THE CAUSES and PREVENTION OF SUICIDE

The vast majority (between 60% and 85%, depending on whose numbers you choose to beleive) of suicides and bona-fide suicide attempts, are caused by psychiatric problems. The psychiatric problems usually associated with suicide are affective system disorders and schizophrenia. The two common affective disorders are Severe Depression and Manic Depression. As detailed below, depression, as related to suicide, is not an emotional problem; rather, it is a physical disorder of the emotional system, which causes emotional problems.

PSYCHIATRIC AUTOPSIES

Investigation of suicides by the police must determine if the evidence is consistent with the death being a suicide. Just as the physical evidence must fit, so must the psychiatric evidence, because the motive for suicide is frequently a psychiatric problem. Suicides do not "just happen". Almost all suicides are the result of months of suicidal thoughts, which are accompanied by specific behavior patterns that match the specific underlying psychiatric problem. Just as a murder investigation is not complete until you have established motive and intent, we need to determine if the suicide victim "fits the mold" of a person who might want to commit suicide. If the victim doesn't, part of the picture is missing, and you should not be comfortable with the certainty of your finding.

Fortunately (for us cops) most suicides are motivated by a fairly limited number of specific psychiatric disorders. Each of the disorders has specific behavioral characteristics, which might have been noticed by the victim's friends and family, and maybe his/her doctor. These pre-death behaviors usually last for months. The knowledgeable officer must ask about these behaviors before completing the investigation. Armed with the officer's information, the coroner or ME can consult with a psychiatrist to get a "psychiatric autopsy", along with the medical autopsy and analysis of the physical evidence.

A "psychiatric autopsy" is a gathering and review of information about an apparent suicide victim's psychiatric health. The death scene investigator should ask the family and friends of the victim for this information. The kind of information you should be looking for is listed below, at some length.

It is quite legitimate for an investigator looking into an apparent or possible suicide, to gather the facts with which a qualified psychiatrist could conduct a "psychiatric autopsy". The officer may legitimately use this information to form an opinion at the scene, as to whether or not the suicidal profile fits the case. If a death investigation reveals physical evidence indicative of suicide, but the friends of the deceased deny that he/she had any of the symptoms of psychiatric disorder, you'd better take a closer look. But police officers are not psychiatrists, and this pamphlet is hardly the definitive text on suicidal psychiatry. A policeman is no more qualified to have en expert opinion about a person's psychiatric problems, than a psychiatrist is qualified to have an expert opinion about a fingerprint. Remember that "a little knowledge is a dangerous tool", and that your estimate of the victim's mental state is no more than a layperson's opinion.

SEVERE DEPRESSION

40% of all suicides are committed by people who have been diagnosed as having Severe Depression. Undoubtably, even more suicides actually had Severe Depression, but had not been diagnosed. A related disorder, Manic Depression, is known to account for at least another 13% of suicides. The two types of Depression account for at least half, and probably quite a bit more, of all suicides.

"Depression" is a common word meaning sadness or dejection, but Severe Depression is a sickness; a specific medical problem. To avoid confusing the two and leaving the impression that Severe Depression is just a case of "being depressed", I'm going to refer to it by its medical name "Unipolar Affective Disorder", or UAD. Similarly, I'll call Manic Depression by its proper name, "Bipolar Affective Disorder" or BAD UAD is more than just feeling sad, being depressed, being troubled, having personal problems, "having the blues", or being down. Everyone has occasional periods of sadness. Everyone has problems that distract and trouble them. UAD is a malfunction of the body's mood-regulating system. It can afflict all mammals. It is a physical malfunction which has emotional effects.

Psychiatrists differentiate between two modes of depression; "organic" and "reactive". Reactive depression is caused by a personal tragedy or difficulty, and is what most of us mean when we talk about Depression. Reactive depression gives a person time to grieve and mentally adjust to new personal circumstances. It will pass with time, and is a normal, healthy reaction to bad times. "Reactive depression", which mimics UAD as to many of its symptoms, does not reflect the more serious dysfunction of "organic depression". Organic depression (UAD) is what causes most suicides. It is not healthy, and is not a reaction to any realistic personal problem. It is a long-term malfunction of the body chemistry.

How Unipolar Affective Disorder works....

The human thinking-feeling process is an incredibly complex interaction of the cells of the brain and nervous system. The interactions take place at the ends of the many thread-like arms (ganglia) of each of the billions of cells in the brain and nervous system. Each ganglia faces another ganglia belonging to another cell, across a small gap called a synapse. Signals pass across the synapse when a molecule called a neurotransmitter shoots from a transmission site on one ganglia to a matching receptor site on the other ganglia. There are many different kinds of neuro-transmitters, and each has (a) specific receptor(s) type that can receive it. Each ganglia has lots of receptor sites on its face, including different types of receptors for different neurotransmitters.

The amount of interaction between ganglia is regulated by the number and kind of receptors on the face of the ganglia, by the amount of each neurotransmitter type available, by the speed with which used neurotransmitter molecules are cleansed from the synapses by other bio-chemicals, and even by the distance that the receptors project above the face of the ganglia. Hormones, proteins, and many other substances in the body have an effect on neurotransmitter activity. There are thousands of chemicals involved, and they all react with, and have direct and indirect effects upon, each other.

The sum of all this chemical, electrical, and physical activity is what we experience as thinking and feeling.

Your "mood" is regulated by a few specific neurotransmitters and a few other substances, which are produced and regulated by the Hypothalamus at the center of your brain, the Pineal Gland on top of your brain stem, and the Adrenal Gland on top of your kidneys, and by the endocranial system. These organs and chemicals involved in regulating mood, are collectively called the "Affective System". However, each component of the Affective System is also involved in other brain and body functions.

As with any other bodily system, things can go wrong with the affective system. By far, the most common serious malfunction of the affective system is the one called Unipolar Affective Disorder (UAD). Because each type of neurotransmitter has more than a single function within the brain, disorders of the affective system cause problems with more than just your mood. Accordingly, UAD has some symptoms which seemingly are unrelated to mood.

The symptoms of UAD can also be caused by many other diseases, for instance diabetes. However, once the disease has passed or been controlled, the affective system will bounce back. If the problem is really UAD, the symptoms may persist for months. It is an episodic disorder; you have it for several weeks or months, and then it goes away. It may return several months, a year, or several years later, or never.

Medically, UAD is defined as a loss of interest or pleasure in almost all usual activities, which lasts most of the day and persists for more than two weeks, and which is not explained by any other illness.

SYMPTOMS....four or more of the following, which last most of the day and persist for more than two weeks, and not related to other medical problems.

A family history of UAD is not really a symptom of UAD, but is frequently found in UAD patients.

UAD victims typically feel worse in the morning hours, and their mood may increase somewhat as the day wears on. Reactive Depression victims feel worse in the evening.

In addition, blood tests will show an absence of other diseases which might explain the symptoms.

UAD can also be caused by disease-related damage to the neuroreceptors.

CHEMICALS RELATED TO UNIPOLAR AFFECTIVE DISORDER (and BIPOLAR)......

Tests of the spinal and cerebral (brain) fluids of a UAD victim will show an imbalance of the specific chemicals that are related to UAD. What follows is a partial list, including the main bio- chemicals known to be related to UAD.

Dopamine...

You may remember dopamine from your training on illegal drugs. Morphine and many illegal psychotropic drugs (opium-based drugs, etc) produce their effects by interfering with the activity of dopamine.

Dopamine is a neurotransmitter. Its normal function is to regulate your feelings of pleasure and pain. There are at least two types of receptors on the ganglia for dopamine, called Mu Opioid and Delta Opioid receptors. Mu receptors produce pain messages, and Delta receptors transmit pleasure/reward messages. Suicidally depressed people have 8 times as many Mu receptors, and half as many Delta receptors, as normal people. Correspondingly, they are less able to feel pleasure, but far more likely to feel pain, than healthy people. UAD patients often say that they cannot feel pleasure in anything, and that they are in constant pain. Unsuccessful suicides, and many suicide notes, say that they "just wanted the pain to end."

Dopamine also serves as a natural regulator of norepinephrine and serotonin, two neurotransmitters directly related to UAD.

UAD Patients have low levels of dopamine.

Norepinephrine...

Norepinephrine is made by the pineal grand in the center of the brain. The pineal gland has its own direct circulation system, to the back part of the frontal (intelligence) lobes, and to those parts of the brain which regulate sleep, appetite, sex drive, memory and pain/pleasure. It is a natural tranquilizer, whose action is blocked by the illegal drug methamphetamine.

Low levels of norepinephrine are characteristic of UAD. Manic Depression, a separate but related disorder, is closely related to problems with the regulation of the amount of norepinephrine in the brain.

Serotonin...

Serotonin is also made in the pineal gland. It has a lessening effect on your ability to feel pain, and on your aggressiveness. Low levels of serotonin, by itself, is directly tied to unusual aggression in mammals. Suicidal people in general are usually found to be lacking in sufficient serotonin. Suicidally violent people, are usually even lower in serotonin. Most victims of UAD report feelings of hostility, irritability, or aggression, even if they don't act them out. This may account for the pointless vindictiveness and accusations found in so many suicide notes.

Melatonin...

Melatonin is secreted by the endocranial system. Like adrenalin, it produces wakefulness, and serves as a stimulant for the whole body, but especially the brain. It also regulates your appetite. Depressives have too little melatonin.

Cortisol...Cortisol is chemically related to the natural lubricant cortisone, but it is a steroid. It is produced by the adrenal gland, and serves as a sleep inhibitor.

Your level of cortisol normally changes with your daily routine (your "circadian rhythm"), so that you are alert during work and play hours, and ready for sleep at the appropriate times. Depressives have a large amount of cortisol all day and night, more than most people have during their peak hours.

Monoamine-Oxidase...

MAO is the chief chemical responsible for eliminating oversupplies of neurotransmitter in the brain. It chemically breaks down neurotransmitter molecules, as they float in the synapses between the ganglia. Without it, the receptors would become clogged and unable to function. Too much of it, and the neurotransmitter will be depleted and unable to carry signals between nerve cells. The most common treatment for UAD, is to prescribe a MAO-inhibitor, which makes it harder to MAO to do its work.

All of the substances listed above have other functions in the body, too. They all interact with each other, and with the hundreds of other bio-chemicals that regulate the many functions of the brain and body. In a healthy person, the amounts of these substances in the body is regulated naturally, so that an appropriate supply is available and useable. UAD is one of the common results of a malfunction in the overall inter-reaction pattern between them. The system apparently breaks down in such a way that it loses the ability to fix itself, and spirals into a pattern of low norepinephrine, serotonin, melatonin, and dopamine, and high cortisol and monoamine-oxidase

As you can see from the pattern of these chemicals and their uses in the brain, UAD is a condition of OVER-stimulation. UAD victims are "stressed-out". The brain apparently loses the ability to react to its own stimulants, and settles into a long-term pattern of boredom, pain, and fatigue. The lost concentration, indecisiveness, sleeplessness, lost appetite, and irritability seem to be side effects. If they are into drugs, depressives are most likely to be addicted to "downers". Many become heavy drinkers. They are self-medicating themselves to feel better by tranquilizing themselves.

The most common factor believed to lead to UAD, is stress. Stress is a long-term, constant condition of stimulation, which is known to produce over 600 chemical changes in the body. Stress is a natural thing, essential to a happy, productive life. However, too much stress can produce UAD, especially in people who are geneticly disposed to it.

It need not be "negative" stress that causes UAD. Even success, if it produces a lot of unfamiliar changes in one's life, can be very stressful. This may be the reason that successful people have such a high suicide rate, especially successful minorities from impoverished families. Even people familiar with success, if they constantly push themselves to perfection, can over-stress themselves so much that they burn-out and become depressed.

Read and consider this quote, from a dirt-poor backwoods farmer who, driven by an ambitious mother, rose to tremendous success and fame. He endured episodes of Depression throughout his adult life (he may have been helped along by a reportedly acid-tongued wife):

"I am the most miserable man living. If what I feel were equally divided among the whole human family, there would not be one cheerful face on earth. Whether I shall ever be better I cannot tell...I must die, or be better."

Abraham Lincoln

The typical course of UAD, is that a normal person, under the influence of stress or some disease, slips into a depressed mood. But instead of rebounding in a few days, the depressed mood becomes worse, and lasts for weeks or months. At bottom, he feels constant emotional and/or physical pain, feels no joy in life at all, and can find pleasure in nothing. He/she sees life as dull, grey, meaningless and uninteresting, and finds no richness or color in anything, even the things that mean the most to him/her. He thinks often of suicide as a means to make the suffering end, but does not have the mental energy to make the decision to do it. He is constantly fatigued, and never seems to get any restful sleep. He can't concentrate on anything, can't make decisions, and has lapses of memory. He is irritable and may be uncharacteristicly hostile.

In extreme cases, the imbalance of neurotransmitter may have a more widespread effect on the brain. Some depressives begin to hear "clicks" or whispers that aren't there. Over time, if it gets worse still, these brain-generated noises may become voices, or "telepathic assaults", or "FBI/CIA thought control beams". Even though the patient may know that this isn't possible, the noises will be absolutely real to them.

If there is no medical intervention, the victim begins to feel better after several weeks or months. Unfortunately, among the first things to recover is the mental energy, and ability to make decisions. This is the most dangerous period for undiagnosed, untreated depressives. They still want to die, and can now make the decision to commit suicide. You will frequently hear the friends and family of suicide victims say "I thought he was feeling better lately."

UAD will afflict 30% of Americans at least once during their lives. The tendency to have UAD is genetic; that is, it runs in the family. Medical science has even identified the gene that "causes" this tendency. Women are twice as likely to have (or at least, to be diagnosed as having) UAD as men. At any given time, 5 million american women are known to be having an episode of UAD, and 2.5 million men.

Children as young as 5 years old can get UAD. In the very young, the non-chemical symptoms may show up as simply irritability. However, there is an increased susceptibility to UAD with advancing age.

Among people who seek medical help for UAD, there is an 80% cure rate. Unfortunately, only 33% will seek treatment. The usual treatment program is medication to get the bio-chemistry back in balance, followed by counselling to help with any emotional problems that might be left over. The medications take a week or more to begin working, and then the patient recovers very quickly.

MEDICATIONS....

There are a number of drugs which are quite successful in bringing depressives safely back into bio- chemical balance. Unfortunately, there seems to be more than one way that things can be out of balance, so there is no one medicine that works for all patients. Some very effective medicines do not work at all on some patients, they may even make them worse. For that reason, patients who are deeply depressed, or who are just beginning to recover when they first seek medical help, are frequently hospitalized and supervised when the medication is started.

Tricyclic-Anti-Depressants....are the most popular of the Depression treatment medications. There are a number of different kinds. They work for most people. They work by interfering with the means by which the body reabosbs neurotransmitter, thereby increasing the supply of neurotransmitter in the synapses.

They have significant side-effects, and it is not unusual for a number of other medications to be prescribed along with the tri-cyclic, to combat the side-effects. They must be continued for up to 6 months after the patient is fully recovered. Among other things, these very powerful medicines can cause an increase in impulsiveness, which is thought to be a factor in many teenage suicides. For that reason, they are rarely given to teenagers, who are already too impulsive.

An overdose of any tricyclic-anti-depressant is fatal.

MAO Blockers...the second most popular and effective means of medicating UAD. They work by inhibiting the action of Monamine-Oxidase, thereby boosting the availability of serotonin and norepinephrine. They are usually "tried" second, after a tri-cyclic doesn't work. An overdose is fatal.

Non-Tricyclic-anti-depressants....these are less popular and work by a variety of different means. Among the more controversial is Prozac, which is said to be even less predictable than any of these unpredictable medicines. There have been horror stories of quiet meek depressed housewives turning suddenly into maniacal child-killers under the influence of Prozac. Whether or not Prozac is getting a bum rap, the human brain works on the basis of an incredibly complex and vast set of chemical and physical interactions. Messing around with the rules and conditions of these interactions is a tricky business.

Electro-shock therapy.... is the most effective, but least popular means of treating UAD. It developed a bad reputation as inhumane during its infancy. In modern practice, it is painless and frequently has no side effects. The patient is sedated and chemically paralyzed. A moderate electrical current is run through the brain for several minutes, causing a brain seizure. The seizure seems to somehow reset the chemical balance mechanisms of the brain. It results in an "instant cure"; the patient feels better within a day.

It is easy to take cheap shots at the doctor when their patients kill themselves. Psychiatrists are painfully aware that the very medicines they prescribe may backfire, and increase the tendency to suicide. Finding the right medication to help a complex condition that is not fully understood is no mean trick. The number of people who commit suicide while under a psychiatrist's care is grim testimony to the power of the disorders associated with suicide.

MANIC DEPRESSION

5% of depression patients have Manic Depression. Manic Depression is a cousin of UAD. Its medical name is Bipolar Affective Disorder (BAD). It is caused by a malfunction of the mood system, just like Unipolar Affection Disorder. 13% of suicides are manic depressives.

Some researchers think that BAD and UAD, are two different forms of the same problem. They are certainly related, but the system of the manic depressive is even more messed-up than that of the severe depressive. BAD victims have a lower recovery rate, a longer recovery time, and a higher relapse rate, than UAD victims.

While UAD hits twice as many women as men, BAD hits just as many men as women.

The disorder....BAD is a wild, long term swinging of the mood system. Manic depressives feel "too good" for several weeks or months, and then suddenly their mood bottoms out, and they have all the symptoms of UAD just like a severe depressive. Each patient typically has a roof and a basement; they may become extremely maniacal, or just slightly maniacal, and slightly or extremely depressed. Regardless, the symptoms are the same, only the intensity varies.

THE SYMPTOMS....

During the depression phase of the disorder, the symptoms are just like those of UAD.

During the manic phase, the patient will have the following symptoms, which last for several weeks or months, and which cannot be attributed to any other disease:

Feels great....the victim feels terrific, on top of the world. You will not be able to convince him/her that something is wrong with him/her, unless he/she really trusts you and is aware that he/she has the disorder. The victim feels physically and mentally elevated.

Mental racing....The victim's mind works at a rapid rate. It doesn't work better, or even harder, just faster. There is little concentration, but there is interest in everything. There is a need to make decisions and "DO" things, and a need for action on trivial problems.

Grandiose ideas....The victim sees things out of perspective and has no sense of scale. Will do stupid, needless things, sometimes causing major problems for those around him/her. Some victims spend huge amounts of money that they do not have, on stuff they do not need or even really want. They may initiate big projects at work that no one else sees the need for.

Increased energy....The victim is very energetic, despite seeming lack of sleep.

Feeling of imperviousness...the victim has no sense of consequences or responsibility.

Needing little sleep....Not an inability to sleep, but an actual physical need for very little sleep. Some manics get by just fine on 4 hours of sleep per night for months.

Forced speech....The victim speaks forcefully and rapidly. Their choice of words may not be completely appropriate to the meaning, and they may be more interested in the sound of the words than their meaning. They sometimes speak in rhymes.

Sexual intensity....Sexual drives are heightened. May flirt outrageously, and actively seek casual partners. No interest in sexual fidelity.

Sudden emotional swings....the victim goes from one intense emotion to another without warning or seeming cause. May get very angry and irrational over the slightest problem or challenge. May become suspicious of those around him/her.

After several weeks or months of mania, the victim will suddenly become depressed, and have the symptoms of UAD. The change may take place in just hours, frequently in response to an emotional event (such as an arrest). Please refer to the symptoms of UAD, as listed earlier.

The manic phase of this disorder may sound like fun, but maniacs cause a lot of problems for themselves during this phase. They ruin their marriages, run up huge debts, lose or abandon their jobs, and accomplish virtually nothing. They may even commit senseless crimes. Then, with their lives in shambles, they become depressed, and don't have the mental energy to deal with even normal problems.

BAD is not as common as UAD, but it is quite a bit harder to cure. BAD appears to involve a more basic malfunction of the mood system. People who have the disorder have difficulty leading normal lives, even under medication. 13% of all suicides had previously been diagnosed as being manic depressive.

Lithium tri-carbonate is the common medication for the manic phase of Bipolar Affective disorder. The usual UAD medications are used during the depressive phase.

SCHIZOPHRENIA

About 5% of youth suicides are schizophrenic.

Schizophrenia is a complex disorder of the brain, which interferes with the brain's ability to interpret reality consciously. Like UAD and Bipolar Affective Disorder, it is the result of chemical imbalances in the brain. It is frequently accompanied by paranoia and Severe Depression. There are 800,000 diagnosed schizophrenics in the United States. 80,000 of them will eventually commit suicide.

"Schizophrenia" is a catch-all label for a group of related (probably) psychotic reactions characterized by personal withdrawal, fragmented and distorted perceptions of reality, and mood and emotional disorders. Patients also have at least some of the following: hallucinations, delusions, negativistic expressions, and progressive deterioration. Psychiatrists have identified four "types" of schizophrenia; disorganized, catatonic, paranoid, and undifferentiated. However, there is no definite set of symptoms for any of these types, nor even for schizophrenia itself. It is a poorly defined, and barely understood illness. Doctors frequently do not agree on its diagnosis, and some doctors are much more likely to diagnosis it than others. It may be more than one illness, so poorly understood that they cannot even be distinguished.

Though schuzophrenia may be hard to define, most of us can recognize a schizophrenic personality right away.

Schizophrenia is not the "multiple personality" disorder Hollywood portrays. While multiple personalities are a legitimate psychiatric disorder, it has nothing to do with whatever schizophrenia is. It is an entirely separate disorder.

Acute schizophrenia comes on suddenly, features wild behavior, and appears to be stress-related. There are medicines which are effective in treating acute cases, and patients have a good chance for full recovery and a normal life. "Process" schizophrenia comes on gradually and mildly. Victims of this version become withdrawn and "different" as children, and but it does not become obvious that they are sick until their mid teens or early twenties.

There are medicines which seem to alleviate the symptoms of process schizophrenia, but not actually cure the disease. The disorder is not as well understood as the affective disorders. The medications now known for this disorder are not always effective and have serious side effects. Victims will probably not be able to lead a normal life.

Most schizophrenia victims are male.

Schizophrenia comes and goes. It usually becomes obvious in young males (mid-teens to mid-20's, but the family will recall that "he was always a little "different"), and the first episode results in medical attention and diagnosis. After recovering from the first episode, the victim may hope that the medications have worked and that the disorder will not return. After several episodes, however, suicide is a definite possibility. In fact, about 10% of all schizophrenics will eventually commit suicide. Psychiatry is still arguing about whether such suicides are a rational decision to not endure the "disease", or a result of accompanying Unipolar Affective Disorder. Many psychiatrists, however, have noted what they believe to be symptoms of UAD in schizophrenics.

There is little need to gather information for a psychiatric autopsy after the suicide of a schizophrenic. The victim will have been in the care of a psychiatrist, and there will be the appropriate medications in the victims possession or home. Almost all severe schizophrenics are under a doctor's care, because it is so obvious that there is something wrong with them.

DELUSIONS

Some suicides are in response to delusional voices telling the victim to kill him/her self. The voices are obviously a malfunction of the brain, but there is no one cause of the malfunction. The malfunction can be caused by many different diseases, by any of a number of brain disorders, including extreme BAD, extreme UAD, and schizophrenia, and even by some medications.

Such victims would probably have mentioned the delusions to others close to them. They may even have called the police to report the "telepathic assaults", or similar absurdities.

PAINFUL TERMINAL ILLNESSES

A painful or incapacitating illness of injury for which there is no cure and which is sure to end in death, may cause some people to choose a more comfortable death at their own hands. This might be called a "rational" suicide, because it makes some sense to most of us, and might even seem a logical choice. This is more common in older people, who may have no other symptoms to suggest a reason for suicide.

PERSONALITY DISORDERS

A personality disorder is not caused by a malfunction of the brain. It is the result of distorted thinking patterns, usually learned as a child. People with personality disorders can't be fixed by medication; long-term intensive counselling and therapy are needed. There is no set of symptoms to look for. People with personality disorders look and act just like normal people most of the time.

Personality disorders can cause suicides. You will find a very bizarre, passionate death scene, just like a lust murder. Good luck with this one.

GRIEF AND PERSONAL PROBLEMS

Grief in itself is rarely the sole cause of suicide, unless it is so intense that it becomes the dominant long-term factor in a person's life. Then it can take on the proportion of a painful, terminal illness, so painful to experience that death is the only hope of ending the pain.

Intense grief may lead to suicide indirectly. Grief is a strong stressor, and can lead to UAD, and the symptoms are as listed earlier. The suicide note (if there is one) or the victim's preparatory threats of suicide, may rationalize the suicide intention as a decision to "join" the loved one in death.

Likewise, broken hearts and other personal troubles are rarely the true cause of suicides. Depressives may indeed have personal troubles (manic depressives certainly do) and may blame these problems for their feelings. They may talk about their death and suicide thoughts, attributing them to the lost boyfriend or crummy job or other personal problem. Indeed, the problem may be a factor in the onset of UAD, though more likely, the disorder is the cause of the personal problem. If there are serious thoughts of suicide, tests would reveal the chemistry of a depressive.

The friends and family of a youth suicide frequently talk about the victim having been depressed or despondent over some personal problem. Viewed objectively, the problem may seem fairly normal, the type of thing all kids go through. But to the victim, it had become insurmountable and overwhelming. This is called "cognitive constriction", and it includes a loss of ability to see alternatives and solve problems. Whether this is a symptom of Affective Disorder or not is not clear.

On the other hand, personal problems in a person given to self-pity, or to attentions needs, may cause bogus suicide "attempts". These are called suicidal displays and are not real attempts at dying. Those who perform suicidal displays do engage in dangerous behavior that may accidentally result in a real suicide, however. Suicidologists do not consider these accidental suicides to be "real" suicides for purposes or their research. Whether or not the death certificate calls it a suicide is something you will have to argue on a case-by-case basis with the officials in your jurisdiction.

WARNING SIGNS

A variety of things can serve as warning signs about suicide. The most obvious indicator of a future suicide is a prior attempt. The most alarming indicator of an impending attempt, is a detailed, realistic suicide plan. The symptoms of Severe Depression, Manic Depression, Schizophrenia, Delusions, and Painful Terminal Illness, as listed above, are cause to be alert of signs of impending suicide attempts, but not for alarm..

Prior attempts...

10% of all people who have attempted suicide at least once, will go on to succeed in the future. Anyone who has attempted suicide should be forced to see a psychiatrist. Any suicide attempt, even a mere suicidal display, is a sign of a real problem. There is a good chance that fairly minimal medical intervention can solve the problem, leaving the attempter not only safer, but much happier too.

Only around 70% of successful suicides had a known prior attempt. Probably almost all of them did make a prior attempt, but most attempts are never discovered. Typically, especially with women, the first attempt is just experimental and the method not lethal enough. This statistic (70%) shows that prior attempts are not the best warning sign, because so many attempters go undiscovered. Nonetheless, those who have made attempts at suicide should be considered at higher risk.

Suicide threats...

Talking about or threatening suicide is an indicator of an interest in suicide. While it should not be a taboo subject, anyone who repeatedly brings the subject up during conversation, or during arguments, may be contemplating suicide. It is not, after all, a normal thing to talk or think about casually for most people.

Threats to commit suicide are not difficult to evaluate. The natural tendency is to view them as an attempt at manipulating the person to whom they are made. They may very well be sympathy ploys; but they can also be for real. To evaluate them, ask how the person plans to do it. If the person has a detailed plan on how to commit suicide, and the plan is realistic, then the odds are he's serious, and the attempt is imminent.

A realistic plan is one that includes:

  1. a lethal method that has a good chance of actually causing death
  2. provisions for making sure that the attempt is not interrupted
  3. means that are actually available to the person.
Not all suicides are planned in detail, however. Impulsiveness is not a symptom of any of the psychiatric disorders that cause suicide. Yet impulsiveness is a factor in many suicides. Impulsive people may contemplate suicide for months but never make a plan. They finally do it when the urge strikes them. They then use whatever means is handy at the time. Such impulsiveness is more common in youth suicides, for obvious reasons. Even so, a psychiatric autopsy may reveal that the victim had symptoms of UAD, BAD, or schizophrenia, or painful terminal illness or disability.

Suicide threats should be taken seriously. Parents and others who contact the police about such threats, should be advised not to overreact, but to contact a professional who can evaluate the psychiatric health of the threatener. People who make suicide threats to the police should be questioned about their plan.

People who say things to the police like, "Go ahead and shoot me, I want to die!", should be evaluated on the same basis.

Final arrangements....

It is common for those who have made the decision to end their lives, to continue to plan future events with their friends. They pay their bills, buy things, and generally continue their life according to their usual habits. (Major changes in their habits are uncommon; remember, depressives can't make major decisions) But once the fatal decision is made, they may make some final arrangements. They may begin to give away their possessions, write some letters, and generally put their affairs in order.

Sudden onset of peace of mind....

Victims of UAD, and the down phase of BAD, suffer greatly. When they begin to improve, after months of suffering, they can finally make the decision to die and end their misery. As you might expect, this makes them feel better; they can see the light at the end of the tunnel. Even though they don't want to die, they do want their suffering to end, and knowing that it will end soon is good for them. They will display a sudden and dramatic improvement in their peace of mind. (The most common statement that you hear from the loved ones of a suicide is, "She seemed to be feeling so much better lately.")

The peace of mind state may last for a considerable length of time. Most suicides are planned well in advance. The fatal decision is made, and a date is picked. It is common for a significant date (like New Year's Day, or a personal anniversary) to be selected. Knowing that relief is coming helps them feel better, despite their fear of death.

Symptoms of Unipolar or Bipolar Affective Disorder......

The symptoms of UAD (Severe Depression) and BAD (Manic Depression) have been described above. Only a small minority of such people will commit suicide, however. About 33% of us suffer through an episode of UAD sometime in our lives, but only one in a thousand of us will die by suicide. Thus, UAD symptoms (and the UAD-like symptoms of BAD) are not reliable indicators of an impending suicide. They are cause for concern, but not alarm. UAD, if you have it, is less likely to kill you than even the least virulent form of cancer. It should be addressed medically, but without panic.

Short term risk factors....

The following complaints are more common in people who are close to committing suicide:

PREVENTION

The prevention of suicide hinges on identifying those who are likely to commit it. Few people outside the medical profession understand what causes it, and that the causes can be fixed medically. The tendency is to deny the possibility that a loved one would really "do it", and to dismiss the suicide threat and/or attempt as an attempt to manipulate their relationship.

In law enforcement, we come into contact with many unhappy people. Few of them have UAD or BAD, but an awareness of the symptoms might help you identify one now and them. Ask such people if they have the other symptoms. Remember, if they have just four of the symptoms, they may have the disorder. Don't try to make your own diagnoses, but do try to educate them and their loved ones a little. Suggest that they ask their doctor about a referral, or that they seek a psychiatric professional. If they have UAD or BAD, and take your advise, they will be spared lots of misery.

Potential suicides....

Should you come across what you think may be a suicidal person, ask them if they are thinking about committing suicide, or have been thinking about it. Ask them how they plan to do it. Remember, the more specific, lethal and realistic the plan, the greater the risk. Take their timetable seriously. If the person gives you a good, solid, detailed plan, you should take them into custody, and take them to help. UAD victims know that they need help, and want it, but cannot make the decision to seek it. Do not be discouraged by their hostility. Hostility is normal in a UAD victim.

In Minnesota, law enforcement is safeguarded from most civil liability in commitment cases by the Good Samaritan Law. If a person describes a realistic suicide plan to you, and states his/her intention to follow it, you are on absolutely safe ground committing them on a 72-hour hold. Civilly, you are far more exposed if you fail to commit such a person.

The phone call....

Occasionally, a person contemplating immediate suicide will call the police. Obviously they want help, but getting them to accept it isn't easy. They can be reasoned with, if you talk on their terms.

Emphathize the help and caring topics. Offer them specific help, things that you will do that require no action or decision on their part.

Avoid arguing with them; they are naturally aggressive. Avoid platitudes such as "you don't mean it," or "you have so much to live for." Persons with terminal illnesses, affective disorders, schizophrenia, or delusions, know better, They have "known" for months that all is hopeless, uninteresting, and painful, and they want it to end. They do not need to be reminded that their perceptions of life are "different".

Instead, tell them that they can be helped, that you want to help them, and propose things that you will do to help them. Find out where they are. Ask them if they have done anything yet. Point out that they called you for help, that even though they want the pain to end, they still have mixed feelings about death.

Negotiating with an immediate threat....

Dealing onsite with a person threatening immediate suicide (i.e.; the gun is pointed at his head) is a special challenge. The person still is reluctant to actually do it, and still wants an alternative way out. But the hostility of UAD and the paranoia of the schizophrenic are factors, and you are in danger yourself.

If the threat does not appear to be well planned out, it may be an impulsive decision. Impulses last about 15 minutes, so just keep them talking until the impulse passes, and then work on getting the gun away from them.

If it is planned, and you are there, then the victim may have planned it that way. This could be either a form of hostility towards the police, or a way of asking for your help. Use the method listed above (point out their mixed feelings about death, offer to help them with their pain); suicide hotline workers say that it really works.