Abstract
The pathoplastic effects of social and cultural influences on psychopathology have been well documented [1–3]. Surprisingly therefore, research initiatives appear to have ignored the impact of the recent widespread penetration of mobile phone technology on psychopathology. Australian statistics for the year 2007–8 suggest a 104% penetration for mobile phone technology (22.12 million mobile phone subscriptions for a population of 21.3 million) [4]. Anecdotal evidence suggests that an increasing number of suicide attempters have used mobile phone text messages to convey their suicide notes; a trend the authors do not find surprising. Surveys report that up to 84% of adult Australians send text messages every week [5]. We describe two such cases and use this as a starting point to initiate a discussion on the implications of modern technology for the practice of psychiatry today.
A 32 year old mother of two was diagnosed with post-partum depression after the birth of her second child 2 years ago. She had been managed by her GP in the community with a combination of medication and psychological therapy. Recent stresses included gambling debts, increasing demands of motherhood and living in a partially renovated house. While the family was interstate she became intoxicated and overdosed on a combination of medications. She subsequently sent text messages to several family members bidding them farewell, asking forgiveness and making arrangements for the family to assist with caring for the children. Family living near by attended the house and foiled the suicidal attempt. She responded well to medical management of her overdose and was discharged home after a week-long stay in a psychiatric unit.
Another 45 year old mother of two adult children had a past history of treatment for episodes of depression. Her current deterioration in mood was precipitated by relationship difficulties, financial and occupational issues. She made elaborate preparations including transferring money into the accounts of her children, writing suicide notes and making sure her children had left home before driving into the bush and overdosing on a cocktail of alcohol and psychotropic medications. She simultaneously text messaged several friends and relatives bidding them farewell and asking for forgiveness. Her family alerted authorities who launched a region wide hunt resulting in her rescue. She was discharged following a short admission to hospital with follow up services that emphasized non-pharmacological interventions.
Suicide notes are potentially valuable sources of information about the psychological state of the suicidal person [6]. This has led to a considerable volume of research exploring the psychodynamics of suicide by studying notes left by those who commit suicide [7]. Suicide notes are traditionally considered as markers of the severity of the suicide attempt [8] and have therefore frequently found mention in scales attempting to rate the severity of a particular suicidal attempt [9–11]. This is an important clinical activity for mental health clinicians when working with people who are suicidal. The perceived severity of the suicidal attempt or ideation influences further management including therapeutic options (physical versus psychological remedies or a combination), the venue for such treatment and the circumstances for treatment (voluntary versus detained or sectioned under the Mental Health Act). The Beck's Suicide Intent Scale (BSIS) and the Pierce Suicide Intent Scales (PSIS) are both valuable tools that help the clinician arrive at an understanding of the severity of the patient's attempt.
We argue that both tools were formulated and validated well before the widespread penetration of mobile phone technology and are therefore not adequately equipped to deal with the complexities of suicide messages being sent via mobile phones. The salient difference between a handwritten suicide note and one sent via texting is that the latter almost invariably reaches the recipient immediately as opposed to the former which is generally discovered following the event. Sending a text message that may be accessible immediately should therefore automatically generate low scores for the individual on the circumstances subsection (Isolation, Timing, Precautions against discovery and/or intervention and Action to gain help during or after the attempt) of the BSIS and PSIS. This is not reflected in the scores in either scale in their current format.
This therefore begs the question: Are people who send suicide text messages genuinely serious about completing suicide, and is the severity of intent captured adequately in existing scales? All suicide messages, whether delivered in real time or otherwise, are cries for help and deserving of succour. Interventions for individuals who texted messages could possibly be less aggressive or coercive, as they may potentially represent a subset with a less serious intent to complete suicide. We acknowledge that there may be exceptions to this principle and that clinical decisions need to be based on individual circumstances. We also acknowledge that further research is required to understand the impact of newer technologies on psychiatric presentations and tools validated before the mobile phone culture became ubiquitous. Such tools may require modifications to make them more suited to the current milieu in which we practice psychiatry.