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Rethinking Suicide

Sep 26, 2023, 13 min read

Rating: 3/5

Key takeaways

  • I liked the part about systems thinking the most: that there is not really a clear continuum and dose-response relationship between risk factors and risk. We need a new way of viewing suicide risk that is beyond just ticking of risk factors.
  • The patient examples with rapid cycling in risk was also interesting. It’s not a static thing.
  • When he discussed harms reduction with traffic incidents as a comparator the conclusions were kind of obvious. We can reduce the harms without focusing so much on the individual, move to the environment instead.
    • On the traffic fatality side, we don’t expect that any algorithm will ever be able to tell us when and where any driver will experience a traffic accident, let alone die in a traffic accident, and we generally do not anticipate or expect that any algorithms or tools will ever be developed for this purpose. When it comes to suicide, however, we assume that detection and identification methods are critical or even necessary for prevention, and we generally expect that suicide-risk screening methods and algorithms should be able to do so.

Highlights

  • the prevailing model for suicide prevention was limited by survival bias, a logical error wherein we focus on the people or things that survive some selection process while overlooking those who did not. (Location 105)
  • According to this theory, dying by suicide (or making a nearly lethal suicide attempt) requires the combination of suicidal desire (in other words, wanting to die by suicide) and suicidal capability (Location 224)
  • The interpersonal-psychological theory further posits that suicidal capability involves the combination of a diminished fear of death and heightened pain tolerance. (Location 235)
    • Note: Pain tolerance from self harm?
  • Our finding, therefore, suggested that military personnel, even those who were very young and had no history of deployment, were less afraid of death than civilians who had repeatedly attempted suicide. When we later found similar results in a separate sample of deployed military personnel, we became increasingly confident in the conclusion that military personnel possessed greater suicidal capability. This characteristic or trait made it easier for them to attempt suicide. (Location 248)
    • Note: Fear of death = less likely to attempt suicide?
  • The results of these studies lent support to the hypothesis that the capability for suicide could develop or be acquired over time as a result of accumulated exposure to painful and provocative experiences. (Location 259)
  • combat exposure was related to fearlessness and pain tolerance; and (2) fearlessness and pain tolerance were related to suicidal thoughts and behaviors. We had not yet, however, connected these two separate links of the chain into a single continuous one—a critical step for testing the theory. (Location 262)
  • We simply could not conclude that combat exposure was related to suicidal thoughts and behaviors because of increased fearlessness and pain tolerance. It was incredibly frustrating. (Location 274)
  • When some studies suggest one conclusion and other studies suggest the opposite conclusion, it’s possible that one of these two sets of studies is completely wrong and the other is completely right. Another possibility is that some overlooked factor or explanation is exerting some sort of influence that isn’t immediately apparent. (Location 319)
  • Being deployed, in and of itself, was not necessarily correlated with increased risk for suicidal thoughts and behaviors, but seeing someone die or causing someone’s death was. Notably, this correlation seemed to persist even many years after service members and veterans had been deployed. (Location 362)
  • Seemingly overnight, certain catchphrases that had long been familiar within the suicide prevention community were being repeated over and over again in newspapers, opinion-editorials, television interviews, radio talk shows, blogs, and online memes: Ask the question, save a life; All suicides are preventable; Know the warning signs; Have the courage to ask for help; Suicide prevention is everyone’s business. (Location 448)
  • If we’re so certain about what causes suicide and what needs to be done to prevent it, why are we so bad at this? What if we’re wrong? (Location 462)
  • I also believed that all suicides could be prevented; it was just a matter of recognizing warning signs and intervening early. I certainly didn’t come up with these ideas on my own; they were (and continue to be) central axioms of the suicide prevention community and society more generally, and I had never really questioned them or wondered about the information upon which they were based. (Location 573)
  • Over and over again, I found myself encountering cases like these, in which a sudden decision was made within the context of a stressful situation. Over and over again, some version of the refrain, “it just happened,” was offered as an explanation—in many cases accompanied by a confused shrug of the shoulders and resigned shake of the head. (Location 661)
  • The prototypical story involved an acute reaction to a life stressor, although sometimes no stressor could be identified at all, but the time course and nature of their reactions did not rise to the level of a mental illness. Indeed, if these people had not engaged in suicidal behavior, their reactions would typically be considered “normal” by most standards and would not have reasonably led to the diagnosis of a mental illness, not even an adjustment disorder. (Location 665)
  • diagnosable mental illness did not seem to exist prior to the behavior’s occurrence. If the individual had not made a suicide attempt, their reported symptoms and behaviors would not have met the threshold for diagnosing a mental illness at all. (Location 782)
  • In each of these cases, there was little evidence that a mental illness existed before the suicidal behavior occurred. Furthermore, the suicidal behavior served as the only source of evidence supporting the presence of a mental illness. This pattern suggests our traditional assumptions about the causal role of mental illness for all (or nearly all) suicidal behaviors warrants further consideration. (Location 788)
  • Wicked problems like suicide do not have a single or even a finite number of causes. On the contrary, wicked problems are influenced by so many different factors that the concept of “cause” no longer holds much meaning. (Location 920)
  • First, mental illness is only weakly correlated with suicidal behaviors. Second, a much larger percentage of suicides than we may have traditionally recognized occur in the absence of mental illness. (Location 927)
  • Thoughts about suicide or wanting to die should be taken seriously because they reflect being in a vulnerable state, but they do not necessarily lead to suicide. (Location 1026)
  • First, change is constant in complex systems. In its most general sense, a system can be defined as a set of things that work together as interacting parts of a network. A system is considered complex when the interactions among its many components and pieces are so complicated that they cannot be easily understood or modeled. (Location 1163)
  • If we assume that suicidal behaviors result from linear cause and effect relationships, we can mistakenly assume that suicide warning signs are always apparent before the occurrence of suicidal behavior when in reality this may not always be the case. (Location 1199)
  • The fourth and final assumption of emergence is that complex systems behave in nonproportional ways. This means that small changes within the system can lead to very large differences in the outcome, whereas large changes within the system can have virtually no effect on the outcome at all. (Location 1200)
  • Indeterminism refers to the idea that an outcome or event (e.g., suicide) is not caused or determined by any particular combination of factors. (Location 1209)
  • Here again we have an apparent paradox: a nearly perfect scale can be wrong almost all the time when it’s used in a population wherein the vast majority of individuals do not attempt suicide or die by suicide. (Location 1295)
  • In like fashion, our estimation of an individual’s risk for attempting suicide may be improved when we consider how their change patterns are deviating from their own typical patterns, but our accuracy is reduced when we try to distinguish between those who will attempt suicide and those who will not. (Location 1402)
  • This suggests that, at least for some people, suicide risk may not lie on a unidimensional spectrum or continuum. Rather, two distinct states seem to exist, one that is low risk and one that is high risk, sort of like two buckets placed side by side. Under these circumstances, changes in suicide risk would take the character of sudden jumps from one state to the other rather than the smooth, gradual transition that characterizes the unidimensional continuum. (Location 1491)
  • In combination, these three studies lend support to the first and third properties of the cusp catastrophe model: Suicide risk has two distinct states and intermediate suicide risk levels are much less probable than lower and higher risk levels. (Location 1642)
  • up to half of suicide attempts occur within five to 20 minutes of deliberation over the act. (Location 1655)
  • When it comes to the tipping point between suicidal behavior and the absence of it, the wish to live seems to carry somewhat more weight than the wish to die. (Location 1706)
  • If you’re inclined to delve into the history of suicide, so to speak, there’s no better source than Margaret (Peggy) Battin’s book, The Ethics of Suicide: Historical Sources. (Location 1919)
  • Overall, these studies suggest that the central concepts described by many of the newer theories were not all that different from other, more general indicators of mental illness. The reasons why some treatments and interventions are better at preventing suicide attempts therefore remain unknown, but there is now a fair amount of evidence that the reasons probably involve something other than mental illness. (Location 1967)
  • The decisions we make do not reflect who we are so much as they reflect what is happening to us. (Location 2063)
    • Note: Context matters
  • This is something I’ve heard from many suicidal people, especially the patients I’ve treated over the years. They have, for example, explained that they stopped calling a friend because the friend was unhelpful or unavailable once in a time of need. Never mind that the friend was there all the other times they needed help—that one time was enough to abandon this strategy. (Location 2191)
  • As a result, options that are more likely to succeed do not carry much more perceived value than options that are less likely to succeed. “Obvious” strategies and solutions, therefore, may not be so obvious to someone who is vulnerable to making a suicide attempt. (Location 2217)
  • Reducing emotional distress and mental illness is certainly helpful, but that strategy alone may not be enough to stop someone’s forward momentum toward suicide. The ability to quickly identify and utilize self-regulatory strategies is also essential, and these concepts are central to the treatments that are most effective for reducing the occurrence of suicidal behaviors. Considerable research supports the value of these approaches, but mental health professionals rarely use them when working with suicidal or high-risk patients. (Location 2240)
    • Note: Decision making beyond just mental health trt
  • improvements in mental illness seem to have little (if anything) to do with the reduction of suicidal behaviors in suicide-focused treatments. If mental illness is unrelated to the reduction of suicidal behaviors in suicide-focused treatments, what is the “something else” that these treatments are acting upon? Based on the research reviewed in the previous chapters, I would argue that the “something” involves decision-making processes related to self-regulation. Specifically, DBT and CBT-SP seem to reduce the probability of suicidal behaviors because they strengthen individuals’ internal braking systems, helping them to choose not to act upon suicidal impulses and urges in stressful situations. (Location 2373)
  • On the contrary, we simply accept this reality and focus instead on two related goals: (1) reducing the probability of all traffic accidents and (2) reducing the probability that unpreventable traffic accidents will result in death. (Location 2816)
    • Note: Don’t predict but work on structural issues
  • Instead of seeking to change environmental and contextual hazards that contribute to suicide, our efforts have by and large focused on methods designed to change the individual. If a person is suicidal, we recommend mental health treatment. If a person is not suicidal but is experiencing stress and/or other risk factors for suicide, we recommend mental health treatment as well. (Location 2923)
  • On the traffic fatality side, we don’t expect that any algorithm will ever be able to tell us when and where any driver will experience a traffic accident, let alone die in a traffic accident, and we generally do not anticipate or expect that any algorithms or tools will ever be developed for this purpose. When it comes to suicide, however, we assume that detection and identification methods are critical or even necessary for prevention, and we generally expect that suicide-risk screening methods and algorithms should be able to do so. (Location 2964)
  • We might consider instead the potential impact of redirecting these efforts toward environmentally focused strategies that are more likely to reduce suicide rates. Just as we’ve been able to significantly reduce traffic fatalities without knowing which drivers are fatigued, intoxicated, or inclined to reckless driving, we can almost certainly reduce suicides without knowing who has been thinking about suicide or who has various risk factors for suicide. (Location 2971)
  • The law also required that registered owners store their firearms either locked up or unloaded and disassembled, two types of engineering controls. Soon after the law took effect, firearm suicides dropped by 23% but the number of suicides by all other methods did not change—people were not switching to a different method. Researchers further showed that suicides in neighboring Maryland and Virginia counties—jurisdictions that were not subject to the law’s provisions—did not change during the same period of time, thereby ruling out the possibility of other naturally occurring shifts in suicide rates within the region. The law’s effect on suicide, therefore, was limited to those who were subject to it. (Location 3069)
  • Taken together, the many, many studies supporting the effectiveness of means restriction provide very strong evidence that suicides can be prevented through environment-oriented, prevention-through-design approaches. These methods prevent suicide without suicide-risk screening, without suicide-risk detection systems and algorithms, and without mental health treatment, all of which are best categorized as personal protective equipment controls because they seek to mitigate risk and harm when in the presence of an environmental hazard. (Location 3091)
  • widespread adoption of suicide-focused treatments could, in the best-case scenario, potentially reduce the national suicide rate by up to 15% to 22%. Means restriction, by comparison, reduces suicide rates by margins that consistently range from 30% to 60%—nearly double the estimated impact of improved mental healthcare. (Location 3099)
  • Means restriction methods work irrespective of the potential causes of suicide, and do not depend on our ability to predict who will attempt suicide or when suicidal behaviors will occur. Instead, means restriction focuses directly on reducing the lethality of suicidal behaviors, thereby increasing the likelihood that someone will survive a suicidal crisis, giving them a second chance. (Location 3184)
  • suicide-attempt survivors for up to 10 years, around seven out of 10 people who attempted suicide and survived did not attempt suicide again and nine out of 10 did not go on to die by suicide. If someone survives their first suicide attempt, there’s a very good chance that they will not die by suicide at all, even many years later. (Location 3188)

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