Mapping the road to suicide — (Los Angeles Times)

SSRI Ed note: Edwin Shneidman psychological autopsy of Arthur misses the most serious potential problem - antidepressants.

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Los Angeles Times

By Thomas Curwen

Monday, June 14, 2004

Statistics National suicide data
Suicide took the lives of 29,350 Americans in 2000.
In 2000, there were 1.7 times as many suicides as homicides. Overall, suicide is the 11th leading cause of death for all Americans and the third leading cause of death for people aged 15-24. Males are more than four times as likely to die from suicide than are females. However, females are more likely to attempt suicide than are males.

57 percent of suicides in 2000 were committed with a firearm.

Source: Centers for Disease Control and Prevention


LOS ANGELES — Edwin Shneidman is an old man, and death is often on his mind. But then, it always has been. Only now it’s personal, and like many people of his age, Shneidman is not ready.”Am I afraid?” he asks. “No. But our language is insufficient. ‘Afraid’ is not the right word. It is more ‘rueful,’ but even that is too vague.”

Death has been his companion because Shneidman has stood at the forefront of suicide studies in the United States for more than 50 years. He is not ready to step aside, even though he is 86 and slowed by cancer and diabetes. He admits surprise, however, when he wakes up in the morning, and in idle moments pens his own obituary: “Noted thanatologist dies.” He laughs at the irony. Much better, he says, than “Noted suicidologist commits suicide.”

Rising from bed each day, he shuffles through the living room, dining room and kitchen and into his office, where he sits at an old computer, takes solace in the photographs of his deceased wife, Jeanne, and writes.

“I am a rather elderly man,” begins a recent essay. “I am a thanatologist (one who studies death) … I realize that there is a certain whiff of sulfur in this profession, but my assertion is that anyone who spends a good deal of time with Thanatos, the Greek god of death, can live a life made much richer by that intimate association with the darker side of life.”

Far from a morbid investigation into the enigma of self-destruction, the study of suicide is often philosophical, and Shneidman writes to clarify his ideas. His work — 17 books that he has either written, edited or co-edited — is an intellectual diary and a compelling reminder that suicide is part of our lives and our culture. We see it in the most diverse quarters: in the retrieval of writer/artist Spalding Gray’s body from the East River in New York, in recent concerns that some antidepressants contribute to suicide in youth, and in a controversy over a Britney Spears video that shows her submerging herself in a bathtub.

Over the years, however, Shneidman’s lifelong project has been marginalized by the shifting winds of science. The more scientists study the brain and discover effective synthetic treatments for mental illness — what many believe is the underlying cause of suicide — the less critical private histories, personal stories and emotional circumstances, the major tenets of Shneidman’s work, become.

Herbert Hendin, the medical director of the American Foundation of Suicide Prevention, said Shneidman was the first person in this country to call public attention to the problem of suicide. “He had a charismatic quality and played a pivotal role in dramatizing the problem of suicide,” he said.

But as Hendin points out, the biggest advances in the field of suicide prevention in the past 15 years have been in the biology and pharmacology of depression and suicide, and it borders on malpractice for a doctor not to prescribe medication for a seriously depressed individual. Shneidman, nevertheless, “remains an advocate of the position that the medical treatment of depression is the problem and not the solution.”

If every life is a narrative, then every death is its conclusion foretold, and Shneidman works to ensure that his story will continue. He is eager to tell the story of his latest book, “Autopsy of a Suicidal Mind.”

Grief and despair are often inseparable for those left behind by a suicide, and Shneidman recognized both in a woman who approached him after one of his lectures. With some urgency, she pressed upon him a photocopy of an 11-page suicide note. Please help me understand the death of Arthur, my son, she said; he had so much to live for.

In his lifetime, Shneidman has read thousands of suicide notes. They are, he says, surprisingly banal. He made no promises. He folded the note under his arm and didn’t look at it until he got home that afternoon. The first sentence was strikingly familiar. “All I do is suffer each & every day,” Arthur wrote.

Suffering is what Shneidman believes is at the heart of every suicide, and in that first sentence, he found a concise expression of that pain and a potential window to look upon the most puzzling of human behaviors. Let others talk about mental illness when they talk about suicide and then point to a diagnosis such as depression. Shneidman chooses instead to talk about “psychache,” a word he coined almost 20 years ago to describe psychological pain.

When the woman called him later in the week, he agreed to help decipher her son’s death. He had once again been given an opportunity to make his case for psychache.

More than 50 years ago, when he was treating mostly schizophrenic patients at the VA Hospital in Los Angeles, its director asked him to write to the widows of two patients who had committed suicide. The request took him to the coroner’s office in Los Angeles, where he unexpectedly found himself surrounded by the files of all the city’s suicides, enough raw data to make a career.

One of Shneidman’s first innovations was the psychological autopsy, based on a series of hourlong interviews with family and close relations. He developed the technique in consort with Norman Farberow and Robert Litman, who were his partners in founding the Suicide Prevention Center at Los Angeles County General Hospital in the late 1950s.

The psychological autopsy made the recovery of Arthur’s life possible. Through overlapping memories, his death becomes less an abstraction and more of an intimate portrait of a young man who one weekend at the age of 33 realized he could no longer befriend the demons that we all somehow live with.

The interviews took two months to complete, and when Shneidman was done, he changed the names (to protect confidentiality) and sent the material to eight friends — psychologists, psychiatrists and sociologists — and invited them to write their opinions.

With the interviews, the essays and the note itself, “Autopsy of a Suicidal Mind” reads like a novel but with a purposeful bias: It is a credo of Shneidman’s long-held beliefs told by colleagues who maintain his ideological bias.

Arthur was ambitious and hard-working. He graduated Phi Beta Kappa. He made top honors in medical school, and when medicine proved unsatisfying, he studied law, scoring in the 99th percentile on his LSATs. He was even offered a Supreme Court justice clerkship.

Yet beneath these accomplishments, Arthur’s life was disquietingly restless.

He married at 24 and was divorced three years later. He had last seen a psychiatrist when he was 28 and a psychologist when he was 30. He had an on-again, off-again relationship with a girlfriend. It was a pattern that seemed to be part of his childhood: His mother and father paint a picture of a boy who was prone to temper tantrums at an early age, who was a finicky eater and a slow learner and always in competition with his older brother.

When Shneidman heard this, he saw red flags. “Adulthood is an extrapolation from childhood,” he says. “People are loyal to themselves.”

Arthur’s parents divorced when he was 10, and by then he was having tantrums every day.

When he was 14, after a “wonderful” camp experience, according to his father, he took an overdose of Tylenol, so worried was he that life could never be as good again. In the succeeding years his fears never seemed to abate. Moments of happiness were brief and mistrusted, and as he told his girlfriend, depression became a physical pain “like lying on a bed of needles.”

On his last weekend, Arthur stood between life and death, uncertain which way to turn. On Friday he started to write his farewell. On Sunday he had breakfast with his father, even asked for a loan, and later he helped a friend repair a car alarm. All the time, however, he was writing his note, recording an attempt on Saturday night before he killed himself on Sunday.

This is, of course, the great puzzle of suicide: How can one be involved in life while taking steps to end it? Shneidman found nothing in his interviews that led him to believe that Arthur was psychotic. He may have been depressed, but given a lifetime of depression, this diagnosis fails to explain why on this particular weekend he chose to take his life. The reasons are more complicated and more subtle. “He was too fragile,” Shneidman says, “too vulnerable, too excitable.”

“Autopsy” presents a man defined not only by himself but also by his family and friends, and in this context suggests a message hidden in the connections we create with one another, in the meaning of love, of anger, hope and disappointment.

Disconnection is vulnerability, says contributor and psychiatrist Jerome Motto. Its treatment can be quite simple. “I’ve often just hypothesized that there is more suicide prevention that goes on over the back fence, talking to a neighbor, than goes on in physicians’ offices,” he says.

When people talk about suicide prevention nowadays, the conversation often turns to the work being done at the New York State Psychiatric Institute in Manhattan, one of the premier research facilities in the country.

In the offices and laboratories of the Department of Neuroscience on the second floor, researchers take slices of human brains and pore over their cellular structure in an attempt to discover a difference between those who have committed suicide and those who haven’t.

Although they concede that suicide is not entirely a biological phenomenon, they devote their time and resources to studying the role of serotonin, a neurotransmitter associated with depression, aggression and impulse control, and charting the complicated skein of biochemical reactions that occur at times of stress and stimulation. It is a study that one day they hope might lead to biological tests and genetic screens for suicidal dispositions.

Shneidman acknowledges their work but thinks it will provide only part of the answer. “You don’t understand psychopathic murder by slicing (Jeffrey) Dahmer’s brain … ,” he says. “Unfortunately, it’s in the mind. And the mind is not a structure. It is an ephemeral concept.”

Two years before his death, Arthur had been taking Effexor. Later, it was Prozac, and a year before his death, Wellbutrin, Effexor again, Eskalith and Celexa. “I have gone through literally countless years of therapy & now over 2 years of antidepressant medications,” he wrote. “Why is it that I should believe that one day I will be ‘happy.’ ”

Yet it is a regimen that is widely accepted.

For depression and social anxiety today, there is less consideration of private histories and more prescriptions of Zoloft and Paxil, now advertised on television as if they were cold medicines.

While most contributors to “Autopsy” believe that drug therapy treats only symptoms, none argues against it. Treating an ephemeral concept — to borrow Shneidman’s phrase — is a difficult proposition, made more difficult by numbers (nearly 30,000 people commit suicide in the country each year), institutions and culture.

Bucking the zeitgeist is difficult, but it is at the heart of Shneidman’s work, especially as he has watched, in the past 25 years, the mental-health pendulum swing from left to right, from clinics to laboratories, from social to pharmaceutical agendas.

“If I were to do it all over again,” Shneidman says, “I would probably study love.”