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 Recent systematic reviews by others and ourselves (unpublished) have found overwhelming evidence for such effects.1 (emphasis mine)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.

Good debate going on over at Shrink Rap.

I've posted a few comments there, but in summary: 

Hunter College didn't expel her for being suicidal; they EVICTED her from her DORM for ATTEMPTING suicide.  They wouldn't be allowed to do the former; they are obligated to do the latter, for public safety.

People want to refer to the George Washington University case.  Ok, but let's get our facts straight, from the Superior Court: 

Jordan Nott's roommate jumped out the window OF HIS DORM in April 2004, while Jordan and a friend were trying to break in to save him.  In October 2004, thinking about this, Jordan himself became suicidal but went to the ER instead.

The University suspended him. Well, not exactly:

 in order to be “cleared” to return to the residence hall, the UCC and Community Living and Learning Center (“CLLC”) had to assess Jordan’s “ability to obtain recommended treatment” and ability to “live independently and responsibly.” In order to obtain clearance, Jordan had to set up an appointment with UCC within 48 hours, and develop an agreed-upon treatment plan."

That's not GWU's defense-- that's Jordan's complaint.  That he had to go through that.  Is that so  unreasonable? 

Living in the dorm is a privilege, not a right.  If the University thinks you are a risk AND it doesn't violate constitutional rights, you're gone.  It's not up to them to prove you are a risk; it's up to you to show you aren't. 

And people are angry about GWU and Hunter because it seems that they're just out to minimze their liability?  Yeah, so what?  And it's not just the liability of  student who kills himself.  It's about his effect on public safety.   People say that an OD or jumping out a window doesn't put other students at risk.  Well, clearly Jordan's roommate's suicide had an effect on Jordan-- he admits this himself.  So there's the copycat risk.   And what if Jordan had decided to blow himself up?  Why should anyone in the dorm have to live with that risk?

Again, it's not up to the school to show she's dangerous; it's up to her to show she's not. 

The best line is this one:

If he had known [about the evictions, etc], he said, he never would have gone to the hospital.

So what are you saying?  That he would have simply killed himself? 

Hunter college caves to lawyers.

A student takes a bunch of Tylenol in an OD attempt, and after 4 days inpatient returns to her dorm to find she has been evicted.

The article makes it sound as if Hunter College kicks you out of school if you attempt suicide, which wouldn't necessarily be improper, but it's also not true.  Hunter College's housing contract says you can't live in the dorms if you have a suicide attempt.  That's a little different.

So the student sues, and Hunter decides to settle.  Her lawyer gloats:

“We’re pleased that Jane has been compensated for the college’s discriminatory treatment based on the stigma attached to a mental illness,” said David Goldfarb, one of the law firm’s attorneys representing her. “If Jane had been hospitalized for mononucleosis or pneumonia, I am confident that she would have been welcomed back to her dorm,” he added.

Well, gee, maybe a suicide attempt made volitionally, with a good chance of happening again, is a little different than pneumonia?  Stigma of mental illness?  So she was evicted for being on Zoloft?

The lawyer for the Bazelon Center for Mental Health Law , who should know better, says,

"Schools that exclude students who seek help discourage them from getting the help they need, isolate the students from friends and support at a time when support is most needed, and send students the message that they have done something wrong.”

Hmm.  I thought Hunter was a college, not a daycare?  Since when is it a school's responsibility to ensure adequate access to friends?  Is it responsible for finding them mates as well?  The problem with this statement is its logical conclusion: when can a school exclude students who seek help?  Never? Let's say the next time she tries suicide by turning the gas on, and she blows the dorm up.  Oops?

The most dangerous quote of all is from someone who really, really should know better, but obviously doesn't:

[Rachel] Glick, who is also associate chair for clinical and administrative affairs and a clinical associate professor in the Department of Psychiatry at the University of Michigan, emphasized that "universities should be open to being informed by psychiatrists and other mental health professionals about what to do to enhance the care of the students, rather than just thinking about protecting themselves from lawsuits."  

So let me get this straight: the university should ask the psychiatrist about whether the person could stay on campus or not?   Any psychiatrist out there who wants that liability football?

College:  So now that you've evaluated her, should she be allowed to return to the dorm?
Psychiatrist:  Huh?
College: Is she going to kill herself again?
Psychiatrist: How the hell would I know that?  I can't predict the future.
College: But you all told us we needed to seek your advice.
Psychiatrist: Hey man, don't try to pin this on me.  I'm going to lunch. 

Interestingly, the Psychiatric News article doesn't mention last month's case  where the parents of  Charles Mahoney sued Allegheny University because Charles was not put on mandatory leave of absence while he battled depression for two and a half years.

Everyone wants it their way; sue when you don't get your way, logical consistency be damned.  Has it now become outrageous to say that  the liability for a suicide attempt and its prevention lies  entirely with the person attempting it? 

(Addendum: many angry at my post, so I refer to the specifics of the case itself.) 

I'll write this for the ER psychiatrist seeing acute cases, but the strategy applies to all types of psychiatry.  Always keep in mind what is the purpose of the note, and who will actually be reading it.

I'll give you the punch line first:   In each of the Danish, Swedish, Finnish, American,  and Canadian  studies,  appx. 0.4% of breast implant patients killed themselves, representing a two to threefold higher risk than the general population.  In some studies, the risk of suicide was increased to 1.5 times for any type of plastic surgery. Getting implants over 40 may also be a risk for suicide.

2761 Danish women who got breast implants from 1973-1995 were compared to 7071 women who got breast reduction, and 11736 who were considered controls.  Median age was about 31.

14 (0.5%) breast implants committed suicide, 3 times more than expected (i.e. standardized mortality ratio=3).   7 of them  had been previously psychiatrically hospitalized.  220 (8%) of all implants were psychiatrically hospitalized.  

22 (0.3%) breast reduction committed suicide, 1.6 times more than expected. 6 of them had been previously psychiatriically hospitalized.  329 (4.7%) of all reductions were previously psych  hospitalized.

0 controls committed suicide. 96 (5.5%) were previously psychiatrically hospitalized.


A U.S. study  followed 12144 implant patients (mean age 31) and 3614 other plastics patients (mean age 40) from 1970-2002.  29 (0.24%) implant patients suicided vs. 4 (0.1%) other plastics patients.  Thus, the 29 suicides were 1.6 times more than expected (SMR=1.6).

Interestingly, the risk of suicide was increased only after ten years;  22/29 died after 10 years.  And while the majority killed themselves before 35 (16/29, SMR=1.4), the biggest risk was for >40 year olds. (SMR=3.4)

Really interestingly, the authors found that for breast implants there was no excess risk for any kinds of accidents-- why should there be, they were accidents-- except car accidents.  Hmmm. 10 MVA deaths (occurring 15 years post implant) vs. 0 for other plastic surgery.  The authors speculate these may not have been accidents.

Swedish study, prospective but no comparator group, of 3521 women (mean age 31) found 15 (0.4%) suicides, SMR 2.9.  

Finnish study of 2166 breast implant women from 1970-2000 were studied (retrospectively) until 2001; there were 10 (0.4%) suicides, SMR 3.  6/10 happened in the first five years (in contrast to the U.S. study.)  (Accidents here were 14, SMR 2.1.  No explanation given for this.)

Canadian study:  24558 women with breast implants vs.  15893 women with other plastic surgery from 1974-1989, studied through 1997.  Mean age 32.  Once again, overall all-cause mortality was lower for breast implant women, except in suicide: 58 (0.24% SMR 1.73) ) suicides vs. 33 (.20%, SMR 1.55)  for other plastic surgery.  Like the U.S. study, women over 40 with implants carried the greatest risk of suicide (SMR 2.3), but no relationship to how far after surgery suicides occurred.

So in these studies, appx. 0.4% of breast implant patients killed themselves, representing a threefold higher risk than the general population. In some studies, the risk of suicide was increased to 1.5 times for any type of plastic surgery.  At least in North America, getting implants over 40 is a risk for suicide.   It goes without saying that the number of actual suicides was very small, and this could all be bunk.

All studies excluded implants for breast cancer surgery. 

You may be interested in knowing that suicide is the only serious risk that has been regularly  associated with breast implants-- silicone included-- and supported by real evidence, so far.  Everything else is either no greater risk, or less risk.  For example, there is a higher risk of lung cancer, but it most likely is related to  smoking, not the implant.

The obvious next step is to see if there is a causative link between implants and suicide (likely impossible) or the implant is a clue to something else (poor self image, depression, drinking, etc.)

Something else: the stereotypical breast implant recipient (e.g. 20 year old coed in Playboy) is not really the typical recipient.  The average recipient is older (mean age 34,); is more affluent; is married (75%) and has two kids; had kids at younger ages; has had abortions; and smokes.  I mention this so that you have the right person in mind when you go looking for risks.

Other fun facts:

80% are cosmetic, 20% are breast cancer surgery reconstructions.

290,000+ breast implant surgeries done last year (compared to 130,000 in 1998).  25% are replacement surgeries for ruptures, pain, etc.  Compare to 324k liposuction and 300k nose jobs.

10% of US women have implants. (This seems wrong.)  95% are white.

10% did it in California. 

Since we're on the subject of implants and suicide, it seems to me an easy maneuver to fill breast implants with liquid explosives, puncture and mix. I am not sure why no one has tried this, actually-- or, more specifically, why no one at the TSA is looking for this as they stop to search my stupid tube of toothpaste.   Not that there's any good way of checking, of course.

Here is a suicide statistic:

"Suicide is the eighth leading cause of death in men."

That's useless, because there is no context. Other useless statements are: the risk is higher in psychiatric illness; the risk is higher the more previous attempts; men have higher rates of sucide than women, etc.

Here are some statistics (1999, 2001 and 2003-- they're all the same) which may help you.

In the US in 2001, 30,622 people died from suicide.   Yes.  That few.

24,672 were men. 5950 were women. (That's 80/20). In the whole world (WHO 2000), it was about 815,000.

5395 were over 65. (85/15 males to females)
3971 were 15-24. (85/15 males to females)

So 70% of all suicides are adults.
73% of all suicides are white males (20,000+). To put it in perspective, in 2003, the number of black women who suicided was 358.
Guns were involved in 55% of all suicides; 60% of the men's, and 73% of the elderly's, and 54% of youth's.

In other words, mostly white adult males die.

White men over 85 have the highest rate given their popualtion (54/100,000), vs. an overall rate of 10.7/100,000 (.01%) But this number of suicides is so small that the statistic doesn't help you.

So the real risk factors are white males with a gun.

I should also point out that 30,622 is a really small number of people-- even though it is almost as many as homicides (20k) and AIDS deaths (14k) combined.

How about suicide attempts that don't result in death?

Well, there are a lot: in 2002, 132,353 were hospitalized for a suicide attempt, and 116,639 were seen in an ER and released. But here's the thing: they didn't die.

The problem with our suicide assessment is that it screens for attempts, not death. And while non-psychiatrists might be surprised to hear this, a whole lot of people commit impulsive suicidal acts with no or little interest in actually dying. Psychiatry cannot do much to stop these acts, nor should it be responsible to do so. A psychiatrist should be no more responsible to prevent these parasuicidal acts than an endocrinologist is to guarantee that the patient takes their insulin. If psychiatric illness-- that's major Axis I-- so impairs their reason that they don't know what they're doing, can't stop, etc-- then it's our responsibility, just like, given that same patient, it's the endocrinologist's.  Otherwise, it is not.

We spend a lot, a lot, of money and time hospitalizing people who are not going to die. A not insignificant portion are outright malingerers, and everyone knows it. The rest may be at risk, but they may not be best served in a hospital.

So we can either spend our time and resources on preventing suicide attempts, or on preventing the 30k actual suicide deaths. It's not the same thing.