Suicide explained!

Why do people take their own lives?

In this issue of the Journal, Pridmore takes aim at what he sees as the ‘dominant medical view’ – ‘that at least 90% of suicide is the result of mental disorder’ (Pridmore, 2015: 2). He is not alone in believing this is the prevailing view in medicine or psychiatry. In this year alone, Rich has confidently asserted that it is a ‘kind of gospel’ in psychiatry, that ‘anyone who contemplates, expresses a desire for, or takes any overt action toward shortening their life must be afflicted with a mental illness’ (Rich, 2014: 1) and, in more muted terms, in the Journal’s Canadian sibling, Ho has urged clinicians to ‘recognize that suicidality may not necessarily be driven by mental illness’ (Ho, 2014: 142). In July, controversial euthanasia campaigner Philip Nitschke repeatedly claimed the medical profession equated suicide with mental illness and that doctors failed, for example, to recognise even the possibility of rational suicide.

I am not aware of any actual evidence that psychiatrists, or even doctors in general, have such a simplistic view of suicide. As a counter to Nitschke’s claim, I am aware of a 1998 survey suggesting 86% of UK psychiatrists believed suicide may be rational in some circumstances (Shah et al., 1998).

In the last 25 years I have spent nearly every working day in the emergency department of a large tertiary referral hospital. Over that time I have seen literally thousands of people who have attempted to end their lives (Brakoulias et al., 2006). I believe this has given me some insight into why people suicide, or at least why they try to end their lives. I suspect my views are not too dissimilar from those of my colleagues who have had similar experience.

People try to end their lives when suicide seems like their best, or their only, way out of their current predicament. It occurs when the pressures that confront them overwhelm any resources they have to deal with them. Often the stressors are enormous, or at least they are perceived that way, owing to the meaning the individual attributes to them. Often their resources are at a low ebb, perhaps because their usual supports have abandoned them or because their ability to find another solution is diminished by illness or intoxication. Always, somewhere on the journey to the fatal decision, there is intense psychological pain.

It is that simple, and that complicated. This single paragraph sums the permutations that precipitate chosen oblivion; yet in those few lines lie all the wounds of outrageous fortune that a person might bear.

Written there is the psychotic adolescent pursued by delusional demons; the drunken lover heart-stabbed by revelations of infidelity; the woman borne down by months of pervasive despair; the mountaineer severing his tether to save his friend; the cancer patient, overtaken by disease, choosing his own moment of exit. All are tragedies. All should be prevented. The last, perhaps, should also be assisted to die (Ryan, 2012).

Psychiatrists stand as the counsellors and protectors of many who touch this twilight realm. Our participation in efforts to reduce suicide numbers is vital. However, I suspect that few believe that the tide will be stemmed by the efforts of medicos alone.

See Viewpoint by Pridmore, 2015, 49(1): 18–20.