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Elements of Suicide

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David Foster Wallace, who killed himself by hanging in 2008, gave this phenomenological account of “depression” in his 1996 novel Infinite Jest:

And re Ennet House resident Kate Gompert and this depression issue:

Some psychiatric patients — plus a certain percentage of people who’ve gotten so dependent on chemicals for feelings of well-being that when the chemicals have to be abandoned they undergo a loss-trauma that reaches way down deep into the soul’s core system — these persons know firsthand that there’s more than one kind of so-called ‘depression.’ One kind is low-grade and sometimes gets called anhedonia or simple melancholy. It’s a kind of spiritual torpor in which one loses the ability to feel pleasure or attachment to things formerly important. The avid bowler drops out of his league and stays home at night staring dully at kick-boxing cartridges. The gourmand is off his feed. The sensualist finds his beloved Unit all of a sudden to be so much feelingless gristle, just hanging there. The devoted wife and mother finds the thought of her family about as moving, all of a sudden, as a theorem of Euclid. It’s a kind of emotional novocaine, this form of depression, and while it’s not overtly painful its deadness is disconcerting and . . . well, depressing. Kate Gompert’s always thought of this anhedonic state as a kind of radical abstracting of everything, a hollowing out of stuff that used to have affective content. Terms the undepressed toss around and take for granted as full and fleshy — happiness, joie de vivre, preference, love — are stripped to their skeletons and reduced to abstract ideas. They have, as it were, denotation but not connotation. The anhedonic can still speak about happiness and meaning et al., but she has become incapable of feeling anything in them, of understanding anything about them, of hoping anything about them, or of believing them to exist as anything more than concepts. Everything becomes an outline of the thing. Objects become schemata. The world becomes a map of the world. An anhedonic can navigate, but has no location. I.e. the anhedonic becomes, in the lingo of Boston AA, Unable To Identify. . . .

* * *

Hal isn’t old enough yet to know that . . . dead-eyed anhedonia is but a remora on the ventral flank of the true predator, the Great White Shark of pain. Authorities term this condition clinical depression or involutional depression or unipolar dysphoria. Instead of just an incapacity for feeling, a deadening of soul, the predator-grade depression Kate Gompert always feels as she Withdraws from secret marijuana is itself a feeling. It goes by many names — anguish, despair, torment, or q.v. Burton’s melancholia or Yevtuschenko’s more authoritative psychotic depression — but Kate Gompert, down in the trenches with the thing itself, knows it simply as It.

It is a level of psychic pain wholly incompatible with human life as we know it. It is a sense of radical and thoroughgoing evil not just as a feature but as the essence of conscious existence. It is a sense of poisoning that pervades the self at the self’s most elementary levels. It is a nausea of the cells and soul. It is an unnumb intuition in which the world is fully rich and animate and un-map-like and also throughly painful and malignant and antagonistic to the self, which depressed self It billows on and coagulates around and wraps in Its black folds and absorbs into Itself, so that an almost mystical unity is achieved with a world every constituent of which means painful harm to the self. Its emotional character, the feeling Gompert describes It as, is probably the most indescribable except as a sort of double bind in which any/all of the alternatives we associate with human agency — sitting or standing, doing or resting, speaking or keeping silent, living or dying — are not just unpleasant but literally horrible.

It is also lonely on a level that cannot be conveyed. There is no way Kate Gompert could ever even begin to make someone else understand what clinical depression feels like, not even another person who is herself clinically depressed, because a person in such a state is incapable of empathy with any other living thing. This anhedonic Inability To Identify is also an integral part of It. If a person in physical pain has a hard time attending to anything except that pain, a clinically depressed person cannot even perceive any other person or thing as independent of the universal pain that is digesting her cell by cell. Everything is part of the problem, and there is no solution. It is a hell for one.

The authoritative term psychotic depression makes Kate Gompert feel especially lonely. Specifically the psychotic part. Think of it this way. Two people are screaming in pain. One of them is being tortured with electric current. The other is not. The screamer who’s being tortured with electric current is not psychotic: her screams are circumstantially appropriate. The screaming person who’s not being tortured, however, is psychotic, since the outside parties making the diagnoses can see no electrodes or measurable amperage. One of the least pleasant things about being psychotically depressed on a ward full of psychotically depressed patients is coming to see that none of them is really psychotic, that their screams are entirely appropriate to certain circumstances part of whose special charm is that they are undetectable by any outside party. Thus the loneliness: it’s a closed circuit: the current is both applied and received from within.

The so-called ‘psychotically depressed’ person who tries to kill herself doesn’t do so out of quote ‘hopelessness’ or any abstract conviction that life’s assets and debits do not square. And surely not because death seems suddenly appealing. The person in whom Its invisible agony reaches a certain unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise. Make no mistake about people who leap from burning windows. Their terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the same window just checking out the view; i.e. the fear of falling remains a constant. The variable here is the other terror, the fire’s flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors. It’s not desiring the fall; it’s terror of the flames. And yet nobody down on the sidewalk, looking up and yelling ‘Don’t!’ and ‘Hang on!’, can understand the jump. Not really. You’d have to have personally been trapped and felt flames to really understand a terror way beyond falling.

But and so the idea of a person in the grip of It being bound by a ‘Suicide Contract’ some well-meaning Substance-abuse halfway house makes her sign is simply absurd. Because such a contract will constrain such a person only until the exact psychic circumstances that made the contract necessary in the first place assert themselves, invisibly and indescribably. That the well-meaning halfway-house Staff does not understand Its overriding terror will only make the depressed resident feel more alone.

One fellow psychotically depressed patient Kate Gompert came to know at Newton-Wellesley Hospital in Newton two years ago was a man in his fifties. He was a civil engineer whose hobby was model trains — like from Lionel Trains Inc., etc. — for which he erected incredibly intricate systems of switching and track that filled his basement recreation room. His wife brought photographs of the trains and networks of trellis and track into the locked ward, to help remind him. The man said he had been suffering from psychotic depression for seventeen straight years, and Kate Gompert had had no reason to disbelieve him. He was stocky and swart with thinning hair and hands that he held very still in his lap as he sat. Twenty years ago he had slipped on a patch of 3-In-1-brand oil from his model-train tracks and bonked his head on the cement floor of his basement rec room in Wellesley Hills, and when he woke up in the E.R. he was depressed beyond all human endurance, and stayed that way. He’d never once tried suicide, though he confessed that he yearned for unconsciousness without end. His wife was very devoted and loving. She went to Catholic Mass every day. She was very devout. The psychotically depressed man, too, went to daily mass when he was not institutionalized. He prayed for relief. He still had his job and his hobby. He went to work regularly, taking medical leaves only when the invisible torment got too bad for him to trust himself, or when there was some radical new treatment the psychiatrists wanted him to try. They’d tried Tricyclics, M.A.O.I.s, insulin-comas, Selective-Serotonin-Reuptake-Inhibitors, the newand side-effect-laden Quadracyclics. They’d scanned his lobes and affective matrices for lesions and scars. Nothing worked. Not even high-amperage E.C.T. relieved It. This happens sometimes. Some cases of depression are beyond human aid. The man’s case gave Kate Gompert the howling fantods. The idea of this man going to work and to Mass and building miniaturized railroad networks day after day after day while feeling anything like what Kate Gompert felt in that ward was simply beyond her ability to imagine. The rationo-spiritual part of her knew this man and his wife must be possessed of a courage way off any sort of known courage-chart. But in her toxified soul Kate Gompert felt only a paralyzing horror at the idea of the squat dead-eyed man laying toy track slowly and carefully in the silence of his wood-panelled rec room, the silence total except for the sounds of the track being oiled and snapped together and laid into place, the man’s head full of poison and worms and every cell in his body screaming for relief from flames no one else could help with or even feel.

The permanently psychotically depressed man was finally transferred to a place on Long Island to be evaluated for a radical new type of psychosurgery where they supposedly went in and yanked out your whole limbic system, which is the part of the brain that causes all sentiment and feeling. The man’s fondest dream was anhedonia, complete psychic numbing. I.e. death in life. The prospect of radical psychosurgery was the dangled carrot that Kate guessed still gave the man’s life enough meaning for him to hang onto the windowsill by his fingernails, which were probably black and gnarled from the flames. That and his wife: he seemed genuinely to love his wife, and she him. He went to bed every night at home holding her, weeping for it to be over, while she prayed or did that devout thing with beads.

The couple had gotten Kate Gompert’s mother’s address and had sent Kate an Xmas card the last two years, Mr. and Mrs. Ernest Feaster of Wellesley Hills MA, stating that she was in their prayers and wishing her all available joy. Kate Gompert doesn’t know whether Mr. Ernest Feaster’s limbic system got yanked out or not. Whether he achieved anhedonia. The Xmas cards had had excruciating little watercolor pictures of locomotives on them. She could barely stand to think about them, even at the best of times, which the present was not.

— David Foster Wallace, Infinite Jest, pp. 692-998 (Little, Brown, 1996). Footnotes omitted.

When I first read Infinite Jest, around 1999, I felt particularly comforted by this passage. I was comforted at seeing the thing It named and described, but on a more practical level, I was comforted by the reminder that I could always try ECT, and maybe even surgery. (I read about the practice of trepanation with longing.) Something about this thought seemed a little traitorous to me, believing as I did at that point that suicide was wrong. Is there, at the most essential level, any difference between suicide on the one hand, and attempting to erase one’s experience with electroconvulsive therapy or psychosurgery on the other? What is the difference, if there is one, between suicide and having one’s capacity to feel emotion removed?

I suspect that many people who would want to prevent Ernest Feaster from committing suicide would want to allow him to get his desired emotion-destroying psychosurgery. This, I think, is inconsistent.

The most essential thing another human being is to us is a co-experiencer. To experience ourselves and to have a truly human experience of the world, we need to see ourselves and our environments reflected through the eyes of another person. A body without an experiencer within is but an animate doll, of no use to the doll himself, and by that fact of no morally appropriate use to those who love him.

If we want to offer mercy to a man by ridding him of painful aspects of his experience, how different, then, to allow him to rid himself of all aspects of his experience, if all he experiences is pain? What reason, save religion or cruelty, to force a man to experience pain against his will?

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Written by Sister Y

April 14, 2011 at 3:14 am

For Those Still Convinced Antidepressants Have Non-Placebo Value

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Even though meta-analyses of antidepressant studies have repeatedly shown that antidepressants’ effects are barely distinguishable from placebo, many opponents of suicide rights still point to meds as a proper course of action for those who wish to die. Those unlucky enough to be hospitalized after a suicide attempt (like me) are still administered antidepressants in hospital – by force, if necessary.

Anyone who still thinks antidepressants have non-placebo value should listen to this 20-minute interview with Dr. Irving Kirsch, the lead investigator on the major meta-analyses of antidepressant drugs.

Major points:

  1. The serotonin hypothesis is “dead in the water.” Studies have repeatedly failed to demonstrate that serotonin deficiency is responsible for depression.
  2. The effects of antidepressants are indistinguishable from placebo, especially when data is included from studies that have not been published because they did not get a positive result. (Dr. Kirsch and others obtained these unpublished studies using the Freedom of Information Act.) Both the publication bias in general, and specific monetary incentives, are implicated.
  3. Antidepressants’ “effects” are independent of the drug mechanism. Antidepressants that work on inhibiting serotonin reuptake have the same effect as antidepressants that work on other neurotransmitters or even other chemicals; that is, their effect is indistinguishable from placebo.
  4. Antidepressant “effects” are independent of dosage.
  5. SSRIs (selective serotonin reuptake inhibitors) show the same level of response as SSREs (selective serotonin reuptake enhancers) – that is, drugs with the opposite mechanism show the same result!
  6. Contrary to my previous suppositions, the antidepressants’ effects are dismal regardless of the severity of depression. Severely depressed patients (who make up most of the study groups!) are not significantly more likely to respond to antidepressants than less severely depressed individuals.

As Dr. Kirsch puts it, “that’s what I call a placebo.”

The next time you see someone recommend drugs as a course of therapy for depression, please point them here, or to the podcast.

Meanwhile, the only drug that consistently cures depression in laboratory studies is only available on the black market.


(In the interests of full disclosure, I take one of these yummy placebos every day – citalopram. Similarly, millions of people feel better every day by using quack therapies such as chiropractic, homeopathy, and prayer. The folks making money off those therapies feel even better.)

Written by Sister Y

March 7, 2011 at 6:12 pm

The Underground Railroad

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He might have done it for ideological reasons. He might have done it for money. I don’t care. He is the motherfucking Underground Railroad to me. His name is Jeff George Ostfeld, and he was arrested recently for allegedly smuggling barbiturates into the United States – and potentially supplying these drugs to a 29-year-old Oregon woman who used them to commit suicide.

Authorities say Ostfeld, from Las Vegas, was carrying 1,200 milliliters of pentobarbital — vials with a picture of a Great Dane on the label — when U.S. officials stopped him May 18 at the Progreso International Bridge in South Texas. Officials said at a detention hearing last month that he was also carrying a camera with still photos of what appeared to be a deceased [Oregon woman Jennifer] Malone and videos that included what appeared to be her last words, “I’m scared.”

At that May hearing, U.S. Immigration and Customs Enforcement Special Agent Robert Haberkamp III said Ostfeld, 33, told him that he planned to sell the remaining animal tranquilizers he bought in Mexico. He said he wanted to sell them to others seeking to end their lives, including a woman in the United Kingdom and a man in Australia, according to Haberkamp. He has not been charged in Malone’s death.[Emphasis mine.]

Suicide is the only act that is not a crime, the assisting of which is a crime.

Fuck that. We would-be suicides are slaves. Those who would assist us, at the price of their own liberty, are no less heroes than the conductors and stationmasters of the Underground Railroad.

From the AP:

Malone’s boyfriend, Tom Piazza, says she suffered from chronic depression and had attempted suicide before. But he says she couldn’t have done it without help.

To me, it sounds like Jennifer Malone was in the same situation I am in – she was even within two years of my age. Would my last words have been “I am scared?” Possibly. But should that have any effect whatsoever on Ostfeld’s criminal liability? How could it? Who would not be somewhat scared on approaching death? But a determined adult who ingests poison is the proximate cause of her own suicide – not the person who provided the poison to her. A person who provided pentobarbital to me would be nothing but an agent of my deliverance.

Ostfeld was charged with importing a controlled substance and intent to distribute.

Yes, let’s keep that drug war going. It seems to be working out so far.

Written by Sister Y

June 25, 2009 at 4:58 am

How People Die By Suicide

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A review of Why People Die By Suicide, by Thomas E. Joiner. Harvard University Press, Cambridge, 2005.

Thomas Joiner provides a robust descriptive model of suicide, but repeatedly refuses to consider the deeper “why” – the answer to which might be evolutionary adaptation in the Pleistocene.


In bathrooms at Disneyland, signs over the sinks offer what are described as “hand washing tips.” The alleged “tips” are:

  • Wet hands and apply soap.
  • Scrub hands and rinse.
  • Dry hands thoroughly using paper towels.

People find this sign amusing from an epistemological standpoint: it’s not so much a set of hand washing tips as it is a (humorously unnecessary) phenomenological description of the act of hand washing. It is funny because it purports to have normative content, but fails to contain anything but description.

Similarly, Thomas Joiner’s Why People Die By Suicide promises, in its title and its project, to provide an explanatory model for suicide. Joiner does provide a useful descriptive model of suicide, but he fails to live up to his title’s promise of an explanation of suicide. In fact, he explicitly rejects, on what are essentially aesthetic grounds, the most promising candidate for a genuine explanatory model of suicide – that is, evolutionary psychology.

Joiner’s Model

According to Joiner, three factors cause suicide: competence, or the ability to carry out a suicide; the feeling of being a burden; and social failure to belong. The first factor, competence, includes the physical ability, knowledge, and pain tolerance required to carry out a suicide, as well having lost or overcome the fear of death. The second and third factors, burdensomeness and failed belonging, join together to create the desire for death. Both the desire for death and the capability to achieve death must coexist in order for a person to commit suicide; that much is obvious. Joiner’s main contributions are setting this up in a clear formulation, and positing the two specific factors that constitute the desire for death.

Importantly, while maintaining that mental illness is relevant to suicide, Joiner does not implicate mental illness in causing suicide – rather, his model explains the elevated suicide levels in people with disorders like Bipolar I and II and Borderline Personality Disorder by the fact that such disorders (a) facilitate comfort with increasingly lethal self-harm, (b) increase feelings of (and perhaps actual) burdensomeness, and (c) decrease the ability to belong.

Joiner’s model is clear, helpful, and well-supported by studies. The problem with Joiner’s model is that, while it describes who commits suicide and how they manage to do it, it fails to explain why those people commit suicide. Why should people care about being a burden to others? Why should people care about social belonging? Why should they care about these things, but not other things, enough that death is preferable to the pain of burdensomeness and thwarted belonging?

Joiner is comfortable providing an answer as to why it should be difficult to commit suicide, and why the first element of his model, competence, should be necessary: natural selection. He implicates specific genes and brain traits in suicidality (even distinct from the genetic contribution to mental illness). Yet he explicitly refuses to consider the possible role of natural selection in regard to the other elements of his model, or to suicide as a phenomenon.

Why should people care about whether they are burdens on other people? Why isn’t it, say, the feeling of being overburdened by others that causes suicide? And why should failure to belong be so painful as to facilitate suicide? Why not anger, or guilt, or physical pain, or even excessive social contact? Joiner makes no attempt to explain. But an adaptive model readily explains the features of Joiner’s model, in addition to clarifying Joiner’s more questionable results; indeed, the adaptive model has more explanatory power than Joiner’s model.

Failure to Consider Suicide as an Adaptive Behavior

Suicide, like filicide, seems upon first consideration to be a ludicrous act, viewed from the perspective of evolutionary biology: how can one’s genes go on if one kills oneself or one’s child? However, the act of filicide (the killing of one’s child or children) is clearly adaptive in many cases. Not only that, but it can be shown through statistical evidence that actors seem to differentiate between adaptive and non-adaptive filicides when they “decide” to commit filicide (as well as other apparently fitness-threatening homicides, like uxoricide and siblicide). What about suicide?

An act is adaptive when it increases the inclusive fitness of an actor – that is, when the act’s benefits – in terms of survival, procreation, or nepotistic distribution of resources to one’s genetic relatives – exceed the act’s costs, in the same terms.[1]

Under certain conditions, one’s expected contribution to one’s own genetic fitness (likelihood of reproduction, likelihood of the survival of one’s future offspring to reproduce, effectiveness at materially supporting one’s offspring and other relatives) may fall to virtually nothing. However, as long as one survives under these circumstances, he not only contributes nothing to his own genetic fitness, but also likely drains the resources of his genetic relatives. His continued survival is contrary to his genetic interests. Therefore, suicide, in this limited situation, must be said to be adaptive. (For my earlier thinking on this topic, see my essay, The Evolutionary Biology of Suicide: Is Suicide Adaptive?)

It would be callous and cruel to think of a sick relative as a burden who would be better off dead. And that is not the message of an inclusive fitness model – its message is merely that, in the Pleistocene era when modern humans were evolving, a heritable trait that functioned to tell a human something like “die if you’re a net burden on your genetic kin, otherwise stay alive” may have carried benefits in terms of selection. However, Joiner cannot get past the (admittedly substantial) emotional load of the adaptive model of suicide, and rejects it on what are essentially aesthetic grounds:

. . . I do not much like this adaptive suicide view; my own dad died by suicide and the idea that he was an actual burden is offensive. My view is that self-sacrifice is adaptive in some animal species. It may have been adaptive under certain conditions in the course of human evolution, but we will never really know. Most important, it does not really matter now. What matters now is that perceived burdensomeness – and, to the extent that it exists, actual burdensomeness – are remediable through perception- and skill-based psychotherapies. Death is no longer adaptive, if it ever was. [Joiner, p. 115]

This is a strange statement for a scientist. Although Joiner is writing a book called Why People Die By Suicide, he asserts that the essential “why” of his research does not matter – especially to the extent that it might be “offensive.” In this, I think he misunderstands the nature of the adaptive view. It is not to say that suicide is good or bad, or that Joiner’s dad really was a burden to Joiner or his family – simply that, in the human environment of evolutionary adaptedness, the ability and predilection to commit suicide under certain conditions may have conferred a benefit. Joiner also wrongly asserts that “we will never really know” about the adaptive theory, when he should know that the evolutionary psychology model is perfectly capable of generating testable hypotheses, and has done so in the past with robust results.

Joiner pushes the notion that it is perceived burdensomeness – not actual burdensomeness – that facilitates suicide. However, this may be more nice than true: suicidal persons’ perceptions of their own burdensomeness may in fact be highly accurate. Just before he dismisses the adaptive theory of suicide, Joiner summarizes a study supporting the view that suicides really are a burden: “when researchers interviewed the significant others of eighty-one people who had recently attempted suicide, a majority of significant others reported that their support of the patient represented a burden to them.”

The adaptive model leads to different predictions (and, in turn, possibly different risk assessments and treatment models) from Joiner’s model. For instance, in Joiner’s model, “belongingness” is all that matters. But an adaptive model would predict that some forms of belongingness would be more protective against suicide than others – specifically, contributing to the welfare of one’s genetic relatives (or, perhaps, surrogates for genetic relatives) would be more protective than other forms of belonging. Relationships with spouses and children would matter more than relationships with friends in an adaptive model, but not in Joiner’s model. Joiner does not even consider this to be a question worth researching. Similarly, in Joiner’s model, all that matters is “burdensomeness” – no matter who is burdened. An adaptive model might predict that burdensomeness on genetic relatives in particular (or their surrogates) would trigger suicidal behavior, rather than burdensomeness on non-relatives. Again, Joiner is not interested in testing this hypothesis, although it might have major implications for treatment and risk assessment. It cannot be said, with regard to the adaptive view of suicide, that “it does not matter now.”[2]

Joiner’s model, including a refusal to consider the adaptive view, seems to strain when it encounters certain data. For instance, when explaining the data that pregnant women experience a lower suicide rate than non-pregnant women – one-third the non-pregnant rate in one study – Joiner says: “I would suggest that the protective influence involved feelings of connection to the baby, as well as feeling needed by the baby and thus not a burden.” But a relationship to an unborn, unseen person who cannot respond is a strange sort of “relationship.” An adaptive explanation – pregnancy confers clear survival value compared to non-pregnancy – is less strained than a belongingness/burdensomeness model, and, in fact, provides a deeper explanation of why a pregnant woman might develop deep feelings for a non-speaking person inhabiting her body.[3]

Joiner’s model accounts for sex differences between the suicide rates of men and women in two ways: first, in terms of competence, men are more likely to be exposed to provocative stimulation (all kinds of violence and more) that break down one’s fear of death over time; second, in terms of desire for death, men are more likely to be disconnected and more likely to feel they are burdens than women. This is probably true – the first part, in particular, accords well with what I believe to be the most accurate explanation for the differences between the suicide rates of men and women – but, again, why should this be? Why should men be more prone to risky, painful, violent, or as Joiner terms it, “provocative” behavior?

The answer, again, lies in evolutionary biology. Men are not merely “socialized” to be more violent – there are good evolutionary reasons for their greater violence and risk-taking in all areas. A great deal of this is due to what Daly & Wilson term the “effective polygyny” of human beings (at least in the EEA) – that is, that the fertility variance among men is much higher than among women, with many more men than women having a high number of children, and, similarly, many more men than women having zero children. This leads to the sad phenomenon of male disposability – while a woman is “valuable,” with a certain, nearly guaranteed level of reproductive success, a man may have no reproductive success at all – but may, by engaging in risky behavior (e.g., successful killing in wars or honor battles), increase his reproductive success to well beyond what a woman might have. A human male is, sadly, invited by his genetic heritage to gamble his life on the chance of a big payoff in reproductive success.[4] What is driving differential violence in general may also drive differential suicides – even independently from the greater access to fear-reducing, provocative experiences.

More specifically, Joiner’s model does not explain why, in addition to varying between genders and across age groups, the time pattern in suicides across age groups is different between men and women. Men’s suicide rates are a linear function of age: the older the male, the higher the suicide rate. Women’s suicide rates vary with time differently, however. While in some countries, the pattern for women matches that for men, in other countries the pattern is very different. In Canada, rather than rising linearly with age, suicide among women peaks during the 35-44 age range; in the United States, the Netherlands, and Sweden, it peaks during the 45-54 age range; and in Australia, Denmark, and Poland, female suicides peak in the 55-64 age range.[5] While belonging and burdensomeness are probably implicated, the fact that these are the age ranges of menopause and post-menopause in women seems to lend support to the adaptive view as to why burdensomeness and thwarted belonging would come into play at those times.

While Joiner’s model is compelling, I think there is persuasive evidence that an adaptive model explains suicide better than Joiner’s model.[6] At the very least, such a hypothesis deserves to be considered, and should not be rejected on merely aesthetic grounds. To do so is irresponsible and unscientific. An accurate analysis of the etiology of suicide affects both assessment of the risk of suicide and treatment for the suffering that causes suicide.

Failure to Consider Unsuccessful Attempted Suicide as an Adaptive Behavior

Joiner refuses to consider whether a successful, completed suicide may be adaptive. Elsewhere, he refuses to consider data suggesting that making an apparently lethal but ultimately unsuccessful suicide attempt may be not only adaptive, but economically beneficial – provided one does not die in the attempt. In a 2003 article in the Southern Economic Journal, Dave Marcotte presented data that suicide attempters experience an increase in income after the attempt that is proportional to the lethality of the attempt. Charles Duhigg summarizes in his Slate article, provocatively subtitled “Why trying to kill yourself may be a smart business decision“:

Marcotte’s study found that after people attempt suicide and fail, their incomes increase by an average of 20.6 percent compared to peers who seriously contemplate suicide but never make an attempt. In fact, the more serious the attempt, the larger the boost — “hard-suicide” attempts, in which luck is the only reason the attempts fail, are associated with a 36.3 percent increase in income. (The presence of nonattempters as a control group suggests the suicide effort is the root cause of the boost.)

Marcotte’s data suggests that a suicide attempt, particularly an apparently lethal one, acts as a signal that the individual needs help – and, as it is a signal that entails significant cost (the risk of death), it is a particularly believable signal. This signal seems to act to make resources “cheaper” – a suicide attempter may get access to resources that he did not have access to before the attempt.

Again, Joiner is having none of it, and again, it’s for aesthetic, not scientific, reasons. Joiner’s complaints are two: the economic “viewpoint” is dangerous, in that it may encourage lethal-seeming suicide attempts; and it is callous, in that it denies the reality of the suffering experienced by the suicidal individual. Both of these “complaints” are without merit and are, I think, evidence of shoddy thinking on Joiner’s part.

As to the “danger” of the economic model, Joiner says

The danger of viewpoints like this should be pointed out. Any analysis that encourages suicidal behavior in any way – particularly in ways that romanticize or glorify it, or make it seem easy and normative – has potential negative consequences for public health.

But it is hardly the viewpoint that is dangerous – it’s the existing incentive structure in our society that encourages apparently lethal suicide attempts in people who often don’t really want to die. I have argued that if the suicide prohibition were ended, this dangerous incentive structure – the “fantasy of rescue” – would also end. (I have also proposed an outline of a model for ending the prohibition on suicide, with particular attention to ending the dangerous fantasy of rescue.) Analyses are not dangerous. Problems are dangerous; analyses identify the problems and point the way to solutions. By suggesting that the economic analysis is dangerous, Joiner is contributing to the taboo against speaking about suicide.[7]

Joiner’s idea that the economic hypothesis denies the reality of the suffering of suicide attempters is even more ridiculous. He believes that the economic idea is part of some kind of “deconstructionist” philosophy – he actually mentions Jacques Derrida by name (not kidding): “What is left for the deconstructionist, then, is a constant questioning of the very existence of reality and meaning – including the reality of emotional pain. Try telling that to a suicidal person.”

This objection makes so little sense that I had to reread the section (pp. 43-44) a couple of times before I understood it.[8] Joiner thinks that the economic model does not account for the pain suffered by those who attempt suicide. But the economic model suggests no such thing! Despite Duhigg’s unfortunate opening example in his popular reporting of the Marcotte study, the hypothesis is not that people coldly calculate that they will get a benefit from an apparently lethal suicide attempt. Rather, suffering people are motivated by that awful, extremely real suffering to do something awful – to, essentially, gamble their lives on a chance at making the suffering stop.

Culture, Language, and Occam’s Razor

One of the anomalies that Joiner believes he can explain with his theory is the fact that, while, in general, men commit suicide at a much greater rate than women, women in China commit suicide at a greater rate than men. Joiner is quick to find a cultural culprit: Confucianism. Specifically, he says that “the role of Confucianism in Chinese society and its view of the inferior position of women has been emphasized as one explanation, one that is consistent with the current emphasis on effectiveness as a buffer against suicide. (p. 157)” Social scientists, particularly white, Southern social scientists[9], are often quick to reach for a complicated but distancing cultural explanation when there is a perfectly good, but uncomfortable, solution available that might actually survive Occam’s Razor.

In the case of female suicides in China – and higher comparative rates of female suicide throughout Asia, including India (a noted hotbed of Confucianism) – the uncomfortable but obvious explanation is that lethal poisons are available in Asia, but not in the United States. Most females who commit suicide in China do so by poison, and the pattern holds true in other areas where female suicides exceed those of males, such as Bangalore, India. In the United States, many people, including females, attempt suicide by poisoning, but few succeed – lethal poisons are just not available in the United States, and in the event of a potentially lethal poisoning, medical care is not only available, but compulsory. The medical care necessary to treat a poisoning is often not available in China, especially in rural areas.

According to Joiner’s own model, females, who are exposed to less violent, provocative stimulation than men, should have less capability to commit suicide – by violent means. However, death by overdose or poisoning is not violent and is within the capabilities of many women. One need not reach for what even Joiner admits is speculation – that Chinese women, since they perform well in sport competitions (is he thinking of the Olympics?), are, as a group, encouraged to engage in athletics, leading to the development of more masculine traits, such as violence. Joiner’s explanation is, indeed, speculation, and ignores an obvious explanation that is consistent with his model. Perhaps the poison explanation is not as satisfying to Joiner as speculation about the effects of athleticism, because it fails to portray Asian people as sufficiently different from whites.[10]

Joiner indulges in even less responsible speculation when he considers language. Joiner devotes considerable time to the hypothesis that suicidal people fuse themes of life and death – that death becomes a focus for belonging and effectiveness. In contrast to the rest of his book, in which peer-reviewed studies are frequently cited as evidence for his claims, his main evidence for the “fusing of life and death themes” hypothesis is Nirvana lyrics (though he does give us a few isolated quotations of suicidal people that, if you squint the right way, seem to back up his idea).[11] I think that Joiner likes the idea that suicidal people fuse themes of life and death because it makes us seem more psychotic, and less rational in our actions.

The Ethics of Suicide and the Reality of Suffering

Though Joiner clearly has an ethical opinion (suicide is bad), he devotes no time to the question of the ethics of suicide and of forced hospitalization and the suicide prohibition in general. This is not unexpected. It is considered polite and compassionate to do “what is best” for suicidal people, and it is considered to be a serious failure of compassion to suggest that some of us might just know what is best for ourselves. To question suicide prevention on ethical grounds would be extremely foreign to Joiner’s way of thinking.

In addition, Joiner is sure that every death by suicide is preventable because treatment is available, but he fails to cite studies of treatments for suicidal misery that have a 100% long-term success rate. Instead, he proposes, in addition to the usual coercive suicide prevention techniques, public service announcements that say “keep your friends and make new ones too – it’s strong medicine.” He thinks that if more people called a friend every day, just to chat for a few minutes, there would be fewer suicides. He does not seem to apply this thinking to the suicide of his own father, however. His father, at the time of his death, was receiving what Joiner terms “reasonable treatments” (a mood stabilizer and an SSRI), but “his treatment came too late.” Joiner notes that his father sought out friends toward the end of his life, as Joiner’s patronizing public service announcement would have advised him, but “his efforts were not sufficient . . . . These things were beyond him . . . . (p. 226)”

Based on his (undefended) position that suicide is wrong, Joiner repeatedly describes websites like ASBS (an incarnation of the usenet group alt.suicide.holiday.bus.stop) as “pernicious” (God knows what he would think of my project). He wrongly and tellingly characterizes ASBS as pro-suicide – ASBS is pro-choice, as am I. He approvingly cites restrictive guidelines for news outlets regarding reporting on suicides. Joiner says he is against lying about suicide, and is in favor of removing its stigma, but he doesn’t want conversations about suicide to occur if he doesn’t approve of their content.

Joiner promises an explanatory model – he calls his book “a comprehensive theory of suicidal behavior (p. 222)” – and makes assertions based on tacit moral assumptions. I think that Joiner owes us not only an explanation of why people die by suicide, but also of why dying by suicide is wrong – and why coercive means of suicide prevention are ethically appropriate.


Notes

1. Of course, traits are heritable, not acts, but the ability and predilection to commit certain acts, and the ability to distinguish when to do so and when not to do so, may be seen as traits to the extent that they are specifically heritable. More precisely, we must say that a trait is beneficial when it increases one’s inclusive fitness. A trait may be very specific.

2. There is one sense in which it really doesn’t matter, of course, and that is the ethical sense. In fact, this is the sense in which even I have previously stated that an adaptive model makes no difference. But this is not the sense in which Joiner means it. He means that it can have no assessment or treatment consequences and that it is not an appropriate topic for scientific inquiry. As I stated above, the adaptive model has clear assessment and treatment implications. Whether the adaptive model is supported or refuted, it does matter.

3. Another set of data must be explained – a group of “initially pessimistic” teenage mothers reported low depression while pregnant, but high depression postpartum. Joiner attributes this to “the belief that connection to the baby and the baby’s father would solve ongoing problems” during the pregnancy, and to the fact that “the idea that motherhood would solve ongoing problems was not confirmed” after birth. However, the adaptive model gives a cleaner explanation: it makes evolutionary sense for the chemical changes during pregnancy to promote positivity and effectiveness, but also for the fitness prospects of the new baby to be evaluated coldly once the baby is born. This is particularly true for a young mother with no mate. This view is supported by Martin Daly and Margo Wilson’s work on infanticide.

4. See, e.g., Chapter 6, “Altercations and Honor,” in Homicide by Martin Daly and Margo Wilson. Aldine de Gruyter, New York, 1988.

5. Suicide Across the Life Span by Judith Stillion and Eugene McDowell. Taylor & Francis, Washington, D.C., 1996, p. 18.

6. I have not even mentioned the work of Denys DeCatanzaro, whose studies demonstrated a correlation between factors indicating low reproductive value and suicidal ideation. See, e.g., DeCatanzaro, D. (1991). Evolutionary limits to self-preservation. Ethology & Sociobiology, 12, 13-28; and DeCatanzaro, D. (1995). Reproductive status, family interactions, and suicidal ideation: Surveys of the general public and high-risk groups. Ethology & Sociobiology, 16, 385-394.

7. The unquestioning acceptance of the idea of suicide contagion, and of the harm to free speech and freedom of the press done in its name, are also ways in which the taboo against speaking about suicide is maintained.

8. I suspect that Joiner has limited familiarity with economic models and economic thinking, which may be why he seems even more threatened by this idea than by the idea that suicide is adaptive.

9. I don’t think this characterization and its implications are unwarranted. Joiner reports two incidents of people doing crazy things that might inure them to the pain of suicide. In one, a man Joiner specifically identifies by name, Huyn Ngoc Son, “swallowed three metal construction rods, each around seven inches long,” on a bet from drinking buddies, and had to have them surgically removed. In the other story, a man in England, whose name Joiner does not mention, drank fifteen pints of beer, had an argument, and went home to get a shotgun – which, while he was carrying it back to the bar in his pants, discharged shotgun pellets into his “groin area,” potentially rendering him infertile. Research reveals that the man’s name in the second incident was David Walker – the non-Vietnamese name was apparently not funny and foreign-sounding enough for Joiner to include in his description of the event.

10. I know that’s not warranted, but I have as much evidence for that claim as Joiner does for his claim that Chinese women are “sportier.” Also, I am an Internet crackpot, and Thomas Joiner is a goddamn principal investigator.

11. Elsewhere, Joiner reports that he did a “social word” analysis of a suicidal and a non-suicidal Faulkner character – yes, characters from literature – and found that, indeed, the suicidal character used fewer social words. “Faulkner accurately portrayed relatively poorly understood, intense, and rare psychological processes – still more indication of his literary genius.” This is a fun stunt, but the fact that Joiner thinks it belongs in a section called “Research on Social Isolation, Disconnection, and Suicidal Behavior” calls his judgment and intellectual honesty into question.

Thanks to Chip Smith for comments on this piece.

An Interview With Me

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Chip Smith of The Hoover Hog recently conducted an interview with me. The resulting document is an excellent synthesis of, and introduction to, my strange ideas.

What the DSM-II Got Right

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The DSM-II, or Diagnostic and Statistical Manual of Mental Disorders, Second Revision, was the diagnostic guide specifying the criteria for psychiatric disorders between 1968 and 1980.

In general, the DSM-II is very suspect. Until 1974, the DSM-II famously listed homosexuality as a mental disorder – specifically, it was listed under Personality Disorders and Certain Other Non-Psychotic Mental Disorders, Sexual Deviations, as DSM-II 302.0, Homosexuality. (Certain wacky Christian fringe groups and many Catholics still think the removal of homosexuality from the DSM was a real shame.) The DSM-II uses quaint terms like “neurosis” and includes controversial diagnoses like “Psychosis with childbirth,” “Involutional melancholia,” and “Depersonalization syndrome.”

More recent revisions of the DSM (DSM-III, DSM-IV, and DSM-IV-TR) are generally considered to contain diagnoses that map more scientifically onto observable real-world phenomena.

Partially due to a realization of ignorance of the etiology of many diseases, revisions beginning with the DSM-III tended to erase etiology from the names and diagnostic criteria of many conditions (except conditions where the etiology is obviously central, such as 292.1, “Psychosis with other syphilis of central nervous system” (psychosis caused by syphilis).

Unfortunately, the refusal to link mental diseases with etiology resulted in a step backwards in the diagnosis and treatment of depression, according to Professor Gordon Parker (“Is depression overdiagnosed? Yes,” British Medical Journal 2007:328).

“Fifty years ago [under DSM-II criteria],” says Professor Parker, “clinical depression was either endogenous (melancholic) or reactive (neurotic). Endogenous depression was a categorical biological condition with a low lifetime prevalence (1-2%). By contrast, reactive depression was exogenous – induced by stressful events affecting a vulnerable personality.” In other words, the DSM-II recognized a type of biologically-determined depression, with a population frequency similar to other major, debilitating psychiatric disorders such as schizophrenia. (In fact, for various reasons including the severity and similar lifetime prevalence as schizophrenia, my reading of this is that endogenous “melancholic” depression, if studied in more detail, would be found to be specifically genetically linked, just like schizophrenia.) Another type of depression, much less severe and much more common, resulted from people “becoming depressed” secondary to negative life events.

Then, in 1980, the DSM-III revisions changed all that. They created a new taxonomy of depression, and rather than exogenous and endogenous, began to classify depression as “major” or “minor,” with no reference to etiology. Only the diagnostic modifier “melancholic features,” which I’ve previously discussed in my essay “Depression, Cognition, and Value,” was left of the endogenous depression distinction.

Unfortunately, the major/minor classification has never been borne out by scientific studies (though the “melancholic features” modifier is scientifically robust). As Professor Parker points out,

Meta-analyses show striking gradients favouring antidepressant drugs over placebo for melancholic depression. Yet trials in major depression show minimal differences between antidepressant drugs, evidence based psychotherapies, and placebo. . . . Extrapolating management of the more severe biological conditions to minor symptom states reflects marketing prowess rather than evidence. Depression will remain a non-specific “catch-all” diagnosis until common sense prevails. [Emphasis mine; citations omitted.]

Scientific studies do not back up diagnoses of “major” and “minor” depressive disorders as true disorders. The DSM-III criteria for major depression has “failed to demonstrate any coherent pattern of neurobiological changes or any specific pattern of treatment response outside in-patient treatment settings,” says Professor Parker. In other words, while the quaint diagnosis of “melancholic depression” under the DSM-II retains some scientific validity, the diagnosis of Major Depressive Disorder under the DSM-IV is not scientifically valid in any of the normal senses.

The implications for suicide rights are several. First, to the extent that everyone who is suicidal is assumed to be suffering from “Major Depressive Disorder,” we are being diagnosed with a disease whose scientific validity is extremely questionable. The laughable overdiagnosis of “Major Depressive Disorder,” coupled with the diagnosis’ failure to “demonstrate any coherent pattern of neurobiological changes or any specific pattern of treatment response,” must shake our confidence in the fashionable hypothesis that all suicide is secondary to a genuine mental disorder. Second, to the extent that our psychiatric establishment chooses to use these diagnostic criteria (Major Depressive Disorder), and since meta-studies generally show little significant difference between antidepressant medications, “evidence-based psychotherapies,” and placebo, if we have depression, we must be said to have an incurable disease. Both citizens in general the those in medical professions should be much more circumspect about their willingness to force people with “Major Depressive Disorder” to remain alive against their will, and especially to forcibly medicate or “treat” this “disease.”

While I think endogenous depression is a “real” disease, unlike DSM-IV Major Depressive Disorder, I do not think that all suicides have endogenous depression – not even close – nor do I think that endogenous depression is always treatable. At best, it is marginally more treatable than DSM-IV Major Depressive Disorder – that is to say, not very. The famous study that found that SSRIs work no better than a placebo found a slightly significant difference between drug and placebo for the most severely depressed people, which could be tracking endogenous depression, but this was primarily due to that group’s much lower response to placebo. From the study:

Drug–placebo differences increased as a function of initial severity, rising from virtually no difference at moderate levels of initial depression to a relatively small difference for patients with very severe depression, reaching conventional criteria for clinical significance only for patients at the upper end of the very severely depressed category. . . . Drug–placebo differences in antidepressant efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients. The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication.

Written by Sister Y

August 1, 2008 at 10:31 pm

That Statistic that 90% of Suicides Have a Diagnosable Mental Illness

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There’s a widely reported statistic floating around, unquestioningly reported (often without noting its source) by groups with a stake in its truth, such as the National Institute of Mental Health and the American Foundation for Suicide Prevention. The statistic is this:

Ninety percent of all people who die by suicide have a diagnosable psychiatric disorder at the time of their death.

The statistic is used to imply that, first, mental illness, and not individual choice, is the cause of suicide, and is often cited to justify coercive suicide prevention policies; and, second, that money invested in mental health treatment will reduce suicides. I wish to question the reliability of this statistic, as well as the two implications that are often drawn from it.

What is the source of this alarming statistic? It may surprise advocates of evidence-based medicine to learn that many of the source studies hardly qualify as scientific studies at all, in that many of them are entirely uncontrolled. The studies rely on a technique known as a “psychological autopsy,” which tries to diagnose mental disorders in a deceased person based on interviews with family members. The so-called first generation of studies simply chose a study group of known suicides, and tried to identify mental disorders within the study group, with no control at all. This 1996 study, for instance, has no control, but purports to find that 90.1% of suicides have a diagnosable Axis I mental disorder. This is the study that the National Institutes of Mental Health cite as their basis for the figure!

A new generation of studies “during the last decade” has attempted to apply basic scientific control procedures, however. In these studies, a group of known completed suicides was matched with a control group of living people with similar characteristics. Interviews, medical records, and “information from the coroner” are collected and evaluated by psychiatrists who are often supposedly “blind to outcome” – that is, they are not supposed to know who is a suicide and who is alive. If an evaluator knew someone was a suicide, he might be predisposed to look extra hard for information indicating a psychiatric disorder.

Keeping evaluating psychiatrists outcome-blind seems like a particularly difficult task, especially given that “information from the coroner” is included in the case reports. More importantly, those preparing case reports are necessarily not outcome-blind. The idea that their preparation would not be influenced by knowledge of outcome (suicide or living) is rather hard to swallow.

At any rate, one (dubiously) controlled study of young men found that 88% of the suicides, compared with 37.3% of the non-suicides, had a diagnosable mental disorder. To report this study as finding that “90% of suicides have a diagnosable mental disorder” is to ignore its more important implications: well over a third of this population of young males has a mental disorder! But 37.3% of young men do not commit suicide. Clearly, mental illness is not much of a “cause” of suicide. Some scientists characterize it as a necessary but not sufficient condition.

It is also important to point out what counts as a mental disorder in these studies. Depression counts, but also alcohol or drug dependence, and often any Axis I or even Axis II disorder (as in the study of young men). It is instructive (and suspicious) that the percentage of suicides found to have a “mental disorder” does not seem to vary depending on the investigator’s definition of “mental disorder.”

It is also important to think about the vague, unscientific definitions of mental disorders found in the DSM-IV and its earlier incarnations. Given the vague definition of depression, for instance, is it really any surprise that people who commit suicide would meet the criteria for depression? (Actually, studies vary extremely widely in how many suicides they find to have been depressed – all the way from 30% to 90%. Personality disorders vary even more widely – from 0% to 57%. This variance should make us very suspicious.) What person deciding to end his life wouldn’t, for example, experience a loss of pleasure in ordinary activities, or changes in sleep or appetite, or feelings of hopelessness or guilt? As for drug and alcohol use, what person, faced with the desire to die, wouldn’t try to assuage his pain by any means available – including alcohol and drugs? In my own case, as a suicide, I view alcohol and drugs as a temporary suicide prevention device. Recent research in nicotine use, for instance, has revealed that nicotine may help symptoms like anxiety and depression, and help people with ADHD to function:

An even more important reason for the link between depression and smoking may stem from the pleasure that smoking can bring. As Dr. Fowler’s research suggests, smoking triggers higher dopamine levels in the brain; elevated levels of dopamine have been linked to feelings of well-being and pleasure and have been found in users of heroin and cocaine. Such emotions may be particularly welcome by individuals suffering from depression.

I would like to point out that I do not smoke. But it is easy to see how this logic would apply to alcohol and other drugs. We should expect suicidal people to be more willing to experiment with illicit ways of promoting happiness, compared to the general population. To say that people who commit suicide are likely to have used drugs or alcohol is not to say that alcohol or drug use caused suicide.

Does investing money in mental health care prevent suicide? The relationship is shaky at best. The Japanese government’s recent efforts to reduce suicide, through both coercive and non-coercive means, including increased mental health spending, have failed miserably. A 2005 study published in JAMA found that “despite a dramatic increase in treatment, no significant decrease occurred in suicidal thoughts, plans, gestures, or attempts in the United States during the 1990s.” While the frequency of treatment of individuals who engaged in suicidal behavior more than doubled, the suicide rate dropped only 6%.

The statistic that 90% of suicides have a diagnosable mental illness, so gleefully reported by those in the anti-suicide industry, is questionable. Even if it has some basis in fact, vagueness of diagnostic criteria and other special factors detract from any conclusions that can be drawn from it. What is most uncertain is whether investing in mental health treatment actually reduces suicide. (This is made even more uncertain by the failure of mental health treatment even to, well, treat mental illness.)

A more realistic and ethical route would be to accept suicide as a relatively rare but natural and acceptable way to end life, to provide means of suicide that are effective and not harmful to bystanders, to allow competent adults to opt out of coercive suicide “rescue,” and to focus any government or private spending on alleviating suffering, rather than preventing suicide.

See also: What the DSM-II Got Right, my examination of changes in the diagnostic taxonomy for depression since the DSM-II and their implications for suicide rights.

Update: Jason Malloy points me to this 2004 meta-study, studying suicides in North America, Australia, Europe, and Asia. “Twenty-seven studies comprising 3275 suicides were included, of which, 87.3% (SD 10.0%) had been diagnosed with a mental disorder prior to their death,” say the authors. This is far superior to the studies that attempt to backwards-infer mental illness. My main problem with this study is that it’s tracking any and all “mental disorders” and even crap like “alcohol use” is coded as a disorder, not to mention “intermittent depressive disorder” and “neurotic depression” (i.e., they’re not even using the piss-poor standards of the DSM-IV).

(See Malloy’s admirably tolerant responses to my increasingly drunken arguments here.)

Written by Sister Y

June 20, 2008 at 3:14 am