Abstract
Divining a purpose in life, giving life direction, and understanding the origin and ending of life are perennial problems of the human condition. This first issue of 2015 touches on these profound matters with an extensive discussion of the phenomenon of suicide and with a call for academic psychiatrists to engage new young scholars to consider the rewards of devoting their own lives to the pursuit of research and teaching in psychiatry.
Suicide
In this issue, articles from leading authorities from around the world provide an extensive discussion of suicide. Pridmore (this issue) argues that suicide occurs because of a ‘faulty connection’. He also argues for a broader concept in which suicide is a consequence of a number of stressors, ranging from relationships, substance misuse, employment and powerful emotions such as guilt, shame and sadness. Specifically, he posits that current understanding of suicide has been directed wrongly towards an association between mental illness and suicide to the exclusion of all other factors. Reification of this concept has led to a belief, which Pridmore describes as a faulty connection, that mental illness contributes and thereby ‘causes’ suicide. Interestingly, he suggests that one of the reasons the role of mental illness cannot be lessened is because otherwise the burden of responsibility with respect to prevention would fall on society as a whole, rather than on psychiatrists. Pridmore outlines how this faulty connection and faulty belief stem from supposedly misleading findings from psychological autopsy studies. He suggests supplanting these instead with evidence from coroners’ reports, and also points to the worldwide variance of national suicide rates and the fact that this does not seem to accord with the gender ratio of mental illness. Pridmore then draws on Durkheim and classical philosophers and concludes that mental disorder, and more specifically distress, does not inevitably lead to suicide, and is not a necessary precursor. Finally he returns to his thesis that this faulty connection provides a skewed perspective that needs to be repaired.
Pridmore’s Viewpoint is challenged by Haw and Hawton (this issue), who question whether this faulty connection is really so. They point to the fact that many systematic reviews have shown that those who die by suicide, more often than not, have a mental disorder, and that suicide-prevention strategies have not focused solely on mental health but instead have been directed towards reducing access to lethal means, increasing access to psychological health and addressing social disadvantage. Haw and Hawton highlight the close link between mental disorders and suicide, indicating how those with mental illness have a higher risk of suicide – often manyfold. They also point out that the interplay between psychiatric disorders and the biopsychosocial factors that contribute to mental illness and suicidal ideation is rather complicated and involves genetic factors, personality, environmental milieu (in particular that of the family) and the impact of stressors in childhood. At the same time, they emphasise that suicidal behaviour is not inevitable, and that many with a psychiatric illness do not go on to manifest either suicide or self-harm. They also note that self-harm is a significant risk factor for future self-harm, perhaps through an intriguing process of ‘kindling’. These authors defend the many benefits of psychological autopsy, in particular the complex and sophisticated understanding it has provided, which they summarise in a model illustrating various factors and their interplay, and, while acknowledging that it is complicated, and that it necessitates further enquiry, they maintain that mental illness is a critical ingredient.
Goldney provides a more direct critique of Pridmore, examining the quality of evidence that is drawn upon and dissecting the various arguments put forward. He questions Pridmore’s approach and wonders why some evidence has not been cited. In typical Goldney style, he provides an interesting series of quotes referring to suicide from leading figures in the 19th century, such as George Burroughs, and Bucknell and Tuke, and discusses the origins of sociology in this century, in which Durkheim was born. Goldney then expands on population risk studies, genetic research and neurobiological research to emphasise the link between each of these and suicide, making the point that mental illness is a key factor, but not the only factor, and that a biomedical contribution to suicide is critical. He concludes that many factors are clearly important, referring no doubt to his own model, which is commented upon by Dignam in his Debate piece on suicide prevention. The latter also quotes John Mackey’s term ‘inus’, which describes how various combinations of factors interact to produce an illness. Dignam’s engaging Debate also refers to other contributors to ANZJP and integrates argument with personal experience gleaned from extensive patient contact.
These thought-provoking discussions provide a suitable background for the paper by Kang et al. (this issue), who, using a web-based nationwide survey, examine the predictors of suicidal ideation and suicide attempts amongst Korean adolescents. Impressively, they managed to draw on the responses of more than 70,000 adolescents aged 12 to 18, and, in keeping with the discussions above, conclude that a multidisciplinary approach is needed to consider the many factors that contribute to suicide when developing prevention and treatment programs. Closer to home, Spittal and colleagues (this issue) examine calls made to crisis help lines (in excess of 400,000 calls from nearly 100,000 individuals), in particular by those who call frequently – approximately 2500 callers. Not surprisingly, self-harm and suicide feature strongly in the assessment made by respondents to such calls.
The self-harm and suicide theme continues with Wang et al. (this issue), who studied a community cohort in northern Taiwan, and examined switching suicide methods to predict completed suicide in individuals with repeated self-harm. This unique study attempts to ‘read into’ the patterns of switching and how these relate to suicidal intent/seriousness of suicidal behaviour. They find, for example, that switching to a more lethal method is a significant predictor of completed suicide, and that the adoption of a particularly dangerous method of self-harm in the first instance, such as charcoal burning, is more likely to culminate in death through suicide. Examining the intricacies of arguments and questioning the actual meaning of certain statistics, Ryan and Sara provide further insightful commentaries on the issue of suicide, incorporating additional aspects such as euthanasia. The impact of suicide is also palpable in the correspondence section of ANZJP with Gupta and Fitzgerald and Kulkarni considering the role of antidepressants and the prevention of suicide, respectively.
Academic psychiatry
Turning to a different kind of danger, Henderson and colleagues (this issue) discuss the potential demise of academia and the threat to future academic psychiatry. In an Editorial co-authored by Heads of Departments and Schools of Psychiatry across both Australia and New Zealand, the authors collectively voice their concerns regarding the future of academic psychiatry in this region.
This threat to our discipline may come as a surprise to medical students interested in pursuing a career in psychiatry, who usually rate it as interesting and intellectually challenging (Malhi et al., 2011). After all, the brain, and indeed the mind that it houses, is the final frontier. It is where we reside. It contains the secrets to self and other, the mystery of consciousness and, that most elusive of treasures, the soul of mankind. Who would not find this interesting? It is intrinsically engaging, thought-provoking and intellectually stimulating to attempt to understand the healthy mind and the perturbations in thinking that lead to the very many psychiatric manifestations that we see in practice. Why then are these qualities lost or not emphasised enough in our training?
Many papers have examined aspects of career choice and the perceptions of those at various stages in their training and of established psychiatrists. Somewhere along the line ideas about the merits of a career in academic psychiatry are distorted or lost altogether, and the satisfaction and fulfilment that it can provide is forgotten. Within the specialty itself, as Henderson et al. discuss, the process of attempting to formally understand aspects of psychiatric disorders (ranging from their clinical phenomenology and epidemiology to their biological substrates), along with imparting knowledge and experience through formal programs and clinical training, can be financially unattractive and difficult to map in terms of a career path. Academic psychiatry may perhaps also be less valued because the challenges of procuring adequate training, scholarship, doctoral qualifications, grant funding, publication and of providing didactic teaching exsanguinate the more rewarding components of an academic career. In doing so, sadly we can lose the core reason for embarking upon this journey: namely, because it is fascinating and offers an opportunity to gain an understanding that confers with it expertise and acknowledgement.
Suicide and self-harm, career endangerment and specialty extinction may appear to be somewhat nihilistic topics for the first issue of the new year. But they are important aspects of our specialty and clinical practice that signal the existence of significant problems, both with our understanding of psychiatric disorders and with our approach to investigating them. The start of a new year is an opportune time to present these issues, centre stage, and to renew our response to them. As always, the Journal welcomes active discourse regarding these and other topics within its pages.