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Attitudes Toward Suicide

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Note: If you are interested in evolutionary biology, please see my article on Thomas Joiner and the evolutionary psychology of suicide.

The question:

227. Do you think a person has the right to end his or her own life if this person: a. Has an incurable disease?

The General Social Survey, available through the Survey Documentation & Analysis project at the University of California, Berkeley, tracks how attitudes of Americans vary with time and against other variables. The answer to the question above, known as SUICIDE1, tracks attitudes toward a special kind of suicide right – that for the incurably ill. Answers vary strongly with age and over time.

The trend over time indicates that more people are favoring the right to suicide in the case of incurable illness. This chart indicates the percentage of people in the 50-60 age group responding to the above question – red for yes on suicide rights, blue for no on suicide rights – for the years 1972-2006, in five-year increments:

Attitudes within the 50 to 60 age range are clearly changing. Support for suicide rights climbs steeply until 1996, when it flattens out.

Similarly, attitudes toward suicide rights upon incurable illness vary with age; the chart below tracks answers to the above question by age group in ten-year increments, for the years 2002-2006.

Generally, the older the respondent, the less he favors suicide rights for the incurably ill, up until the 71-80 age range – the only age range in which a majority of respondents disfavor suicide rights. This is consistent either with (a) stable attitudes over the lifespan, set at an early age; or (b) changing attitudes over the lifespan toward disfavoring suicide rights – perhaps over concerns with one’s own mortality. However, the data above suggesting that attitudes are changing in favor of suicide rights, controlling for age, makes the first hypothesis more likely.

Interestingly, the direct correlation between age and negative attitudes toward suicide has an exception: the 81-90 age group. 81-90 year olds are more likely to favor suicide rights for the incurably ill than not, and they favor suicide rights more than the 71-80 age group. This may be suggestive of attitudes changing over the life span in response to events (in this case, advanced aging).

Sadly, there seems to be little to no progress in attitudes about suicide when someone is “tired of living.” Attitudes on the question known as SUICIDE4, as follows:

227. Do you think a person has the right to end his or her own life if this person: d. Is tired of living and ready to die?

show little change over time:

There is, unsurprisingly, a strong correlation in religion (THEISM) and attitudes toward suicide. The more one agrees with the question

1387. Do you agree or disagree with the following. . . a. There is a God who concerns Himself with every human being personally.

the more one disfavors suicide rights, both on incurable illness

and when one is tired of living:

What about education? Education is associated with favoring suicide rights. Here is the response to SUICIDE1 (suicide rights for people with incurable illnesses) against highest year of school completed:

The correlation for suicide rights for those tired of living is present but not as strong:

Interestingly, the correlation to college major (COLMAJR1) is the opposite of what I would have predicted: those with a major in fuzzy studies – English, literature, foreign language, fine arts, or other humanities (values 1-4) – were much more likely to favor suicide rights for the incurably ill than were those who majored in science or math (values 8-9):

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Written by Sister Y

December 7, 2008 at 1:00 am

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.

More Than Half of Gun Deaths Are Suicides

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In 2005, according to CDC statistics, 55% of gun deaths were suicides. Apparently, suicides have outnumbered homicides and accidental deaths by gun for 20 of the past 25 years. An interesting and surprising statistic. But what’s missing from this article by Mike Stobbe, released in the wake of the United States Supreme Court decision interpreting the Second Amendment as a personal right to bear arms?

First, and most importantly, it’s missing any hint that a perspective might exist recognizing a right to suicide. Second, it fails to provide a single reason justifying the paternalism underlying gun bans enacted to prevent suicide in particular (“You can’t have a gun because you might use it to kill yourself”). And, third, there’s something glaringly missing from the recital of success rates for different suicide methods:

More than 90 percent of suicide attempts using guns are successful, while the success rate for jumping from high places was 34 percent. The success rate for drug overdose was 2 percent, the brief said, citing studies.

“Other methods are not as lethal,” said Jon Vernick, co-director of the Johns Hopkins Center for Gun Policy and Research in Baltimore.

That’s right – no mention of hanging, which has a lethality rate of up to 70%. Mention of this fact might have undermined the political point Stobbe was trying to make. (The article also fails to address the paradoxically high suicide rate in gun-free Japan – over twice that of the United States.)

As I have previously written, there is some evidence that reducing guns correlates to reducing suicides. What I object to is taking the “more guns means more suicide” statistic as license to argue in favor of coercive suicide prevention policies, such as gun bans, without examining in the slightest the philosophical basis for such a policy.

Written by Sister Y

June 30, 2008 at 9:52 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