details of time and place), and overt expressions of
suicidal intention, plus such behavior as putting effects in order, making out a

will, and writing notes and letters with specific instructions. They suggested:

“The most serious suicidal potential is associated with feelings of

helplessness and hopelessness, exhaustion and failure, and the feeling I just

want out.’ ” Others have stressed that the feeling of “being a burden” to one’s
family or friends is also a special danger sign.

However, the intensive small-N investigation by Weiss et al. has

indicated that the many social, ecological, and personality factors that appear
to relate to the seriousness of suicidal attempts in large-scale nomothetic

American Handbook of Psychiatry 41

studies do not for the most part seem to be useful for prediction with limited
samples or individual patients. The only statistically significant indicators of

the gravity or danger of the suicidal attempt for individual attempters

appeared to be (a) attempts in which the psychological intent was “serious”;

(b) attempts of older adults; (c) of those who attributed the act to concern

about personal “mental illness”; and (d) of those who were diagnosed as

suffering from a clinical psychotic process of any nature, but especially

depression. In a ten-year follow-up study of the same patients, Weiss and

Scott found the risk of subsequent successful suicide to be much higher

among those who had earlier made such serious attempts than among those

who had made non-serious attempts, that persons who made any kind of
attempt tended to have continuing psychosocial problems after the attempt,

and that the lifestyle of suicide attempters generally showed little change

when followed over that long period and no change significantly different

from that evidenced by matched controls. The attempts of younger persons,

of those whose method involved solely the ingestion of barbiturates or other

substances of limited toxicity, and of those who attributed the act to the
precipitating stress of “family trouble,” were generally not psychologically

serious or medically dangerous. The presence of a “death trend” (one or more

close relatives of the attempter being dead) and the presence of nonpsychotic

clinical depression appeared to be functions of increasing age rather than

substantive indicators.

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 The WHO expert committee stated, “Persons with [endogenous and

involutional] depressive illness appear everywhere to constitute a high risk

group. In suicide-prevention programs, high priority should therefore be

given to improvement in recognition and treatment of these conditions and

organizations of after-care for treated cases.” Rosen noted that insomnia prior

to the attempt is an additional sign of high risk. Sainsbury also emphasized

that suicidal risk is correlated with depression and with the primary medical
symptom of insomnia, especially in the elderly.

Although such information provides a guide to probabilities, the fact

remains that every emotionally disturbed person who indicates suicidal

intent should be evaluated by a competent psychiatrist. Any depressive

reaction may carry with it some danger of suicide, and no suicidal talk should

be taken lightly. Almost all experienced clinicians indicate that, if there is any

suspicion at all of suicidal intent, the patient should be questioned about it.
Such a procedure will not give the patient any ideas of suicide that he does

not already have, and his response will often help to determine his intent. If
his response is bizarre, illogical, or delusional, or if it includes ideas of

worthlessness or indicates a preoccupation with thoughts of suicide and with

actual concrete procedures for carrying out the act, one should consider the
danger of a serious or successful suicide attempt to be great.

Clinicians who deal with suicidal patients would, of course, find a valid

American Handbook of Psychiatry 43

and reliable screening test predictive of both the possibility of suicidal
attempt and the degree of lethality of such attempt extremely useful. A

considerable number of investigators have developed such suicide risk

assessment schedules, indices, rating scales, and even biochemical tests

(exemplified in Refs. Bolin, Buglass, Bunney, Cohen, Dean, Farberow, Litman,

Pöldinger, Resnick, Sletten, and Tuckman), but neither the specificity nor the

sensitivity of such instruments has been adequate for general acceptance.

Rosen has pointed out the many limitations which make the prediction of
infrequent events such as suicide so difficult. Perhaps the most promising

technique to this end is being developed by Litman and his colleagues, who

are using actuarial methods to quantify the concept of suicidal risk as part of a
mathematical model for predicting suicidal behavior. This model will assign a

suicide probability both to individual subjects and to groups for any coming

year, utilizing multiple factors input with an output providing an index of

present risk and a guide for predicting future self-destructive behavior.

Litman wrote, however, that “suicide probably is too complex and variable a

problem to be handled by any general or unitary scale or testing device,” that

any such scale would need to be adapted to each different setting and utilized

only to supplement the clinical judgment of professional workers with

experience in that particular setting.

Many psychiatrists feel that, if suicidal intent is suspected, immediate

hospitalization of the patient on a psychiatric inpatient service is mandatory.

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Other well-trained psychiatrists take a calculated risk with such patients and

follow them as outpatients. Such a decision, however, must be made on the

basis of special knowledge—knowledge of the probabilities and prognoses in

similar cases, and knowledge of the particular patient, based on intensive

interviews, psychological tests, social histories, and similar data. It seems

obvious that persons who express suicidal intentions or make suicidal

attempts are so emotionally disordered that they are willing to consider

risking their lives in a gamble with death, and it is the responsibility of

physicians and other professional workers who come in contact with such

persons to assess the meaning of each suicidal communication or attempt,

with respect to how best to respond to the implied need for help.

In countries with highly developed and readily available health and

welfare services, a variety of organizations exist for the prevention of suicide

and the treatment of patients with suicidal behavior. These services vary

from networks of general medical practitioners to general hospitals, and from

outpatient clinics to specific psychiatric hospitals and community mental

health centers. In some such countries, specialized institutions have been

established to deal with suicidal patients and those who have already

attempted suicide. A notable example is the Los Angeles Suicide Prevention

Center, operated with the co-operation of available medical, psychological,

welfare, pastoral, and other community resources. This agency maintains a

telephone “hot-line,” and referral in person may be made through medical or

American Handbook of Psychiatry 45

lay sources, or the patient may come on his own. More than 200 such centers

have been established in other cities in the United States and also in other

countries, such as Austria, France, Germany, and Switzerland. Lay

organizations also offer help to suicidal persons who either do not regard
their difficulties as medical problems or refuse to seek medical help. The best

known is the Samaritans, which started in London but has become

international. There are similar groups in several U.S. cities. They rely mainly
on volunteers, who help to maintain full-time telephone services and offer

useful advice and support, as well as referral to medical and welfare agencies.

Former clients often cooperate in running such services.

Two major criticisms have been made of both the professional and lay

suicide prevention services, namely, (1) that many of the patients evaluated
and/or treated therein are not actually suicidal, and (2) that the services of

such organizations cannot be proved to be effective. The first criticism is

probably neither humane nor valid, since clients of such agencies would not
be referred or seek aid voluntarily unless they perceived a need for help, and

since Wold, reviewing 26,000 Los Angeles SPC cases, found that 51 percent

had made a suicidal attempt at some time in the past. The second criticism is

refuted at least partially by Bagley’s study done in Great Britain, which

provided evidence that recently instituted 24-hour telephone and other

services, giving isolated, lonely, or desperate persons a chance to

communicate with volunteer workers, were most probably related to a

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statistically significant drop in the suicide rate of 5 percent in the subject

areas, compared to a rise of 20 percent in matched control areas without such

services. And Barraclough has reviewed evidence that institution of modern

medical and psychiatric services is also likely (perhaps more likely) to be

related to a drop in suicide rates.

The WHO expert committee has recommended several guidelines for

the establishment and development of suicide prevention services: (1) Local

emergency services, accessible at all times, with skilled medical and nursing

staff available, should be provided.

Adequate and prompt psychiatric consultation should be available to

such treatment centers. (3) Emergency psychiatric services with easy access
to care should also be continuously available where there is no other medical

emergency service. Such emergency services should include facilities for

immediate response to telephone calls or to patients who are referred or

come of their own accord. Such services should focus on the handling of the
crisis with which the person is immediately concerned, attempting to

evaluate the suicide potential and to work out a treatment plan for the

patient. Follow-up psychiatric care is highly desirable for many of the patients
seen in emergency services, as well as for others identified as high-risk cases.

Members of the same psychiatric team should work in both emergency and
follow-up care.

American Handbook of Psychiatry 47

 The committee noted that many persons who have made suicidal

attempts are found after screening not to need special psychiatric treatment

but may require other help, such as that provided by social welfare agencies

or voluntary groups. Measures taken to lower the incidence of suicide should

have a four-fold aim: to deal with the desire to attempt suicide, to prevent the

first attempt, to prevent repetition of suicidal acts, and to prevent fatal

outcome of such acts. Education of both the general public and the possible
providers of service, such as medical practitioners and social workers, thus

becomes important, and both national and international associations of

professional persons concerned with teaching, research, care, and prevention

related to suicide have been organized.

Treatment

Just as the suicidal act must be considered in terms of the psychological,

clinical, and sociological aspects of the person involved, so must be his

treatment. The therapy of the suicidal patient can be successful only if all

these factors are investigated and the pertinent ones so modified that the self-
destructive tendency— arising out of an acute emotional crisis, as well as a

life-long accumulation of experience, a set of social circumstances, and most

often a clinically recognizable psychiatric disorder—is reduced to non-

deleterious proportions. Social measures and somatic therapies may be

necessary in some cases and helpful in others, but psychotherapy directed

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toward understanding the need for a suicidal act appears to be a sine qua non

in almost any rational treatment program for suicidal patients. Farberow and

Shneidman and their collaborators, in discussing the varieties of therapy

useful in treating such patients, have noted that successful treatment may
vary with the kind of patient, the nature of the suicidal attempt, the

psychodynamic and psychosocial factors involved, the nature and degree of

associated psychiatric disorder, and to some extent the theoretical

framework within which the therapist operates.

Kessel has stressed that there is considerable advantage in making a

thorough psychiatric assessment of all suicidal cases admitted to emergency

medical services as soon as possible, at least within a few hours of admission.

At that time, inquiries are made into the situation while its impact is still very
strong and before the family and patient attempt to cover up the underlying

factors. And at that time, such patients can be screened and their further care

discussed with the family and other persons most closely concerned.
Frederick and Resnik have developed a well-reasoned therapeutic approach

based on evidence that many aspects of suicidal behaviors may be learned

and that treatment techniques founded in general learning theory can be

useful, and Frederick and Farberow have also found that group
psychotherapy can be very useful with suicidal persons, although some

modifications of standard group methods are probably requisite. In dealing

with suicidal behaviors in children, one should remember that the first goal is

American Handbook of Psychiatry 49

seldom prevention of death or injury (since completed suicides in young

children are rare) but rather—according to Glaser—assessment of the

behavior as a sign of emotional disturbance. The presence of depression is not

necessarily a prerequisite for suicidal acts in childhood, and persons other

than the psychiatrist are most likely to be in a position first to deal with the

problem. Whether one is treating children or adults, however, the clinician

should note that almost all authors emphasize the importance of a therapist
who manifests sensitivity, warmth, interest, concern, and consistency.

In the hospital environment, success in treating suicidal patients is

more likely with a therapeutic milieu having easy lines of communication

than with the previously utilized strictures of rigid “suicide precautions.” As

Stengel and Cook pointed out, the suicide rates of the resident population of
mental hospitals in England and Wales for the years 1920 to 1947 were about

three to five times those among the general population, remaining steadily at

about 50 per 100,000 patients per year. Those were the years when
psychiatrists took away from their patients shoelaces, belts, safety razors, and

any other articles that might conceivably be used for self-destruction. And yet,

the rates remained consistently high within the closed doors of the mental

hospitals of those days. The introduction of electroshock treatment in the late

1930s and 1940s had little or no direct influence on the frequency of

successful suicidal acts per se in mental hospitals (although other studies

clearly have indicated the clinical value of such therapy, especially in

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psychotically depressed older persons). In the 1945-1947 period, when EST

was in widespread use, the suicide rates in mental hospitals in England

actually increased slightly to 51.5. Surprisingly, in 1953 these in-hospital

suicide rates dropped to 27.3, and have remained comparatively lower ever
since. A significant decrease in suicide rates therefore occurred in a period

when the English mental hospitals were adopting more liberal policies,

including “open-door” and “therapeutic community,” before the widespread

use of the newer psychoactive drugs, and in spite of an increased admission

rate during that period for patients with psychotic depression, as well as

higher average ages of resident patients who therefore might be expected to

be more suicide-prone.

Other studies have indicated rather similar trends in mental hospitals in

the United States and elsewhere. Petri’s work in Germany supports these

findings, as does that of Kapamadzija in Yugoslavia. The latter author

suggested that the very humanization of the regimen of psychiatric hospitals

and the abolition of the atmosphere of isolation and alienation are also the

best means of prevention of suicide by the mentally ill in psychiatric units.

Simply increasing the knowledge and sensitivity of all persons who are likely

to come into contact with patients or with others who may be potentially
suicidal has clearly proved of great importance, both in therapy and in

prevention.

American Handbook of Psychiatry 51

 Finally, as has been noted, the establishment of units either in

categorical suicide prevention and treatment centers, comprehensive

community mental health centers, or general hospitals and clinics, to provide

well-publicized and easily available psychiatric first-aid, is already

demonstrating marked value, both in rendering assistance to potentially

suicidal persons and in collecting data that should add inestimable

information to our body of knowledge. The evidence indicates that suicidal

behavior is most often a symptom (or a terminating act) of biologically,

psychologically, and culturally determined psychiatric disorder, not a free

moral choice. As Freud wrote, “The moment one inquires about the meaning

or value of life one is sick, since objectively neither of them has any
existence.” The prediction, prevention, and treatment of suicidal behavior is

therefore a salient responsibility for the interacting efforts of the basic

scientist, the behavioral investigator, the public health specialist, the social
activist, and, not least, the clinician.

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Notes

1 In an attempt to explain the statistical facts as they were then known, Durkheim divided suicide into
three social categories—anomic, egoistic, and altruistic. He postulated that “anomic”
suicide results from a severe disorder in the equilibrium of society, disturbing the
balance of a person’s integration with his culture and leaving him without his customary
norms of behavior. “Egoistic” suicide results from a lack of integration of the individual
with other members of the group, and infrequently “altruistic” suicide results from
“insufficient individuation,” when proneness to suicide stems, rather, from excessive
integration into a group that might at times require an individual to sacrifice his life (as
in the case of the old person who has become a financial burden to his family).

2 Jacobs drew some questionable inferences from these data regarding the nature of successful suicide,
but his basic findings related to attempted suicide among adolescents appear to be valid.

3 Although persons who die from indirect “suicidal equivalents” or from premeditated “accidents,” or
whose deaths from obvious suicide are misreported, may not be included in suicide
statistics, these sources of error seem to be rather constant, and the statistics for
successful suicide in the United States for the past half-century appear relatively
consistent from time to time and place to place.

4 All such rates are statistically adjusted for age, sex, and other relevant factors, when appropriate.

5 Stengel has suggested that reports of suicidal attempts indicate as much about their real occurrence
as the number of divorces granted on the grounds of adultery reveal about the actual
incidence of marital infidelity.

American Handbook of Psychiatry 63