Saturday, January 01, 2000

Living, Loving, Holding On

Night Falls Fast: Understanding Suicide

By: Ellen Frank Ph.D. and David J. Kupfer M.D.

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Kay Redfield Jamison’s Night Falls Fast: Understanding Suicide is a disturbing book. We suspect that Jamison meant it to be that way. She sees the “untold epidemic of suicide” as a national emergency and tells us in her epilogue that writing this book was the only thing she knew to do about it. She clearly wants our attention and she gets it. She wants us to remember this book and we will.

Jamison acknowledges the complexity of her topic and, indeed, the arrangement of her book reflects the complex interplay among brain, behavior, and context that ultimately lead to suicide. Night Falls Fast has four major sections: 1) an introduction to suicide; 2) the psychology and psychopathology associated with suicide; 3) the biology of suicide, and 4) the prevention of suicide. Each of these sections is divided into multiple chapters addressing specific topics, followed by an essay describing a particular suicide: in two cases, those of famous persons and in two others, those of ordinary citizens whose suicides she has studied in great detail. The shift back and forth throughout the book from scientific or historical fact to detailed description of madness and death gives the book a peripatetic quality. Perhaps this is purposeful. After each of the “essays,” the reader feels the need of some relief from the searing pain just described. Without this relief, the book would be intolerable. Without these graphic descriptions, the book would be forgettable. Clearly, Jamison wants it to be neither. 

Like each of Jamison’s previous books, Night Falls Fast is extraordinarily literate. Each section and each chapter begins with an epigram taken from the work of a famous poet or prose writer. Many additional quotations from British and American literature are included throughout the chapters. For those with a scholarly bent, this only serves to enhance the book. Yet, thinking about the attendees at a local suicide support group we observed a few weeks ago, mostly blue collar workers and high school-educated homemakers whose adolescent children had committed suicide, one could wish for a book more accessible to a broader range of individuals trying to make sense of the suicide of someone close to them. On the other hand, we already have numerous memoirs written by those who have attempted suicide. We have what might be termed psychological autopsies written about persons, especially famous persons, who completed suicide and we have technical professional books on suicide. None of these provides quite the satisfying, yet deeply unsettling, combination provided in Night Falls Fast

THE BLACK KNIGHT IN PLAY

Jamison begins her book like a novel: “Summer evenings at the Bistro Gardens in Beverly Hills tended toward the long and languorous.” She goes on to describe a non-suicide pact that she had made years ago while living in Los Angeles. She and a good friend had agreed that should either of them ever again become deeply suicidal (both had manic-depressive illness and both had been suicidal in the past), they would meet in Cape Cod for a week. During that week, they would walk the beach, rest, talk, and the non-suicidal one would have the entire week to argue the suicidal one out of the decision. Yet, Jamison surely, and almost certainly her friend, knew they were kidding themselves: 

Never once during any of my sustained bouts of suicidal depression had I been inclined or able to pick up a telephone and ask a friend for help. Not once. It wasn’t in me. How could I seriously imagine that I would call Jack, make an airline reservation, get to an airport, rent a car, and find my way out to his house on the Cape? It seemed only slightly less absurd that Jack would go along with the plan, although he at least was rich and could get others to handle the practicalities...It is a tribute to the persuasiveness, reverberating energies, and enthusiasms and infinite capacity for self-deception of two manic temperaments that by the time the dessert souffles arrived we were utterly convinced that our pact would hold. He would call me; I would call him; we would out-maneuver the black knight and force him from the board. 

Jamison, to our great benefit, is still with us. Her friend, Jack, is not. As she goes on to point out, “If it has ever been taken up as an option, however, the black knight has a tendency to remain in play.” Many years later Jamison’s friend, Jack, put a gun to his head. “Suicide is not beholden to an evening’s promises nor does it always harken to plans drawn up in lucid moments and banked in good intentions.” What Jamison understands as well as anyone who has ever written on the topic is the unimaginable desperation of those who turn to suicide, and it is that deep and personal understanding that gives her book much of its force. 

THE MANY MEANINGS OF SUICIDE

In her first chapter, “Death Lies Near at Hand,” Jamison traces the history and anthropology of suicide, noting that suicide almost certainly precedes recorded observations about it. She describes the wide cultural variation in attitudes toward suicide and points out that in Western society, while funeral customs were altered somewhat for those who had committed suicide, it was not until the early years of Christianity that strong religious sanctions against suicide emerged. 

“To Measure the Heart’s Turbulence” elaborates with considerable subtlety the many meanings of the term “suicide” and describes the magnitude of the problem, considering everything from mild suicidal thinking to suicidal gestures, serious attempts, and completed suicide. Jamison concludes this first section of the book with what might well be termed a psychological autopsy were it not written more like a novella, as she chronicles the breakdown and ultimate suicide of Drew Soprak, an Air Force Academy graduate who suffered from manic-depressive illness and took his life within 18 months of graduating from the Academy. 

“I SHALL NEVER GET OVER THIS...”

The second section of Jamison’s book, devoted to the psychology and psychopathology of suicide, begins with a chapter that leads us into the mind of the suicidal person through a series of suicide notes. Jamison warns us that these notes often “promise more than they deliver,” yet the notes, journals, and diaries from which she quotes provide a vivid picture of life gone stale, of shame so profound no other solution is possible, of the desperate wish for escape from psychic pain and, in some cases, from incapacitating madness. Virginia Woolf, having lost her capacity to write, wrote to her husband,  “I know that I shall never get over this: and I am wasting your life...You can work, and you will be much better without me.” Believing she had permanently lost her self-defining skill, Woolf chose to drown herself. 

Jamison goes on to consider the forms of psychopathology most associated with suicide in those under 40, including mood disorders, substance abuse, schizophrenia, personality disorders, anxiety disorders, and medical illnesses. (She has chosen to focus her book on suicide in those under 40, arguing that suicide among older persons is a topic for a book in its own right.) She provides personal descriptions, mostly from famous poets and writers, of the inner experience of the kind of psychopathology that leads to suicide and points out that these disorders often come in a lethal combination, for example, alcoholism plus a mood disorder, that often are further compounded, as in the case of poet John Berry-man, by a strong family history of suicide. 

Jamison then describes the many places and methods that have been chosen for suicide, including jumping into volcanoes and eating poisonous plants. In the midst of this chronicle of horrors, she points out that in the United States firearms currently account for far and away the largest proportion of suicides; about 60 percent of those who have succeeded in killing themselves in the United States in recent years have done so with firearms. 

This section of Night Falls Fast concludes with the second of Jamison’s “essays,” probably the most disturbing part of the entire book. In this essay she describes the death of Margaret Davis King, a homeless mother of three suffering from schizophrenia, who had come to Washington with the apparent intent of getting back the custody of her children. Having spent the day in a fruitless effort to obtain the information she sought from a government clerk, who was bewildered by her calm but bizarre behavior, she took herself to the National Zoo, scaled the three and half-foot fence that surrounded the lion enclosure, lowered herself down a nine foot wall, swam the moat that further separated the lions from visitors to the Zoo and climbed onto the grassy terrace where the lions normally fed. When discovered by a zoo worker the following morning, her arms and hands had been gnawed off and bite marks covered her body. The medical examiner listed the cause of death as “sharp-and blunt-force injury associated with massive blood and soft tissue loss” and ruled the death a suicide. It is a measure of Jamison’s daring that she includes this horrific tale in her book. No lyrical, Ophelialike self-drowning here. 

Jamison further uses this awful tale to call into question the wholesale deinstitutionalization of the chronically mentally ill in this country. King had been hospitalized, released, re-hospitalized, and released again in three different states. Although an honorably discharged veteran of the U.S. Navy, the safety net had failed her utterly. What seems to gall Jamison most is the ill-considered nature of the move to deinstitutionalization: as her husband Richard Wyatt, a distinguished mental health researcher, wrote in a 1986 editorial in Science, the policy was based on “virtually no scientifically gathered data.” Thus, our nation embarked upon and has stuck with a policy of keeping the chronically mentally ill out of hospitals as much as possible. Yet, we have no objective evidence that this policy works to the ultimate benefit of the majority of those with severe and persistent mental illness. Clearly, it has worked to the detriment of some. 

THE SUICIDE “GENE”

The third section of Night Falls Fast concentrates on the biology of suicide: neurobiology, neuropathology, and evolutionary and genetic aspects. Jamison lays down the considerable body of evidence that suicide runs in families, which may or may not mean that it is genetic. She acknowledges that “the odd or striking case history [of a family with multiple suicides] is more likely to be noticed or written up for scientific publication, and other factors—such as family exposure to suicide or learning from another family member’s behavior that suicide is a tenable, even desirable, way of handling the problems of life or illness— may be important as well.” 

In trying to understand why from an evolutionary perspective the suicide “gene” survives, she argues that it is associated with mood disorders, and with manic-depressive illness in particular, where risk-taking, creativity, aggression, sociability, and interpersonal success are common, especially during the reproductive years. 

Written in a way that those without medical or biological training can understand, and in a very short space, the chapter “Death Blood” covers a tremendous amount of information about the biology of suicide. Jamison notes the association of suicide with impulsive, aggressive, and violent behavior and the joint association of these behaviors with elevated levels of certain neurotransmitters in cerebrospinal fluid. She argues for a model of suicidal behavior in which the neurobiology, whether through genetics or some other process such as acute physical illness, sleep deprivation, or medication, interacts with external stressors to lead to suicidal behavior. Her third “essay,” on the death of the explorer, Merriweather Lewis, provides a clear case in point. After Lewis’ death, Thomas Jefferson, who knew him intimately, noted that “Governor Lewis had, from early life, been subject to hypochondriac [depressive] affections. It was a constitutional disposition in all the nearer branches of the family of his name, and was more immediately inherited by him from his father.” Indeed, Jamison makes a good argument that Lewis probably suffered from some variant of manic-depressive illness that, by the end of his life, had taken on a rapid-cycling course. While on his famed exploration, Lewis seems to have been energetic, enthusiastic, and optimistic; however, after his return, his many and more mundane responsibilities as governor and, perhaps more important, his severe financial problems, appear to have interacted with his genetic or familial predisposition in such a way as to lead to his suicide. 

AGAINST THE “CHOICE TO DIE”

The fourth and final section of Night Falls Fast is devoted to the prevention of suicide. Jamison reviews what is known about the assessment of suicide risk and prevention at the individual level through effective treatment of mood disorders. In this chapter, Jamison also directly addresses the philosophical issue of whether suicide can ever be considered a “life choice,” in the same vein as getting married or divorced, as the controversial psychiatrist and author Thomas Szaz was wont to consider it. Needless to say, she comes down strongly on the negative side of this debate, arguing that it is a clinician’s responsibility to do everything in his power to prevent a patient from making this choice. 

In discussing suicide as a public health problem and prevention of suicide at the societal level, she notes that “we as a society fail to deal in a tolerant or informed way with serious mental illnesses, addictions or suicide,” and argues that health professionals of all kinds (most elderly people who commit suicide have seen their doctor within the month prior to killing themselves), legislators, and the media all have a responsibility to create a society that does deal in a tolerant and informed way with this issue. In her final essay, “The Half-Stitched Scar—Those Left Behind,” Jamison speaks directly to the family members and friends who must try to understand this act and their own loss and underscores the value of support groups of the kind sponsored by the American Foundation for Suicide Prevention and the American Association of Suicidology. 

A POWERFUL WAY OF HOLDING ON

There are issues that one wishes Jamison had engaged more directly. For example, she looks at stigma in her essay on Merriweather Lewis, as she ponders if a hero can be permitted to commit suicide in the public mind, and again in her final essay, in which she talks about those left behind. We, however, would have liked to have seen a more expansive discussion of this issue. 

Likewise, although Jamison points to the strong association between the easy availability of firearms in our nation and rising rates of suicide, particularly by this method, she never directly engages the issue of whether this might be one more reason to make firearms more difficult to obtain. Finally, although she touches on the rights of the individual in her discussion of a philosophy of suicide, we would have liked to have seen a fuller discussion of this concern, particularly with respect to those—often elderly—with incurable, deteriorating, and painful medical conditions. Although she acknowledges that her focus is primarily on suicide in the young, we feel it a loss that she did not turn her sharp mind to this debate. 

Beautifully written and beautifully produced, Night Falls Fast is not a comprehensive text on suicide, like Jamison’s classic Manic Depressive Illness written with Dr. Frederick Goodwin, but a powerful and scholarly dissertation. In the end, one is left wondering who is the intended audience for this book: mental health professionals, historians, philosophers, other scholars interested in suicide and, maybe as much as anyone, Jamison herself? In the end, this may be a book Jamison wrote as much for herself as to address the national and international emergency with respect to suicide, a kind of sequel to An Unquiet Mind. Night Falls Fast is, to paraphrase Douglas Dunn’s line with which she concludes her epilogue, Jamison’s way of looking to the living, loving them, and holding on. 

EXCERPT

From Night Falls Fast: Understanding Suicide by Kay Redfield Jamison. © 1999 by Kay Redfield Jamison. Reprinted with permission of Alfred A. Knopf. 

EPILOGUE

I was naive to underestimate how disturbing it would be to write this book. I knew, of course, that it would mean interviewing people about the most painful and private moments of their lives, and I also knew that I would inevitably be drawn into my own private dealings with suicide over the years. Neither prospect was an attractive one, but I wanted to do something about the untolled epidemic of suicide and the only thing I knew to do was to write a book about it. I am by temperament an optimist, and I thought from the beginning that there was much to be written about suicide that was strangely heartening. 

As a clinician, I believed there were treatments that could save lives; as one surrounded by scientists whose explorations of the brain are elegant and profound, I believed our basic understanding of its biology was radically changing how we think about both mental illness and suicide; and as a teacher of young doctors and graduate students, I felt the future held out great promise for the intelligent and compassionate care of the suicidal mentally ill.

All of these things I still believe. Indeed, I believe them more strongly than I did when I first began doing the background research for this book two years ago. The science is of the first water; it is fast-paced, and it is laying down, pixel by pixel, gene by gene, the dendritic mosaic of the brain. Psychologists are deciphering the motivations for suicide and piecing together the final straws—the circumstances of life—that so dangerously ignite the brain’s vulnerabilities. And throughout the world, from Scandinavia to Australia, public health officials are mapping a clearly reasoned strategy to cut the death rate of suicide. 

Still, the effort seems unhurried. Every seventeen minutes in America, someone commits suicide: Where is the public concern and outrage? I have become more impatient as a result of writing this book and am more acutely aware of the problems that stand in the way of denting the death count. I cannot rid my mind of the desolation, confusion, and guilt I have seen in the parents, children, friends, and colleagues of those who kill themselves. Nor can I shut out the images of the autopsy photographs of twelve-year-old children or the prom photographs of adolescents who within a year’s time will put a pistol in their mouths or jump from the top floor of a university dormitory. Looking at suicide— the sheer numbers, the pain leading up to it, and the suffering left behind—is harrowing. For every moment of exuberance in the science, or in the success of governments, there is a matching and terrible reality of the deaths themselves: the young deaths, the violent deaths, the unnecessary deaths.



About Cerebrum

Bill Glovin, editor
Carolyn Asbury, Ph.D., consultant

Scientific Advisory Board
Joseph T. Coyle, M.D., Harvard Medical School
Kay Redfield Jamison, Ph.D., The Johns Hopkins University School of Medicine
Pierre J. Magistretti, M.D., Ph.D., University of Lausanne Medical School and Hospital
Robert Malenka, M.D., Ph.D., Stanford University School of Medicine
Bruce S. McEwen, Ph.D., The Rockefeller University
Donald Price, M.D., The Johns Hopkins University School of Medicine

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