1. Does depression in kids raise their risk of violence? 
2. If a kid is violent, is it more or less likely they are depressed?
3. If someone is depressed and violent, is it likely they are a kid?
4. Can you define any of the nouns in the preceding questions?

Do you know how many psychiatry journals there are?  A lot.  I get 8 peer reviewed journals mailed to my house, not to mention the shopping bag/week of "Insights" and "Reviews" and "Expert Series."   What the hell could be in all these journals, other than drug ads?  Is the field evolving that rapidly?  I mean, just how much info can there be about Lamictal?

But I'm happy to announce that the hundreds of articles are all top notch, cutting edge stuff.  Let's look at a recent one, about how to conduct and document a suicide assessment. 

I'm a busy man, with a lot to read-- what are the main, state-of-the-art points that I need to know about suicide?  

Awesome. 

Also suggested was listening to patients, preferred over caning patients, which can sometimes be misconstrued as insensitive. 

The headlines read, "Highest increase in youth suicide" and "girls aged 10-14 increased 75%."  And of course, the only explanation anyone seems to want to debate is antidepressants: was it too many prescriptions, or too few?   And self-righteous indignation all around.

Well, I did something apparently no one else cares to do: I looked up the individual suicides.  They are individuals, right?  With different reasons for doing things?  And guess what?  I have another explanation:  Ohio. 

A reader asked me to help promote the Hong Kong Mental Health Support Group.  My first reaction (after being flattered) was to silently muse, "well, why Hong Kong only?"  What's the difference?   I realize that people from Hong Kong might like the sense of community, but I'd bet anyone from Hong Kong is already plugged into a community-- why another one for mental health issues?  What's the real advantage?  Understand that I am not an idiot-- I see how people would feel more comfortable, but I'm asking whether there is any real, actual, measurable benefit to a culture specific group vs. a general group.

Which got me thinking of this: in the massive push for biological bases for mental illnesses, have we ignored the very real influence of culture on mental health?  And suicide?   Cultural influences so strong, that they not only overwhelm biology but even probability?

A reader asked me to read his book before saying that copycat suicides is not a real phenomenon.

To be fair, his book is really good.  It is worth the price even as a reference guide/catalog of suicides and homicides that share similar characteristics, which are striking.   While the majority of the information is a google search away, the fact is that he actually did the searches.   It's also a  good read-- it neither bores you nor crams the conclusions into your head.

But, I respectfully disagree.  I think.

The main disagreement I have with the book is that he conflates two phenomena.  His stated thesis of the book is that media reporting of violence and suicides begats copycats.  However, in support of this premise, he uses examples of the media itself (e.g. movies) causing copycats.

A perfect example of this is the Werther Effect, so named for the Sorrows of Young Werther, the 1774 comic book by Goethe in which the protagonist kills himself because he can't get the girl.    Subsequently, there were numerous copycat suicides-- staging it (same clothes, same desk) as Werther in the novel.  Ok, I get it-- that's a copycat.  But that's not an example of media reporting causing copycats.

In contrast, here's an example of a reporting-induced copycat: Coleman relates the Bergenfield Four.  For a few months, there were rumors that a bunch of kids who called themselves "The Burnouts" had made a suicide pact.  In September of 1986 their leader killed himself; in March of 1987 four others carbon monoxided themselves in a parking garage, leaving a note that clearly linked the deaths.  One week after that, a cop found two other kids trying to do the same thing in the same garage.  The day after the original four suicides, but in Illinois, two other teens suicided the same way (in a garage, in fact.)  Coleman writes that by checking newspapers, he counted 22 teen carbon monoxide suicides in two weeks-- 47 in a month.

But then there's the case of Barry Loukaitis, who in 1996 shot two kids and a math teach, and said he got the idea from Stephen King's Rage, Pearl Jam's Jeremy, Natural Born Killers and The Basketball Diaries.  Coleman writes that "the media attention...triggered a series of similar events."  So, in these copycats, was it  Basketball Diaries or the evening news?  It's hard for me to see how the news can be more influential to a suicidal kid than the movie itself-- do kids even watch the news?

In fairness, he does cite numerous examples of media reporting induced copycats (check out the chapter "Planes Into Buildings" for a wild ride) but overall the argument is weakened by using  both together.  I left the book reasonably convinced that media can inspire copycat violence, but not that they inspire violence itself.  In other words, I think those Werther scholars were going to kill themselves somehow, but they decided to shoot themselves (as oppposed to self-immolation) because of the book.

The distinction-- media or media reporting--  is important because the solutions are different.  Here's an example: the book opens with the story about how one month after Marilyn Monroe's suicide, 197 (mostly blonde women) "appear to have used the model," to suicide-- an increase in the suicide rate of 12%.  Furthermore, the suicide rate never went down after that.  "This is the copycat effect working with a vengeance."  Maybe.  Or maybe the graphic description of the suicide wasn't to blame, but rather that a huge icon had done it at all.  Are they copying her, or is society ripe for self-destruction?  Either way, should we not report that Monroe killed herself at all?  How much do you control information to protect the people?  If the government is doing the controlling, then I can't imagine the answer should be anything other than "not at all, get the hell out of my face."

I've always said that the "mainstream media" is neither liberal nor conservative-- they are sensationalist.  Of course I think they overreport, and overdramatize unusual violence.  But I see that as more of a symptom of our culture than the cause of anything.  You could close down all news portals, it won't change the amount of violence.  Sure, maybe you wouldn't have thought of playing Russian Roulette.  But you were going to come up with something. 

Coleman wrote a thorough book, using the type of diligent research the CIA is supposed to be good at: compiling open source information and forming links.  I only partly disagree with his conclusion, and I am still open to further arguments.  But I am against the solution.

It's worth remembering that, in response to the copycat suicides, Sorrows of Young Werther was banned in Germany.  I know I am one of only 8 people who has actually read it, but do we really want it banned?    Maybe "dangerous" books need to be delayed by a generation to be published?  And you see my problem.

Absent direct power or wealth, the only thing that keeps us free is information.  I believe it is worth the risk of copycat suicides, especially since influencing the choice of the method of suicide isn't the same as influencing the choice of commiting suicide. 

I came across this in my regular survey of the internet: a student (?)  listed all the suicides at MIT hung it up in a bus schedule frame.

The suicides' names, ages, method, etc, can be found here.   

But there are a few notable findings:

First, you should know that MIT and Harvard have some of the highest suicide rates. 

But, strangely, almost half of the suicides at MIT were grad students or former grads-- 13/30 since 1990.  (Since 1980 , 16 grads at MIT vs. 8 at Harvard.)

Since 1990, there have been a lot of suicides by jump off a building-- 10/29.  In the U.S., this is extremely rare, while in Hong Kong, 50% of suicides are jumps from buildings.  (None of the jumpers here were even Asian.)  (The only school that comes close is a rash of six jumpers in 2004 at NYU (no Asians.)  The first three happened witin 30 days of each other, and the last two happened in the same week a year later.   Only 1 was a grad student.  As near as I can tell, NYU hasn't had any jumpers before or since-- in fact, they hadn't had any suicides since 1996.)

A lot were women: 7/29 (25%), 8/29 if you count the Wellesely student who was renting on campus.   In the U.S., it's 15-20% females.

8/29 were non-white males;  4/29 were non-white females, so 12/29 were not white. In the U.S., non-whites represent about 10% of all suicides.  And 2/3 of non-white suiciders in the U.S. are black.

All three suicides that occurred in April (2000, 2001, 2003) were women.  2000 and 2001 were both sophomore women, who died on 4/10 (burning/OD) and 4/30 (cyanide poisoning.)

I don't have the demography of MIT, but it seems that grad students, Asians and women are at higher risk for suicide at MIT.

And if someone asks you how to get to the roof, lie.

(NB: MIT students, I know, small samples and statistical significance.  I know.)

(Second NB: I looked into each suicide as best as I could, and I was able to supplement the spreadsheet linked above.  For example, I found two additional jumps from buildings.  But in this process it discovered that one "suicide" (KM) might not have been a suicide; and, even more interesting, he was linked to the suicide of another student at MIT (RG).  I use the initials here, but their full names are clearly public, and already contained in the spreadsheet.)

(Third NB: to the guy who made the suicide schedule-- some of the dates and methods are wrong (for example, April.)  Nothing major, but if you want my list let me know.)

I won't give a detailed answer to this question here (it seems to be no), but there is an article making the reddit rounds now that I need to kill before it becomes another meme (like that other badly reported story about psychiatry.)

The article is from BMJ 2002, called Influences of the Media On Suicide, and it puts its conclusion right at the top:

Reporting and portrayal of suicidal behaviour in the media may have potentially negative influences and facilitate suicidal acts by people exposed to such stimuli. Recent systematic reviews by others and ourselves (unpublished) have found overwhelming evidence for such effects.1 (emphasis mine)

And it offers about 8 references in support.  And so now every nut with a microphone can proclaim it loudly: it's the media's fault.

We may want to take a pause and examine these 8 references: none of them offer anything close to "overwhelming evidence."  For example:

Reference 1-- the one directly cited for the above statements-- is indicative of the type of "overwhelming evidence" that exists. The study finds that media reporting of suicide is extensive and detailed, but not that there is a clear link to future suicides.  

In the summary, the authors use phrases like, "dearth of literature," "evidence is less reliable," "few studies permitting/demonstrating [the link]," "does not demonstrate consistency," "many studies fail to demonstrate" over 11 times in the 3 pages describing the studies. 

Despite this, they are sure the link exists-- but they don't actually show the link, they infer a link.    The authors repeat phrases, "it is fair to conclude that the evidence suggests an association [exists]" "tends to suggest," "probably reasonable to regard the association is causal"  13 times in two pages.  Under these criteria, it's reasonable to assume the Matrix is real.

Reference 3 (not even linked correctly) is a letter to the editor, describing two cases, where the method of suicide was affected by internet, but not the decision to commit suicide.  And the methods were rather weak: one guy took two pills of castor oil, and the other woman tried to drink water.  No, I'm not kidding.

Reference 5 is frequently cited in support of media's impact.  It supposedly says that a TV show with a Tylenol OD caused more Tylenol ODs: 20% of these suicidal viewers said it influenced their decision to attempt suicide in the first week post broadcast.  Maybe-- that 20% is really 6 people.  And most had attempted Tylenol OD in the past.  Oh, and the authors note that while 17% of the suicidal viewers' choice of Tylenol was influenced by the show, some of them chose not to use it because of the show.

Reference 12 is probably the most cited reference in this field.  In 1978 Vienna built a subway, which soon became a popular method of suicide.  So the government established guidelines for reporting-- specifically, that the method not be mentioned-- and subways suicides decreased by 80%.  Fantastic.  Overall suicide rates didn't change, though.  Too bad. 

So much for the "overwhelming evidence" for a soon to be media soundbite. 

The article doesn't make a good case for media influencing the decision to kill yourself, though I'll admit that it may influence the method.  And that's where it gets tricky.

It's important to make a distinction between copycat suicides and copycat homicides: more poeple die in the latter, and, let's postulate, they didn't want to die. That has to be part of the calculus in media reporting. Copying suicide by water (instead of pills) is different than copying a 30 person massacre (instead of killing, say, one person.)

But you have to weigh this against the societal costs.  The solution offered in these articles is to restrict media reporting.  I think we can agree that the media are neither liberal nor conservative, but  sensationalists, their bias is titillation.  But to allow anyone, especially government, to affect the content of reporting-- literally, the information we are allowed to have-- seems exactly the wrong solution to a problem which may not actually exist.  (e.g. I know it seems prurient, but I actually want to know all the details of David Kelly's suicide.)

Not to mention that if you say the media are partly responsible, then you're saying that you're less responsible.

(More on copycat suicides here, and on university suicides/copycats here and here.)

I took the data in the paper "Killing the Willing: "Volunteers," Suicide and Competency" and drew this chart.

The paper is fascinating. It observes that although blacks are disproportionately represented in executions versus the general population, volunteers to be execute-- i.e. people who waived their appeals-- are overwhelmingly white, male, and have psychiatric illnesses, especially borderline, depression, and psychoses (and an additional 10% have substance abuse)-- which is basically your demographic for suicide attempts. 30% also had prior suicide attempts.

So the author asks: if there is no such right to assisted suicide (indeed, any suicide at all), can there ever be a waiver of the appeal in capital cases? Even if the defendant is competent, if suicide is a motivation, the author writes, "their decisions should not, indeed must not, be honored, at least so long
assisted suicide is not available to other persons in the jurisdiction."

The counter argument, of course, is that competency is a legal matter, and the person's motivations beyond that are irrelevant. For example, if a guy is sentenced to prison and wants to go, he still goes.

McClesky v. Kemp (1987) attempted to abolish the death penalty under the argument that executions were influenced by racial discrimination. This was rejected. But Atkins v. Virginia (2002) did abolish the executions of the mentally retarded. Consequently, abolition of the death penalty, or at least a drastic curtailing of it, is more likely to occur along lines of competency and mental state, rather than any appeal to morality, race, or class.

I thought I knew how I felt about this issue, and now I am not so sure. But before anyone forms their opinion, I would strongly urge everyone to read the dissent by Scalia in the Atkins case. It should be required reading for every psychiatrist, whether you agree with him or not.

If society has determined that a right to commit suicide does not exist, can a convict sentenced to death waive his appeal?

Just thought you should know:

There are about 1200 murder-suicides per year (i.e. 500-600 suicides by the person who just killed someone else).

75% involve the boyfriend/girlfriend or spouse; 96% of the murderers are males (duh)

92% involve guns 

92% occur in the house of the victim

There is an average 6 year age difference between the murderer and his victim.  Risk increases with widening age difference.

23% of murder-suicides (say, about 130), the murderer is 55 or older.  Contrast this with the general homicide rate by 55 year olds: 5% 

Contrast this with the suicide statistics in the general population,  and I think you'll agree that there are an amazingly high number of people dying at the hands of their idiot boyfriends/husbands.     "You don't understand, I loved her, I'd do anything for her, and she lied, slept around-- all that time meant nothing to her-- she wouldn't listen!  How can she just take what we had and just throw it away?  It doesn't make any sense!" 

The societal question is what has happened to many men that they are unable to define themselves, or affirm their value, except through another person.  And "love"-- or its distortion-- and aggression are closely linked in such people.  But that's narcissism, and it's the disease of our times.  

In the same JCP issue in which atrocities were committed, McGirr and friends looked at 351 Canadian  consecutive suicides, and then performed a psychological autopsy to find out what had been wrong with them.

Almost all of the women killed themselves with two methods: overdose (46%); surprisingly,  hanging (38%).  For men, it was hanging (53%) or firearm a distant second (16%).  I don't know what's going on in Montreal, but it's different than LA.  (Less guns?  More trees?)

In comparison to men, women were more likely to be college grads and have jobs, to have a lifetime history of depression or anxiety, but less likely to have ever abused alcohol (26% females vs 44% males).

In the six months prior to the suicide,

Depression:   males 52%; females 56%

Anxiety: males 10%; females 15%

Alcohol: males 31%; females 18%. 

So there it is, more than half of suicides were depressed at the time of the hanging/shooting/OD.

Which is fine, but there is one statistic the authors neglected to report:

Number of patients who had been in psychiatric treatment at the time of death: 10. 

The number 10 doesn't appear in the study, and repeated attempts to get the actual number from the authors were failures: "we don't have systematic data."  Ok: the same group put out another study: out of 422 suicides, 28% had been to psychiatry in the past year.  Let me translate: 70% had not. 

If a tree falls in the forest, and no one hears it fall, shouldn't we get some guys out to the forest? 

---

Addendum: in the Oct 2006 Am J Pub Health, the authors find that suicide rates have been decreasing-- dramatically-- especially for the elderly since 1985 (from 21/100k to 16/100k) and youth since 1995 (14/100k to 10/100k).  But it's worth repeating that the number of actual suicides is still very small.

Goethe's popular comic book, Sorrows of Young Werther, published in 1774, allegedly inspired two imitations; many young men decided to kill themselves, and many, many young men decided to dress in yellow pants and blue jackets. 

Well, that's all great, but I decded to investigate whether suicide rates really do increase after one is popularized-- a propos of the previous post's discussion about whether Lott's roommate's suicide pushed Lott towards it as well.  I was pretty sure it existed, but I may have been wrong. Preliminarily, here's what I found, through 4 examples:

A study in Austria found that gun suicides increased in the three weeks following a famous gun suicide (as compared to the three weeks preceding).   There are lots of this kind of study, which are correlations based on statistical anomalies.

A better kind of study actually interviewed the suicide attempters to see what had affected them.  For example, a U.S. study found that exposure to parental suicide was not associated with suicide; exposure to a friend or acquaintance's suicide was mildly protective, and media accounts were strongly protective.    However, this study wasn't about the immediate risk (e.g. in the following month), and the authors did note that this protective effect was only if the friend's suicide or media report was greater than a year in the past.  It is easy to speculate that the longer you have to think about what they did, the more likely you are to think it wasn't the best option.

A 1993 study in adolescents found that within one month of the suicide of a friend, depression and suicidal ideation increased; but actual suicide attempts did not. 

Most of the studies finding no correlation are done using the general population; how would it be different if we looked only at people with established mental illnesses?  A 2005 study found that suicides in mental illness patients were clustered in terms of place, time, and method.  Unfortunately, this study looked at the clusters and did not identify whether or not the victims were actually even known-- or whether the patients had even heard about the suicides.    (For example, they might happen at the same clinic, but that doesn't mean they knewabout each other.)

Etc, etc.  So clustering, at least in terms of lethal attempts, appears not to happen much, (and if it does it is primarily in teens.) 

As an observation, most of the articles finding Werther effects were written pre 1980, while most finding no relationship were written post 2000.  One explanation is that we are more rigorous now (HA!); the other explanation being that there is considerably less idealization of suicide now.  In fact, suicide now is unremarkable.  Consider the "medicalization" of depression and suicide, as biological diseases rather than character pathology or expressions of emotion, a communication of sorts.   Suicides then "meant" something-- something more than "I'm depressed," while suicides now are simply symptoms.  Suicide= more Wellbutrin. 

I still think they "mean" something, and I try to interpret it, but the focus nowadays is certainly not to interpret suicide as an expression of anything.  Too bad.

Would you predict suicides increase in the sunshine/summer or darkness/winter?

Obviously, if I'm asking...

A Greek study-- and Greece has one of the lowest suicide rates in the world, about 5/100,000 (U.S. is about 17) with two major findings:

1. Suicides in the northern hemisphere, across 18 very diverse countries (Europe, Eastern Europe, Japan, North America,) peak in May/June, with a relative risk 1.08-1.5.

2. This peak is actually due to the amount of sunshine.  More sun=more death. 

#2 seems a stretch to me, so I looked it up further.  Wow. 

Same guys, find that there was no relationship between suicide and that day's sunlight; but there was a strong correlation with the past days sunlight.  There were several specific sun/day-suicide interactions, but in general for males that past 8 days and the day before, and for females that past 4 days  (but not he day before) were correlated to increased risk.

If you consider that the solar radiance in June is 26 MW/m2, and December is 6 MW/m2, then the risk of suicide increases 3% for every 1 MW/m2. 

Others have found the same.  An illustrative example is the Chile study finding the springtime peak of suicides, but this effect was absent in the north, which is closest to the equator and thus has the least seasonal variability (Chile is a strip that runs up and down the western part of South America.)   Interestingly, other equatorial regions have failed to find seasonal suicide links (e.g. Singapore); some have even identified a reverse pattern in the southern hemisphere.  And  urban areas seem to have a less pronounced or absent effect.

This is all quite interesting, but in order for it to be useful we have to show that there isn't another  obvious explanation.  Here's one: people kill themselves in June because there are more available tools.  Jumping off a building, outdoor hanging, drowning, all prefer better weather.  For example, you don't mull jumping off a building during a week of rain. 

Now you could counter that such a suicidal person would simply come up with something else (e.g. OD) but that's not what happens; suicides are very specific and personal acts.  The jumper doesn't instead use a gun.  (Consider that people with multiple suicide attempts use the same one or two methods each time.)  If two methods are similar, however, then I think such a move could happen.  But if the person is considering drowning, then an OD is probably not an option, because drowning means something, it ihas unconscious significance, and that can't be ignored.

I might even propose that non-OD and non-self-cutting suicides  are just as much about the act as about the desire to die.  When you get drunk and then stab yourself in the abdomen 45 times, you're communicating something as well as trying to die.

Following from this, it has been observed that there is no seasonal pattern to non-weather related methods: cutting, OD, gassing, (i.e. non-violent methods).  There's no seasonality (skew towards winter) to jumping in front of a German subway, which is thankfully free of sunlight's evil effects.

So if it rains for a week, instead of moving to another completely different suicide method, I believe they would simply postpone (i.e. continue to ruminate about it)  their attempt, unless a similar method is available.

BTW, this is about completed suicide, not suicidality or suicide attempts, for which I have no idea about the seasonality. 

I bring this up because of the discussions I've had, especially with the residents at my hospital, on the extent of volitional control in suicide.  I say it is a cognitive process and not necessary outcome of a disorder, and the idea that sunlight or weather can influence the timing or method of a suicide goes along with that.