Mental disorder and suicide: A faulty connection

Influential figures commonly state that suicide is always or almost always the consequence of mental disorder (Insel, 2013). This has become widely believed, and the majority of funds intended for suicide prevention are directed to medically orientated activities (and the community is comfortable, as all that can be done, is being done).

However, this belief is faulty; while mental disorder contributes to suicide rates, it is not ‘the cause’. Should this counter claim be accepted, a broader view of suicide prevention would be necessary, lessening the role of doctors (as they cannot remedy many important factors), and increasing the responsibility of the wider community (the locale of many important factors) (Shahtahmasebi, 2013a).

The psychological autopsy

This belief that suicide is always or almost always the consequence of mental disorder is based on the findings of psychological autopsy studies. A psychological autopsy is an exploration of the death of an individual by reconstructing what he/she thought, felt, and did before death, based on information gleaned from suicide notes, police, medical and coroner’s records, and interviews with families, friends, and others. Scores of psychological autopsies over the last half century and many reviews have concluded that over 90% of those who complete suicide do so in response to mental disorder (or words to that effect).

Evidence indicates that psychological autopsies ‘are flawed theoretically, methodologically and analytically’ (Shahtahmasebi, 2013b: 2). Difficulties in remaining objective and unbiased have been identified (Selkin and Loya, 1979). Methodology has not been standardized and consequently one study cannot be compared with another (Abondo et al., 2008). Validity and reliability are faulty (Ogloff and Otto, 1993). The vast majority have used ill-defined instruments, greatly reducing intended scientific value (Pouliot and De Leo, 2006) to the extent that a recent review concluded that psychological autopsies ‘should now be abandoned’ (Hjelmeland et al., 2012: 622).

Recent psychological autopsies in China have found mental disorder in less than 50% of suicide completers, while in India mental disorder has been found in less than 40% of completers (Manoranjitham et al., 2010). This substantial difference in findings from the East and West may simply reflect the scientific shortcomings of the psychological autopsy method. However, important social and cultural factors have been identified as suicide triggers in the East, providing ‘a challenge to the psychiatric model popular in the West’ (Zhang et al., 2010: 2003).

Another method for identifying factors associated with suicide is the examination of coroners’ reports. While this approach lacks the ‘sophistication’ of psychological autopsies, it has the advantage of close consideration of relevant facts by a responsible person outside the medical system. These studies generally report a history of mental disorder in less than 50% of cases. A recent thorough examination of records in Malaysia (Ali et al., 2014) found reports of mental disorder in only 22% of cases.

National rates

National annual suicide rates are surprisingly stable (Insel, 2013), and the relative positions of nations (according to rate magnitude) remain much the same. Lithuania (around 40/100,000) usually has a suicide rate about three times higher than Australia (around 10/100,000), which usually has a rate about three times higher than Greece (around 3/100,000) (Varnik, 2012). For mental disorder to be the paramount factor in suicide, the people of Lithuania would need to have three times the psychopathology of the people of Australia, who would need to have three times the psychopathology of the people of Greece. This is not the case, and the initial premise is incorrect.

The argument might be made that the different suicide rates of different nations simply reflect different recording strategies. While local strategies doubtless play some role, counter arguments support the presence of real differences. First, the suicide rate in New Zealand is greater than that of Australia, which, in turn, is greater than that of the UK, and this relative relationship has remained constant over decades, even though these are well-resourced populations with comparable data collection systems and common historical roots. Second, immigrants take the suicide rate of their homeland to new domiciles, as demonstrated by French settling in Quebec, Indians settling in the UK and northern Europeans settling in Australia (Morrell et al., 1999). There are real differences (often substantial) between the suicide rates of different nations; these arise not through differences in the prevalence of psychopathology, but through socioeconocultural differences.

Gender ratio

Also against the primacy of the mental disorders theory is the gender ratio (male:female) of suicide. Globally, for the last five decades, it has been around 3:1. The ratios of individual countries differ somewhat from each other, USA being 3.3:1 and Korea 1.8:1, but everywhere (with the possible exception of parts of China) the male rate is greater than the female. There is no evidence of a significant difference in the overall rate of mental disorder between the genders. Some evidence indicates mood disorder is higher among females than males; if this discrepancy was to have an effect, it would be to push the female rate above the male (but the reverse is the case). The higher rate of suicide among men, worldwide, over decades, cannot be explained by mental disorder; culture and gender roles are responsible for this robust difference.

Other disciplines

‘For suicide is not simply a medical “problem”, or even a public health “problem” – it is a complex cultural and moral concern that is deeply embedded in social and historical narratives and is unlikely to be greatly altered by any form of health intervention’ (Fitzpatrick and Kerridge, 2013: 470). These words from ethicists at Sydney University remind us that scholars outside medicine have relevant wisdom to offer. Some such scholars are scathing of the ‘mental disorder is the cause of all suicide’ belief (Weaver, 2014).

Durkheim (1951 [1897]), the first sociologist, conceptualized suicide as a social phenomenon. He proposed that individuals who are insufficiently ‘integrated’ into society are at risk of suicide, being less able to withstand the impact of unwelcome events. Insufficient integration can arise via one of two routes. The first is when society is breaking down (anomy), and no longer prescribing goals, rewards and limits, leaving the individual stranded without a life structure. The second is when society is healthy and functional, but the individual displays ‘excessive individualism’, is aloof or otherwise lacks the capacity to achieve sufficient integration.

Durkheim’s view on the role of mental disorder is often misunderstood. He does not completely reject mental disorder a ‘cause’ of suicide; he acknowledges a causal role for insanity (psychosis) in a small number of deaths. Also, in the terminology of the day he states: ‘The temperament most predisposing man to kill himself is neurasthenia in all its forms’ (p. 137) (neurasthenia representing mild mood and personality disorder). There is a connection between neurasthenia and insufficient integration. Durkheim argues that neurasthenia is not the cause of suicide, for the majority of those with neurasthenia do not kill themselves. Thus, the non-psychotic disorders predispose (rather than cause) the individual to suicide when ‘aggravation’ is encountered. For current purposes, Durkheim assures us that society is of profound importance, and alerts us to ‘cause’ and ‘predisposition’ being distinct designations.

Durkheim’s (1951 [1897]) theories have been challenged by fellow sociologists on occasions, but he has strong current support from historians (Healy, 2006), who have taken low social integration to mean social isolation.

Philosophers have examined suicide since Classical Greek times, frequently focusing on the morality of the act. Plato condemned suicide (Nicomachean Ethics 1138a5–14), but listed extensive caveats to his embargo (Laws IX 854a3–5; 873c–d). Aristotle was not supportive, but nor was he strongly opposed. Socrates and Seneca both completed suicide. In the more recent past, Nietzsche famously wrote (Beyond Good and Evil): ‘The thought of suicide is a great consolation: by means of it one gets through many a dark night’. This enigmatic statement allows the possibility of suicide in response to difficult times. And, Camus famously wrote (The Myth of Sisyphus): ‘There is but one truly serious philosophical problem, and that is suicide’. He was introducing his philosophy of the absurd, and recommended that the way to deal with the world is to recognize and embrace life’s absurdity. However, if this formula failed, he considered suicide to be a balanced solution. Contemporary philosophers reject the ‘uniform assumption that suicide is the causal product of mental illness’ (Battin, 2005: 173).

Conclusion

The current fashion of classifying the experiencing of negative emotions as depressive disorder has permeated the psychological autopsy setting (Zonda, 2005). It is probable that, preceeding the act, those who complete suicide experience feelings of distress/misery (termed ‘psychache’ by Schneidman in 1993). Many authorities with an interest in suicide from outside of medicine (ethicists, sociologists, historians, philosophers and others), and some from within, contend that distress/misery may end in suicide. The dominant medical view (that at least 90% of suicide is the result of mental disorder) can only be maintained by the surmise that adverse events lead to distress/misery, which in turn leads to a mental disorder, which then causes the act. But, not all ‘depressive symptoms’ evolve into depressive disorder, and Occam’s razor encourages us to go, at least sometimes, with the least complicated explanation. Credible psychological models, such as the ‘Cry of pain / Entrapment’ model from Scotland and the ‘Strain Theory of Suicide’ from China, offer conceptualizations without recourse to the medical model.

Experience with people suffering psychotic depression proves to clinicians that mental disorder can be a sufficient cause of suicide. However, it is not necessary for suicide, as the deaths of Judas, Samson, Cleopatra, Dr Harold Shipman and many aging people in suicide pacts well demonstrate. Through the ‘90 percent of suicides are related to a mental disorder’ message (Insel, 2013), the community has been taught and respectfully learned that mental disorder is necessary for suicide. Consequently, monies (and responsibilities) directed to suicide prevention are spent on medical activities (and any hopes of a comprehensive blueprint are abandoned).

A preferred message is that suicide may be the result of a mental disorder, or a single socioeconomic stressor (such as public disgrace), but more often it is the result of a number of stressors, one of which may be a mental disorder, with other possibilities including unemployment, relationship failure, drug and alcohol use, and painful emotions such as shame, guilt and sadness. On suicide prevention, Professor John Werry (psychiatry) of Auckland University, New Zealand said, ‘the thing that’s most likely to have an effect in the long run is social policies which aim to give children, adolescents, and their families a fair break in life’ (Weaver, 2014: 230). Suicide prevention needs to repair the faulty connection and develop a new plan, one which includes clinical people, but also a range of non-clinical people, working to improve awareness, practices and options.